How should I manage a patient with recent‑onset Peyronie's disease (<12 months) presenting with mild curvature (<30 degrees) and minimal pain?

Management of Recent-Onset Peyronie's Disease with Mild Curvature

For a patient with recent-onset Peyronie's disease (<12 months) presenting with mild curvature (<30 degrees) and minimal pain, offer oral NSAIDs for pain management and consider daily low-dose PDE5 inhibitors (tadalafil 5mg) to potentially reduce disease progression, while providing thorough counseling that watchful waiting is also reasonable given the mild presentation. 1

Disease Phase Classification

Your patient is in the active phase of Peyronie's disease, characterized by:

• Symptoms present for less than 12 months
• Ongoing pain (even if minimal)
• Potentially evolving deformity and plaque formation 1

This classification is critical because treatment options differ completely between active and stable phases. 1

Initial Diagnostic Evaluation

Perform an in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound to:

• Objectively document the degree of curvature in the erect state
• Assess plaque characteristics and location
• Evaluate erectile function
• Establish a baseline for monitoring disease progression 2, 1

This assessment is essential before considering any invasive interventions and provides objective documentation of the mild curvature. 2

Pain Management (First-Line Treatment)

Oral NSAIDs are the treatment of first choice for managing penile pain during the active phase. 1

• Use a visual analog scale to quantify pain severity
• Reassess pain levels periodically to measure treatment efficacy 2
• Pain typically resolves spontaneously over time in most patients, even without intervention 3, 4

Consideration of PDE5 Inhibitors

Daily tadalafil 5mg may be considered during the active phase to:

• Potentially reduce collagen deposition
• Possibly decrease progression of curvature 1

This represents an off-label use with theoretical benefit based on the pathophysiology of aberrant wound healing in Peyronie's disease. 3, 5

Treatments to AVOID

Do NOT offer the following oral therapies, as they lack convincing evidence of efficacy:

• Vitamin E
• Tamoxifen
• Procarbazine
• Omega-3 fatty acids
• Combination vitamin E with L-carnitine 2

Using ineffective therapies poses moderate risk by postponing efficacious treatments, failing to alleviate distress, wasting time and money, and creating false expectations. 2

Do NOT offer electromotive therapy with verapamil, as evidence does not support its use. 2

Counseling and Expectation Management

Thorough counseling about disease natural history may be sufficient treatment for many patients with mild disease:

• Approximately 54% of men report relationship difficulties due to Peyronie's disease 1
• Depressive symptoms can persist, indicating significant psychological impact 1
• Many patients may choose not to pursue active treatment after understanding the condition 1

For mild curvature (<30 degrees) without significant functional impairment, watchful waiting is a reasonable approach. 6

Natural History to Discuss

Explain to the patient:

• Pain typically resolves over 12-18 months without intervention 3, 4
• Curvature and deformity are less likely to resolve spontaneously 6, 3
• Without active treatment, most men experience stable or worsening symptoms 3
• Only a minority report spontaneous resolution of curvature 3

When to Consider More Aggressive Treatment

Reserve more definitive interventions for when:

• Disease stabilizes (no changes for ≥3 months) 1
• Curvature progresses beyond 30 degrees
• Erectile dysfunction develops
• Curvature interferes with sexual function 1, 6

At that point, collagenase clostridium histolyticum is the only FDA-approved non-surgical therapy for moderate curvature (30-90 degrees) with intact erectile function. 1

Monitoring Strategy

Schedule follow-up at 3-6 month intervals to:

• Reassess pain levels
• Document any progression of curvature
• Evaluate erectile function
• Screen for psychological distress 1

Critical Pitfall to Avoid

Do not rush to invasive treatments during the active phase. Surgery is indicated only when disease is stable for at least 3 months and curvature compromises sexual function. 1 Premature surgical intervention during the active phase risks operating on an evolving deformity.