What are the treatment options for an adult male diagnosed with Peyronie's disease?

Treatment Options for Peyronie's Disease

Disease Phase Classification is Critical

Treatment for Peyronie's disease depends entirely on whether the disease is active or stable, and these phases require completely different management approaches. 1, 2

Active Disease Phase

Active disease is characterized by:

• Penile or glanular pain with or without erection (the defining symptom) 1
• Dynamic, changing symptoms with progressive deformity 1
• Plaques and deformities that may not be fully developed 1
• Typically lasts 3-12 months 2

Stable Disease Phase

Stable disease is defined by:

• Symptoms clinically unchanged for at least 3 months 1, 2
• Pain absent or minimal 1
• Established curvature and palpable plaques 1
• No progression of deformity 2

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Treatment Algorithm by Disease Phase

For Active Disease (Pain and Progressive Deformity)

NSAIDs are the 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
• Oral NSAIDs provide appropriate pain management without delaying more effective interventions 1, 2

Daily tadalafil 5 mg should be considered to reduce disease progression. 1, 2

• Tadalafil reduces collagen deposition and increases apoptosis in Peyronie's disease 1
• Studies demonstrate lower curvature progression rates and improved symptoms versus controls 1

Avoid ineffective oral therapies that delay appropriate treatment. 1, 3

• Pentoxifylline, vitamin E, tamoxifen, potassium para-aminobenzoate (Potaba), and omega-3 fatty acids are not recommended due to lack of proven efficacy 1, 3
• These treatments may delay more effective interventions 1, 3

For Stable Disease (No Pain, Stable Curvature)

Non-Surgical Options

Intralesional collagenase (CCH/Xiaflex) is the only FDA-approved non-surgical therapy for Peyronie's disease. 2

• Indicated for curvature between 30° and 90° with intact erectile function 2
• Requires palpable plaque and stable disease confirmed on physical examination 2
• Important caveat: Collagenase treats curvature only—it does not treat pain or erectile dysfunction 2
• Protocol involves up to 8 injections of 10,000 U over 24 weeks with clinician and patient modeling 2
• Average improvement is modest: approximately 17° versus 9.3° with placebo 2
• Common adverse events include penile ecchymosis, swelling, and pain; rare but serious complications include corporal rupture 2

Penile traction therapy (PTT) works through collagen remodeling. 1, 2

• Requires extended daily use of 2-8 hours 1, 2
• Works by decreasing myofibroblast activity and upregulating matrix metalloproteinase 1
• Average length increases of 1 cm when used as adjunct therapy 1
• Safe with no serious adverse effects reported 1

Low-intensity extracorporeal shockwave therapy (LI-ESWT) may help with pain but not curvature. 1, 2

• Shows positive results for pain relief in RCTs 1
• No effect on curvature or plaque size 1

Multimodal approaches show promise. 1

• Combination of PDE5I with CCH appears superior to CCH alone for improving curvature and erectile function 1
• PTT as adjunct therapy enhances outcomes 1

Surgical Options

Surgery is indicated when disease has been stable for 3-6 months and curvature compromises sexual function. 1, 2

Three main surgical approaches exist:

1. Tunical Shortening (Plication Procedures) 1, 4

• Indicated for curvature <60° in penises with adequate length 4
• Involves tightening the convex side of the penis 1
• Results in some penile shortening 1, 4
• Preferred when erectile function is adequate and curvature is not severe 4

2. Tunical Lengthening (Plaque Incision/Excision with Grafting) 1, 4

• Indicated for curvature >60°, severe shortening, or complex deformities (hourglass, hinge) 1, 4
• Involves incision or partial excision of plaque on concave side with graft coverage 1
• Requires adequate erectile function 1
• Grafts include autografts (dermis, vein, fascia, buccal mucosa), allografts (pericardium), xenografts (bovine/porcine), or synthetic materials 1
• May still result in some length reduction, especially when combined with plication 1

3. Penile Prosthesis Implantation 1, 4

• Treatment of choice for patients with both Peyronie's disease and refractory erectile dysfunction 4
• Addresses both erectile dysfunction and curvature simultaneously 5
• May require additional straightening maneuvers 4
• Associated with high patient satisfaction rates 5

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Critical Considerations

Erectile Dysfunction Management

If erectile dysfunction is present, it should be treated first or concomitantly with Peyronie's disease treatment. 3

• Erectile dysfunction is common in Peyronie's disease and affects treatment selection 5
• "Borderline" erectile function favors shortening procedures over lengthening procedures 4

Psychosocial Impact

Peyronie's disease has significant psychological and relationship consequences that must be addressed. 1

• 54% of men report relationship difficulties as a result of Peyronie's disease 1, 2
• Depressive symptoms remain consistently high over time 1, 2
• Men report decreased sexual confidence, anxiety in sexual situations, and concerns about satisfying partners 1
• Careful counseling about disease nature and typical course may be sufficient to alleviate concerns for some patients 6

Patient Reassurance

Patients should be reassured that Peyronie's disease does not lead to malignancy. 1, 3

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Common Pitfalls to Avoid

Do not prescribe unproven oral therapies that delay effective treatment. 1, 3

• Despite common prescription patterns, no oral agents have strong data supporting their use as monotherapy 5
• Pentoxifylline, vitamin E, and similar agents lack proven efficacy and delay appropriate interventions 1, 3

Do not use collagenase for pain management. 2

• Collagenase is specifically for curvature reduction, not pain or erectile dysfunction 2
• Using CCH for pain represents off-label use not supported by guidelines 2

Do not rush to surgery during active disease. 1, 2

• Surgery requires stable disease for at least 3 months, preferably 3-6 months 1, 2
• Operating during active phase risks poor outcomes due to ongoing disease progression 1

Do not fail to assess and document erectile function before treatment. 4

• Erectile function status determines appropriate surgical approach 4
• Refractory erectile dysfunction mandates penile prosthesis rather than corporoplasty 4

Set realistic expectations about non-surgical treatments. 2

• Most non-surgical treatments provide only modest improvements 2
• Patients should understand that complete resolution of curvature is unlikely without surgery 5