What are the recommended diagnostic steps and treatment options for a middle‑aged man with Peyronie’s disease presenting with penile curvature, mild pain, and preserved erectile function?

Peyronie's Disease: Diagnostic Approach and Treatment

For a middle-aged man with Peyronie's disease presenting with penile curvature, mild pain, and preserved erectile function, begin with oral NSAIDs for pain control and daily tadalafil 5 mg to reduce curvature progression during the active phase, then transition to intralesional collagenase (Xiaflex) once the disease stabilizes if curvature remains functionally significant. 1, 2

Initial Diagnostic Assessment

Determine disease phase immediately, as this completely dictates treatment strategy. 2

Active Phase Indicators (Present in Your Patient):

• Penile pain with or without erection 2
• Dynamic and changing symptoms 2
• Incompletely developed plaques and deformities 2
• Typically lasts 3-12 months from symptom onset 2

Essential Diagnostic Steps:

• Perform in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound to evaluate penile deformity, visualize plaques, assess pain in erect state, and measure curvature angle 3
• Palpate the penis to detect plaques or areas of induration—this is the hallmark finding that confirms Peyronie's disease rather than age-related changes 4
• Assess erectile function formally, as 54% of men report relationship difficulties and psychological impact is substantial 2

Treatment Algorithm for Your Patient (Active Phase with Preserved Erectile Function)

First-Line Therapy:

Oral NSAIDs are the recommended first-line treatment for penile pain during the active phase. 1, 2 Assess pain using a visual analog scale and reassess periodically to measure treatment efficacy. 2

Concurrent Therapy to Prevent Progression:

Daily tadalafil 5 mg should be initiated to reduce collagen deposition, increase apoptosis in Peyronie's disease, and decrease curvature progression rates. 1, 2 Studies demonstrate lower curvature progression rates and improved symptoms versus controls. 1

Therapies to AVOID:

• Do NOT offer pentoxifylline, vitamin E, tamoxifen, procarbazine, potassium para-aminobenzoate (Potaba), or omega-3 fatty acids—these lack proven efficacy and may delay more effective interventions. 1
• Do NOT offer radiotherapy—it provides no benefit over natural disease progression and exposes patients to unnecessary radiation risks. 2
• Extracorporeal shockwave therapy (ESWT) has low overall utility for pain, as penile pain commonly resolves over time regardless of intervention. 2 ESWT shows positive results for pain relief but no effect on curvature or plaque size in randomized controlled trials. 1

Transition to Stable Phase Management

When Disease Stabilizes (Symptoms Unchanged ≥3 Months):

Disease typically stabilizes at 12-18 months after symptom onset. 2 At this point, reassess curvature severity and functional impact.

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

Intralesional collagenase clostridium histolyticum (Xiaflex) is the only FDA-approved non-surgical therapy for stable Peyronie's disease. 2, 3

Treatment protocol specifics:

• Requires palpable plaque on physical examination and stable disease without active progression 2
• Up to 8 injections of 10,000 U (0.58 mg) over 24 weeks, combined with clinician and patient modeling exercises 2
• Average curvature reduction is 17° versus 9.3° with placebo 2
• Critical caveat: Collagenase treats curvature ONLY—it does not treat pain or erectile dysfunction 2

Alternative Non-Surgical Options for Stable Phase:

• Penile traction therapy (PTT) works through collagen remodeling via decreased myofibroblast activity. Requires extended daily use (2-8 hours) but appears safe with no serious adverse effects reported. 1
• Combination therapy shows promise: injectable verapamil combined with antioxidants and diclofenac demonstrated better pain reduction than verapamil alone. 1

Surgical Considerations (If Conservative Measures Fail)

Surgery should ONLY be considered when:

• Disease has been stable for at least 3 months 2
• Curvature compromises sexual function 2
• Patient has had PD symptoms for at least 12 months 2
• Do NOT perform surgery during active disease phase—surgical outcomes for patients with active disease are unknown 2

Surgical Options by Clinical Scenario:

• Tunical plication (most common, ~50% of PD surgeries): Curvature improvement occurs in ≥90% of cases 2
• Tunical lengthening (plaque incision/excision with grafting): Recommended for severe shortening, curvature >60°, or complex deformities without ED 1
• Penile prosthesis: Reserved for patients with ED and/or penile deformity preventing coitus despite pharmacotherapy/vacuum therapy, with curvature improvement >80% 2

Critical Counseling Points

Natural History Discussion:

• Pain typically resolves over time without intervention, but curvature and deformity are less likely to resolve spontaneously 4
• In approximately 20% of cases, the condition may regress during the initial acute phase 5
• Reassure the patient that Peyronie's disease does not lead to any form of malignancy 1

Psychological Impact:

• 54% of men report relationship difficulties as a result of Peyronie's disease 2, 3
• Depressive symptoms remain consistently high over time, suggesting durable psychological impact 2, 3
• Comprehensive counseling about disease nature and expected course is essential and may be sufficient to alleviate concerns 3

Common Pitfalls to Avoid

• Do NOT use calcium channel antagonists (verapamil, nicardipine) as oral therapy—they lack strong evidence for clinical use with no meaningful improvement versus placebo 1
• Do NOT use collagenase for pain management—it is specifically a curvature therapy, not a pain treatment 2
• Do NOT use semi-rigid prostheses if surgery becomes necessary—inflatable devices allow necessary modeling for optimal outcomes 2
• Do NOT delay effective interventions by prescribing ineffective oral therapies like vitamin E or Potaba 1