What are the management options for Peyronie's disease?

Management of Peyronie's Disease

Initial Assessment and Disease Phase Determination

The first critical step is determining whether the disease is in the active or stable phase, as this fundamentally dictates treatment strategy. 1

• Active phase is characterized by dynamic symptoms including penile pain, developing plaque, and progressive deformity, typically lasting 3-12 months 1
• Stable phase is defined as symptoms unchanged for at least 3 months, minimal or no pain, established plaque, and stable curvature 1
• Perform intracavernosal injection testing with or without duplex ultrasound to document curvature degree, plaque characteristics, and erectile function status 2, 1
• Document whether curvature is between 30° and 90°, as this determines eligibility for intralesional therapy 1

Treatment Algorithm for Active Phase Disease

For patients in the active phase with penile pain, oral NSAIDs are the first-line treatment. 1, 3

• NSAIDs should be used for pain management, with assessment using a visual analog scale and periodic reassessment 3
• PDE5 inhibitors such as tadalafil 5mg daily can be added to reduce collagen deposition and potentially lower curvature progression rates 1
• Avoid oral therapies such as vitamin E, colchicine, pentoxifylline, potassium aminobenzoate, or tamoxifen, as these lack consistent evidence of efficacy 2, 1

Treatment Algorithm for Stable Phase Disease

For Mild Curvature (Not Interfering with Sexual Function)

• Observation is an appropriate option 1

For Moderate Curvature (30° to 90°) with Intact Erectile Function

Intralesional collagenase clostridium histolyticum (Xiaflex) is the only FDA-approved non-surgical therapy and represents the strongest evidence-based treatment for this population. 2, 1, 3

• Requires palpable plaque confirmed on physical examination 1, 3
• Dosing protocol: 0.58 mg per injection into the Peyronie's plaque, up to 8 injections over 24 weeks 1
• Treatment must include modeling by both clinician and patient 2
• Important caveat: Collagenase treats curvature only—it does not treat pain or erectile dysfunction 3
• Expected outcome is modest: approximately 17° reduction versus 9.3° with placebo 3
• Adverse events occur in 84.2% of patients, mostly mild to moderate (penile ecchymosis, swelling, pain), with rare but serious complications including corporal rupture 3

Alternative Non-Surgical Options for Stable Disease

• Penile traction therapy requires extended daily use for collagen remodeling, with weaker evidence than collagenase 3, 4, 5
• Low-intensity extracorporeal shockwave therapy may provide pain relief but does not reduce curvature 3, 4
• Intralesional interferon alpha-2b can be considered as an alternative to collagenase 4

Surgical Management

Surgery should only be considered after disease has been stable for 3-6 months and conservative therapy has failed for approximately 1 year. 1

For Patients with Preserved Erectile Function

• Tunical plication (Nesbit procedure) is recommended for curvatures <60° 2, 6
• Plaque incision or excision with grafting is recommended for curvatures >60° or complex deformities 2, 6
• Tunical lengthening procedures carry significant risk of postoperative erectile dysfunction (up to 50%) 6

For Patients with Concurrent Erectile Dysfunction

Penile prosthesis implantation is the treatment of choice, as it addresses both the curvature and erectile dysfunction simultaneously. 2, 1, 6

• Use inflatable penile prosthesis rather than semi-rigid devices, as modeling to maximize curvature correction is difficult with semi-rigid devices 2
• This approach is associated with high levels of patient satisfaction 7

Critical Pitfalls to Avoid

• Do not use collagenase for pain management—this represents off-label use not supported by guidelines and delays appropriate pain treatment 3
• Do not proceed with surgery until disease has been stable for at least 3-6 months 1
• Do not prescribe oral vitamin E, colchicine, or tamoxifen—these have insufficient evidence and are listed as unproven treatments 2, 1
• Treat concurrent erectile dysfunction first or concomitantly, as ED treatment may improve secondary issues 1
• Set realistic expectations: patient and partner satisfaction should be the primary target outcome, not complete curvature resolution 1
• Collagenase should only be administered by urologists experienced in urological disease treatment 3, 6