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

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

For men aged 40-60 with Peyronie's disease, treatment selection depends entirely on whether the disease is in the active or stable phase—active disease requires conservative management with NSAIDs for pain and possibly daily tadalafil, while stable disease with moderate curvature (30-90°) and intact erectile function should be treated with intralesional collagenase injections, and severe stable disease compromising sexual function requires surgical intervention. 1

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Disease Phase Classification: The Critical First Step

Determining disease phase is mandatory before initiating any treatment, as therapeutic options differ completely between phases. 1, 2

Active Phase Characteristics:

• Penile pain with or without erection 1
• Dynamic, changing symptoms 1
• Incompletely developed plaques and deformities 1
• Typically lasts 3-12 months from symptom onset 1

Stable Phase Characteristics:

• Symptoms unchanged for at least 3 months 1
• Minimal or absent pain 1
• Established curvature with palpable or ultrasonographically visible plaques 1
• Disease typically stabilizes at 12-18 months after onset 1

Essential Diagnostic Evaluation:

• Perform office intracavernosal injection test with or without duplex ultrasound to document curvature, plaque characteristics, and erectile function in the erect state 3, 1

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Treatment Algorithm by Disease Phase

Active Phase Management (First 3-12 Months)

Oral NSAIDs are the first-line treatment for penile pain during the active phase. 1, 2

• Assess pain using a visual analog scale and periodically reassess treatment efficacy 1, 2
• Consider daily tadalafil 5mg to reduce collagen deposition and decrease curvature progression 1, 2
• Provide comprehensive counseling about disease nature and expected course, which may be sufficient for many patients 1

Critical pitfall: Do NOT offer radiotherapy—it provides no benefit over natural disease progression and exposes patients to unnecessary radiation risks. 1

Do NOT use collagenase during the active phase, as it is specifically indicated for stable disease with established curvature, not for pain management. 2

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Stable Phase Management (After 3+ Months of Stability)

For Mild Curvature:

• Observation is appropriate, as many patients function adequately with mild deformity 1

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

Intralesional collagenase clostridium histolyticum (Xiaflex) is the only FDA-approved non-surgical therapy and should be offered as first-line treatment. 1, 2

Treatment Protocol:

• Requires palpable plaque on physical examination and stable disease without active progression 1, 2
• Up to 8 injections of 10,000 U (0.58 mg) over 24 weeks 1, 2
• Combined with clinician and patient modeling exercises 1, 2
• Average curvature reduction is 17° versus 9.3° with placebo 1, 2

Critical limitations to discuss with patients:

• Collagenase treats curvature only—it does NOT treat pain or erectile dysfunction 2
• 84.2% of patients experience at least one adverse event, including penile ecchymosis, swelling, pain, and rare but serious complications like corporal rupture 2
• Must be administered by clinicians experienced in urological disease treatment 2

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Surgical Management for Severe or Refractory Disease

Surgery should only be considered when disease has been stable for at least 3 months and curvature compromises sexual function. 1

Surgical candidates must have:

• PD symptoms for at least 12 months 1
• Stable curvature for 3-6 months 1

Surgical Options Based on Clinical Scenario:

1. Tunical Plication (Most Common—~50% of PD surgeries):

   • Curvature improvement occurs in ≥90% of cases 1
   • Results in some penile shortening 1
   • Best for patients with adequate penile length and intact erectile function 1

2. Plaque Incision or Excision with Grafting:

   • Curvature improvement ranges from 25-100% 1
   • Preserves penile length better than plication 1
   • Higher risk of erectile dysfunction compared to plication 1

3. Penile Prosthesis Surgery:

   • Indicated for patients with ED and/or penile deformity preventing coitus despite pharmacotherapy/vacuum therapy 1
   • Curvature improvement >80% in all reviewed studies 1
   • Use inflatable devices, NOT semi-rigid prostheses, as inflatable devices allow necessary modeling for optimal outcomes 1

Critical surgical pitfall: Do NOT perform surgery during active disease phase, as surgical outcomes for patients with active disease are unknown. 1

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Quality of Life and Psychological Considerations

Peyronie's disease significantly impacts quality of life, with 54% of men reporting relationship difficulties. 1

• Depressive symptoms remain consistently high over time, suggesting durable psychological impact 1
• Comprehensive counseling about disease nature and expected course is essential for all patients 1
• Many patients may be hesitant to discuss symptoms unless inquired directly 4
• Consider referral for psychological support or sex therapy when functional and psychological effects are prominent 5

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Therapies to Avoid

The following treatments lack evidence of efficacy and should NOT be offered:

• Radiotherapy (no benefit over natural disease progression) 1
• Oral therapies as monotherapy (vitamin E, colchicine, pentoxifylline, potassium aminobenzoate, co-enzyme Q10) have limited evidence 3, 6
• Extracorporeal shockwave therapy (ESWT) has low overall utility, as penile pain commonly resolves over time regardless of intervention 1