What are the treatment options for a 40-60 year old male with Peyronie's disease?

Treatment Options for Peyronie's Disease in Men Aged 40-60

Treatment for Peyronie's disease must be stratified by disease phase: oral NSAIDs for pain during the active phase, and intralesional collagenase injections or surgery for stable disease with significant curvature that impairs sexual function. 1, 2

Initial Classification: Active vs. Stable Disease

The critical first step is determining disease phase, as treatment options differ completely between these two stages 1:

Active Disease Characteristics:

• Penile or glanular pain with or without erection (defining symptom) 3
• Dynamic, changing symptoms over time 1
• Developing plaques and deformities not yet fully formed 1
• Typically lasts 3-12 months 2

Stable Disease Characteristics:

• Symptoms unchanged for at least 3 months 1
• Pain absent or minimal 1
• Established curvature and palpable plaques 1
• Plaque visible on ultrasound 1

Diagnostic Assessment:

• In-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound is essential to evaluate penile deformity, plaques, and pain in the erect state 1
• Physical examination with palpation to detect plaques or induration 4

Treatment Algorithm by Disease Phase

Active Phase Management (Pain and Developing Deformity)

First-Line Pain Management:

• Oral NSAIDs are the recommended first-line treatment for penile pain during the active phase 1, 2
• Pain should be assessed using a visual analog scale and periodically reassessed 2

Adjunctive Therapy to Reduce Progression:

• PDE5 inhibitors (tadalafil 5mg daily) may be considered to reduce collagen deposition and decrease curvature progression 1, 2
• This represents an attempt to modify disease course, not immediate symptom relief 1

Critical Pitfall: Collagenase injections are NOT indicated for pain management—they treat curvature only, not pain or erectile dysfunction 2. Using collagenase for pain represents off-label use not supported by guidelines and delays appropriate pain management 2.

Stable Phase Management (Established Curvature)

Treatment selection depends on curvature severity and erectile function status:

Mild Curvature (<30 degrees):

• Observation is appropriate if sexual function is not compromised 4
• Careful counseling about disease nature and typical course may be sufficient to alleviate concerns 1

Moderate Curvature (30-90 degrees) with Intact Erectile Function:

• Intralesional collagenase (Xiaflex) is the only FDA-approved non-surgical therapy for stable Peyronie's disease with curvature between 30-90 degrees and intact erectile function 1, 2
• Requires palpable plaque on physical examination 2
• Protocol involves up to 8 injections of 10,000 U over 24 weeks combined with clinician and patient modeling 2
• Average improvement is modest: approximately 17 degrees versus 9.3 degrees with placebo 2
• 84.2% of patients experience at least one adverse event (mostly mild-moderate), including penile ecchymosis, swelling, pain, and rare corporal rupture 2
• Must be administered by clinicians experienced in urological disease treatment 2

Alternative Non-Surgical Options:

• Penile traction therapy for collagen remodeling (requires extended daily use) 2
• Low-intensity extracorporeal shockwave therapy for pain relief (NOT for curvature reduction) 2

Surgical Intervention Indications:

• Disease stable for at least 3 months AND curvature compromises sexual function 1
• Failed conservative therapy with severe curvature 2

Surgical Options Based on Erectile Function:

• Tunical plication (Nesbit procedure): For patients with good erectile function; results in some penile shortening 2, 5
• Plaque incision/excision with grafting: For more complex deformities with preserved erectile function 2, 6
• Penile prosthesis implantation: For patients with concurrent drug-refractory erectile dysfunction; addresses both issues simultaneously with high patient satisfaction 2, 6

Psychosocial Impact and Counseling

Quality of Life Considerations:

• 54% of men report relationship difficulties as a result of Peyronie's disease 1
• Depressive symptoms remain consistently high over time, indicating lasting psychological impact 1
• Men experience decreased sexual confidence, anxiety in sexual situations, and concerns about satisfying partners 3
• Many patients feel isolated and find it difficult to communicate with healthcare professionals or partners 3

Counseling Approach:

• Attentive patient counseling is the hallmark of managing Peyronie's disease 7
• Patients may be hesitant to discuss symptoms unless directly inquired 7
• Incidental diagnosis rates as high as 16% during routine visits 7
• Thorough discussion of treatment goals, therapeutic options, and realistic expectations is essential 7

Natural History Without Treatment

Expected Course:

• Pain typically resolves over time without intervention in most patients 3, 4
• Curvature and deformity are less likely to resolve spontaneously 3, 4
• Younger men and those with symptoms present for less than 6 months may experience some improvement 3
• In the absence of active treatment, the majority experience stable or worsening symptoms, with few reporting spontaneous resolution of curvature 6

Common Pitfalls to Avoid

• Do not use collagenase for pain management—it is specifically a therapy for curvature, not pain 2
• Do not delay surgical evaluation in patients with stable disease and significant functional impairment 1
• Do not prescribe oral therapies as monotherapy—there are no strong data supporting any oral agents alone for Peyronie's disease 6
• Do not perform surgery during active phase—wait until disease is stable for at least 3 months 1
• Do not underestimate psychological impact—address emotional distress and relationship difficulties proactively 1