What are the treatment options for a patient with Peyronie's disease?

Peyronie's Disease: Treatment Approach

Treatment for Peyronie's disease must be stratified by disease phase—active versus stable—as this completely dictates management strategy, with NSAIDs for pain in the active phase, intralesional collagenase for moderate curvature in the stable phase, and surgery reserved for stable disease causing sexual dysfunction. 1, 2

Disease Phase Classification

The critical first step is determining whether the patient has active or stable disease, as treatment options differ completely between these phases 1, 2:

Active Disease Characteristics

• Defining feature: Penile or glanular pain with or without erection 1
• Dynamic, changing symptoms over time 1
• Plaques and deformities incompletely developed 1
• Typically lasts 3-12 months from symptom onset 2
• May have progressive deformity causing distress 1

Stable Disease Characteristics

• Defining feature: Symptoms clinically unchanged for at least 3 months 1
• Pain absent or minimal 1
• Established curvature (uniplanar or biplanar) 1
• Palpable plaques or visible on ultrasound 1
• Disease typically stabilizes at 12-18 months after onset 2

Diagnostic Evaluation

Minimum requirements: Detailed history assessing penile deformity, interference with intercourse, pain, and distress, plus physical examination with stretching and palpation of the flaccid penis 1

Before any invasive intervention: Perform in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound to assess penile deformity, plaques, and pain in the erect state 1

Treatment Algorithm by Disease Phase

Active Phase Management

First-line: Oral NSAIDs for pain management 1, 2

• Assess pain using visual analog scale 1
• Periodically reassess to measure treatment efficacy 1, 2

Consider: Daily tadalafil 5mg to reduce collagen deposition and decrease curvature progression 2, 3

Critical pitfall: Do NOT offer oral vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or vitamin E with L-carnitine—no convincing evidence for efficacy 1

Avoid: Radiotherapy provides no benefit over natural disease progression and exposes patients to unnecessary radiation 2

Stable Phase Management

For Mild Curvature

Observation is appropriate, as many patients function adequately with mild deformity 2, 3

For Moderate Curvature (30-90 degrees)

Intralesional collagenase clostridium histolyticum (Xiaflex) is the only FDA-approved non-surgical therapy 1, 2, 3

Requirements for collagenase:

• Palpable plaque on physical examination 2, 3
• Stable disease without active progression 2, 3
• Curvature between 30° and 90° 1, 2
• Intact erectile function (with or without medications) 1, 2

Treatment protocol:

• Up to 8 injections of 0.58 mg (10,000 U) over 24 weeks 2, 3
• Combined with clinician and patient modeling exercises 1, 2
• Average curvature reduction: 17° versus 9.3° with placebo 2

Critical limitation: Collagenase treats curvature ONLY—does NOT treat pain or erectile dysfunction 2, 3

Do NOT use: Electromotive therapy with verapamil—minimal benefit compared to placebo 1

Surgical Management

Indications for surgery:

• Disease stable for at least 3 months 1, 2
• Curvature compromises sexual function 1, 2
• PD symptoms present for at least 12 months 2
• Stable curvature for 3-6 months 2, 3

Surgical options ranked by frequency and outcomes:

1. Tunical plication (most common, ~50% of PD surgeries):

   • Curvature improvement in ≥90% of cases 2
   • Results in some penile shortening 2, 4

2. Plaque incision/excision with grafting:

   • Curvature improvement ranges 25-100% 2
   • May use saphenous vein or dermal graft 4

3. Penile prosthesis (for concurrent ED):

   • Treatment of choice when ED prevents coitus despite pharmacotherapy 2, 4
   • Curvature improvement >80% in all reviewed studies 2
   • Use inflatable devices, NOT semi-rigid prostheses 2

Critical pitfall: Do NOT perform surgery during active disease phase—surgical outcomes for active disease are unknown 2, 3

Quality of Life Considerations

Peyronie's disease significantly impacts psychosocial functioning:

• 54% of men report relationship difficulties 1, 5
• Depressive symptoms remain consistently high over time 1
• Men report decreased sexual confidence and concerns about partner satisfaction 1

For some patients, thoughtful counseling about disease nature and typical course may be sufficient, and they may choose not to pursue further treatment 1, 5

Natural History Context

Pain typically resolves over time without intervention in most patients 1

Curvature and deformity are less likely to resolve spontaneously, although younger men and those with symptoms <6 months may experience some improvement 1

Common pitfall: Many patients do not recall a specific inciting event, but repetitive minor penile trauma during sexual activity is thought to be the most common cause 1