Treatment of Penile Disease

Introduction to Penile Disease

Penile disease, such as Peyronie's disease, requires careful evaluation and management, considering patient symptoms, disease stability, and treatment options, as recommended by the American Urological Association (AUA) and European Urology guidelines 1, 2
A patient's disease is considered stable when symptoms have been present for 12-18 months, making them eligible for definitive treatment, as indicated by the AUA guidelines 1

Surgery should only be considered after 3-6 months of disease stability, as recommended by the European Association of Urology 2
Combination of collagenase with PDE5 inhibitors may be superior to collagenase alone for patients with penile disease, according to the European Urology guidelines 2
Penile traction therapy as adjunct treatment can increase penile length (average 1cm) in patients with penile disease 2
Examination of genitalia should include checking for abnormalities in testicular size, fibrosis in shaft of penis, and retractable foreskin, as per the British Medical Journal guidelines 3
Ultrasound has limited utility in diagnosing penile retraction, as reported by The Journal of Urology 4

Tunical lengthening procedures are recommended for severe shortening, curvature >60°, or complex deformities without erectile dysfunction, as suggested by the European Urology guidelines 2
Penile prosthesis implantation should be reserved for patients with concurrent erectile dysfunction unresponsive to medical therapy, according to the European Urology guidelines 2
Plaque incision/excision with grafting is recommended for patients with adequate erectile function and severe curvature, but carries a higher risk of postoperative erectile dysfunction, as per the AUA guidelines 1
Penile prosthesis implantation with modeling is an effective option for addressing both erectile dysfunction and penile deformity, but may result in some shortening, as suggested by urology guidelines 1
Penile plication is suitable for patients without erectile dysfunction, resulting in some penile shortening while preserving erectile function, as per the AUA guidelines 1

The European Urology guidelines recommend NSAIDs for pain management, daily tadalafil 5mg to reduce curvature progression, and low-intensity extracorporeal shockwave therapy (LI-ESWT) for pain relief in patients with Peyronie's disease 2
The American Urological Association (AUA) recommends intralesional collagenase clostridium histolyticum (Xiaflex) as the first-line treatment for stable Peyronie's disease with significant curvature, followed by intralesional interferon α-2b as a second-line option, with average curvature reduction of 13.5° (vs. 4.5° with placebo) and plaque size reduction of 2.6 cm² (vs. 0.9 cm² with placebo) 1
Sildenafil or other PDE-5 inhibitors are appropriate first-line treatments for the erectile dysfunction component, with a starting dose of 50mg taken approximately 1 hour before sexual activity, no more than once daily, and adjusting dose based on response and tolerability (25-100mg range), as recommended by the AUA guidelines 1
Combination of collagenase Clostridium histolyticum (CCH) with PDE5 inhibitors may be superior to CCH alone for improving curvature and erectile function in patients with Peyronie's disease 2

Penile rehabilitation using vacuum erection devices (VEDs) and penile traction therapy should be implemented to prevent length loss after surgery, as recommended by the European Urology guidelines 2
Daily PDE5Is should be prescribed to enhance nocturnal erections and graft perfusion after surgery, according to the European Urology guidelines 2
Vacuum erection devices may help prevent penile length loss in patients with Peyronie's disease, as suggested by the Journal of Urology 5

Patients should be informed about the potential risk of erectile dysfunction (up to 50%) after lengthening procedures, as suggested by the European Urology guidelines 2
Patients with concurrent erectile dysfunction should be considered for PDE5 inhibitors or surgical options including penile prosthesis implantation, as suggested by the European Urology guidelines 2
Patients with compromised erectile function should be prioritized for maintaining erectile function, according to the AUA 5
Psychological counseling may help patients with Peyronie's disease adapt to their condition, as recommended by the Journal of Clinical Oncology 6
Penile retraction can cause significant psychological distress, and setting realistic expectations about treatment outcomes is important, as noted in the AUA guidelines 1

Important safety considerations for CCH treatment include a risk of corporal rupture (penile fracture) in 0.5% of patients and severe penile hematoma in 3.7% of patients, as noted in the treatment guidelines 1
Adverse events associated with treatments, such as penile ecchymosis, swelling, and pain with Xiaflex, flu-like symptoms with interferon α-2b, and penile bruising with verapamil, should be closely monitored, as per the AUA guidelines 1
Recurrent retraction, erectile dysfunction, penile shortening, infection, and preputial edema are potential complications of penile retraction, as reported in the AUA guidelines 1
Calcium channel antagonists like verapamil lack strong evidence for clinical use, showing no meaningful improvement versus placebo in patients with Peyronie's disease 2
Intralesional verapamil has a conditional recommendation with weak evidence, and adverse events include penile bruising, dizziness, nausea, and pain at injection site, as noted in the AUA guidelines 1

Patients with Peyronie's disease should be monitored for disease progression and reassessed after at least 3 months of stability before considering Xiaflex or other definitive treatments, as recommended by the AUA 5
Pain should be assessed using a visual analog scale and periodically reassessed, with NSAIDs recommended for pain control during treatment, as suggested by the AUA guidelines 1