What is the next step in managing a 43-year-old male with a history of penile fracture, presenting with penile curvature, pain during intercourse, a palpable soft plaque, and 70-degree dorsal penile curvature, diagnosed with Peyronie's disease (PD)?

From the Guidelines

The next step in managing this 43-year-old male with Peyronie's disease following a penile fracture is intralesional collagenase injections (option D). This patient presents with significant dorsal penile curvature (70 degrees) and pain during intercourse, along with a palpable plaque, which are classic findings of Peyronie's disease. Collagenase clostridium histolyticum (CCH) injections are FDA-approved for treating Peyronie's disease with curvature greater than 30 degrees in the stable phase, as supported by the American Urological Association (AUA) guideline 1. The treatment works by enzymatically breaking down the collagen in the fibrous plaque. A typical regimen involves two injections given 1-3 days apart, repeated every 6 weeks for up to four treatment cycles, as outlined in the IMPRESS trials 1. Following injections, the patient should perform gentle penile modeling exercises.

This approach is preferred over observation because the significant curvature (70 degrees) is likely interfering with sexual function. While verapamil injections have been used off-label, collagenase has stronger evidence supporting its efficacy, with studies showing a modest but significant reduction in curvature compared to placebo 1. Extracorporeal shockwave therapy has limited evidence for Peyronie's disease, and stem cell therapy remains experimental. Surgical options would be considered if medical management fails. It is essential to counsel the patient on the potential occurrence of adverse events, including penile ecchymosis, swelling, pain, and corporal rupture, as noted in the IMPRESS trials 1.

Key points to consider in the management of this patient include:

• The patient's significant penile curvature and pain during intercourse, which are likely impacting his quality of life
• The FDA-approval of collagenase clostridium histolyticum for treating Peyronie's disease with curvature greater than 30 degrees in the stable phase
• The importance of gentle penile modeling exercises following injections to optimize treatment outcomes
• The potential risks and benefits of treatment, including the possibility of adverse events and the need for careful patient counseling 1.

From the Research

Treatment Options for Peyronie's Disease

The patient's condition, characterized by a 70-degree dorsal penile curvature and a palpable, soft plaque, suggests Peyronie's disease. The treatment options for this condition include:

• Intralesional collagenase injections: This treatment involves injecting collagenase into the plaque to break down the collagen and reduce the curvature. According to 2, intralesional collagenase injections are a safe and effective treatment for Peyronie's disease, with moderate to severe treatment-related adverse events occurring at a rate of 9%.
• Intralesional verapamil injections: Verapamil is a calcium antagonist that can alter fibroblast function and reduce plaque formation. As reported in 3, intralesional verapamil injections have been shown to reduce pain, decrease curvature, and improve sexual function in men with Peyronie's disease.
• Extracorporeal shockwave therapy: This treatment involves using shockwaves to break up the plaque and reduce the curvature. However, there is limited evidence to support its effectiveness for Peyronie's disease.
• Observation: In some cases, observation may be recommended to monitor the progression of the disease and determine the best course of treatment.
• Surgical options: Surgical procedures, such as plaque incision and vein grafting, may be considered for patients with severe curvature or those who have not responded to other treatments. As described in 4, plaque incision and placement of a deep dorsal vein patch graft, combined with contralateral corporeal plication, is a relatively simple and effective alternative to correct angulations greater than 60 degrees.

Next Steps

Based on the patient's condition and the available treatment options, the next steps could include:

• Intralesional collagenase injections: Given the patient's 70-degree dorsal penile curvature and palpable plaque, intralesional collagenase injections may be a suitable treatment option. As reported in 5, multiple courses of intralesional collagenase injections can be effective in reducing penile curvature and improving symptoms.
• Further evaluation: Additional evaluation, including ultrasound imaging, may be necessary to determine the extent of the plaque and the best course of treatment.
• Combination therapy: Combination therapy, including oral antioxidants, topical diclofenac gel, and periodic perilesional penile injections with pentoxifylline, may be considered, as reported in 6.