Peyronie's Disease Management

Initial Assessment and Disease Classification

The American Urological Association recommends determining whether the disease is in the active or stable phase, as this completely dictates treatment strategy 1
Active phase characteristics include penile pain with or without erection, dynamic and changing symptoms, and incompletely developed plaques and deformities 1
The active phase typically lasts 3-12 months from symptom onset 2
Stable phase characteristics include symptoms unchanged for at least 3 months, minimal or absent pain, established curvature, and palpable or ultrasonographically visible plaques 1
Disease typically stabilizes at 12-18 months after symptom onset 3, 4

The American Urological Association recommends oral NSAIDs as 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 to measure treatment efficacy 2
Consider daily tadalafil 5mg to reduce collagen deposition and decrease curvature progression 1, 2
Avoid ineffective therapies, such as radiotherapy, which provides no benefit over natural disease progression and exposes patients to unnecessary radiation risks 3
Extracorporeal shockwave therapy (ESWT) has low overall utility, as penile pain commonly resolves over time regardless of intervention 3

For mild curvature, observation is appropriate, as many patients function adequately with mild deformity 2
For moderate curvature, intralesional collagenase clostridium histolyticum (Xiaflex) is the only FDA-approved non-surgical therapy for stable Peyronie's disease 1, 2
Collagenase requires palpable plaque on physical examination and stable disease without active progression 2
The treatment protocol involves up to 8 injections of 10,000 U (0.58 mg) over 24 weeks, combined with clinician and patient modeling exercises 2, 5
Average curvature reduction is 17° versus 9.3° with placebo 2, 5
Collagenase treats curvature only and does not treat pain or erectile dysfunction 2

Surgery should only be considered when disease has been stable for at least 3 months and curvature compromises sexual function 3, 4, 1
Surgical candidates must have PD symptoms for at least 12 months and stable curvature for 3-6 months 3
Tunical plication surgery is the most common surgical approach, representing ~50% of PD surgeries, and curvature improvement occurs in ≥90% of cases 3, 4
Plaque incision or excision with grafting is also an option, with curvature improvement ranging from 25-100% 3, 4
Penile prosthesis surgery is an option for patients with ED and/or penile deformity preventing coitus despite pharmacotherapy/vacuum therapy, with curvature improvement >80% in all reviewed studies 3, 4

Peyronie's disease significantly impacts quality of life, with 54% of men reporting relationship difficulties 1
Depressive symptoms remain consistently high over time, suggesting durable psychological impact 1
Comprehensive counseling about disease nature and expected course is essential for all patients 1

Do NOT offer radiotherapy, as it provides no benefit over natural disease progression 3
Do NOT use collagenase for pain management, as it is specifically a curvature therapy, not a pain treatment 2
Do NOT perform surgery during active disease phase, as surgical outcomes for patients with active disease are unknown 3, 4
Do NOT use semi-rigid prostheses, as inflatable devices allow necessary modeling for optimal outcomes 4

Collagenase clostridium histolyticum is the only FDA‑approved medical therapy for Peyronie's disease, indicated for men with stable disease, curvature 30–90°, and preserved erectile function (with or without pharmacologic aid). 6
In the IMPRESS I and II randomized controlled trials (832 participants), collagenase achieved a mean curvature reduction of 17° versus 9.3° with placebo—a 34% improvement that was statistically significant (p < 0.0001). 6

The approved regimen permits up to four treatment cycles (maximum eight injections of 10,000 U each) administered over approximately 24 weeks, with a median 7.5‑month safety follow‑up. 6
Mandatory modeling must be performed by the clinician after each cycle and by the patient three times daily between cycles (plus once daily during spontaneous erections). 6
Treatment initiation requires a palpable plaque on physical examination and documented disease stability (no progression for ≥3 months). 6

Eligible candidates are men with stable disease (symptoms unchanged ≥3 months, minimal pain) and curvature measured between 30° and 90°. 6
Intact erectile function is required; the therapy does not address erectile dysfunction. 6

The American Urological Association (AUA) guideline states that oral agents (vitamin E, omega‑3 fatty acids, tamoxifen, pentoxifylline, potassium aminobenzoate) lack convincing evidence of efficacy for Peyronie's disease. 6
Intralesional interferon α‑2b shows a modest curvature reduction (13.5° vs 4.5° placebo) and receives a conditional recommendation with Grade C evidence. 6
Intralesional verapamil administered via electromotive therapy provides no statistically significant benefit over placebo and is not recommended. 6

Adverse events occurred in 84.2% of collagenase‑treated patients versus 36.3% of placebo recipients; most were mild to moderate (e.g., penile ecchymosis, swelling, pain). 6
Serious adverse events such as corporal rupture or penile hematoma were reported in <1% of patients and typically required surgical repair. 6

The average benefit of collagenase is modest: a mean curvature improvement of 17° versus 9.3° with placebo, yielding a net difference of 7.7°. 6