Treatment Summary

Last updated 2015 - currently undergoing updates / revisions - released soon after release of Xiaflex (limited Xiaflex data available at that point) and prior to release of 2nd generation traction devices (e.g. RestoreX)

Notes - This guideline is published by the leading society for urologists and is performed in a rigorous manner.  

Diagnosis

1. Clinicians should engage in a diagnostic process to document the signs and symptoms that characterize Peyronie's disease. The minimum requirements for this examination are a careful history (to assess penile deformity, interference with intercourse, penile pain, and/or distress) and a physical exam of the genitalia (to assess for palpable abnormalities of the penis). (Clinical Principle)

2. Clinicians should perform an in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound prior to invasive intervention. (Expert Opinion)

3. Clinicians should evaluate and treat a man with Peyronie's disease only when he/she has the experience and diagnostic tools to appropriately evaluate, counsel, and treat the condition. (Expert Opinion)

Treatment

4. Clinicians should discuss with patients the available treatment options and the known benefits and risks/burdens associated with each treatment. (Clinical Principle)

5. Clinicians may offer oral non-steroidal anti-inflammatory medications to the patient suffering from active Peyronie's disease who is in need of pain management. (Expert Opinion)

6. Clinicians should not offer oral therapy with vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or a combination of vitamin E with L-carnitine. [Moderate Recommendation; Evidence Strength Grade B(vitamin E/omega-3 fatty acids/Vitamin E + propionyl-L-carnitine )/ C( tamoxifen/procarbazine)]

7. Clinicians should not offer electromotive therapy with verapamil. (Moderate Recommendation; Evidence Strength Grade C)

8. Clinicians may administer intralesional collagenase clostridium histolyticum in combination with modeling by the clinician and by the patient for the reduction of penile curvature in patients with stable Peyronie's disease, penile curvature >30° and <90°, and intact erectile function (with or without the use of medications). (Moderate Recommendation; Evidence Strength Grade B)

9. Clinicians should counsel patients with Peyronie's disease prior to beginning treatment with intralesional collagenase regarding potential occurrence of adverse events, including penile ecchymosis, swelling, pain, and corporal rupture. (Clinical Principle)

10. Clinicians may administer intralesional interferon α-2b in patients with Peyronie's disease. (Moderate Recommendation; Evidence Strength Grade C)

11. Clinicians should counsel patients with Peyronie's disease prior to beginning treatment with intralesional interferon a-2b about potential adverse events, including sinusitis, flu-like symptoms, and minor penile swelling. (Clinical Principle)

12. Clinicians may offer intralesional verapamil for the treatment of patients with Peyronie's disease. (Conditional Recommendation; Evidence Strength Grade C)

13. Clinicians should counsel patients with Peyronie's disease prior to beginning treatment with intralesional verapamil about potential adverse events, including penile bruising, dizziness, nausea, and pain at the injection site. (Clinical Principle)

14. Clinicians should not use extracorporeal shock wave therapy (ESWT) for the reduction of penile curvature or plaque size. (Moderate Recommendation; Evidence Strength Grade B)

15. Clinicians may offer extracorporeal shock wave therapy (ESWT) to improve penile pain. (Conditional Recommendation; Evidence Strength Grade B)

16. Clinicians should not use radiotherapy (RT) to treat Peyronie's disease. (Moderate Recommendation; Evidence Strength Grade C)

17. Clinicians should assess patients as candidates for surgical reconstruction based on the presence of stable disease. (Clinical Principle)

18. Clinicians may offer tunical plication surgery to patients whose rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy) to improve penile curvature. (Moderate Recommendation; Evidence Strength Grade C)

19. Clinicians may offer plaque incision or excision and/or grafting to patients with deformities whose rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy) to improve penile curvature. (Moderate Recommendation; Evidence Strength Grade C)

20. Clinicians may offer penile prosthesis surgery to patients with Peyronie's disease with erectile dysfunction (ED) and/or penile deformity sufficient to prevent coitus despite pharmacotherapy and/or vacuum device therapy. (Moderate Recommendation; Evidence Strength Grade C)

21. Clinicians may perform adjunctive intra-operative procedures, such as modeling, plication or incision/grafting, when significant penile deformity persists after insertion of the penile prosthesis. (Moderate Recommendation; Evidence Strength Grade C)

22. Clinicians should use inflatable penile prosthesis for patients undergoing penile prosthetic surgery for the treatment of Peyronie's disease. (Expert Opinion)

Reference: https://www.auanet.org/guidelines/peyronies-disease-guideline

Last updated 2010 - prior to release of many contemporary therapies (Xiaflex, 2nd generation traction [e.g. RestoreX])

Notes - Specific guideline statements were not issued for Peyronie's Disease.  Below are our summaries from the 2010 Journal of Sexual Medicine Publication titled, "Summary of the Recommendations on Sexual Dysfunctions in Men."  

Evaluation

1. A detailed history should be obtained focusing on onset, duration, pain, deformity, and presence of ED.
2. Plaque measurement is inaccurate by any modality and is operator dependent - it is not a reliable assessment for treatment response.
3. An assessment of curvature is best made by intracavernosal injection of a vasoactive agent.
4. Duplex ultrasound is a useful but unnecessary test.

Treatment - Nonsurgical

1. Men with early phase disease (<12 months) as well as those not psychologically ready for surgery are candidates for non-surgical therapy.
2. Nonsurgical treatment has limited evidence for benefit.
3. It is reasonable to consider electromotive drug administration, intralesional verapamil or interferon, and/or traction therapy.

Treatment - Surgical

1. Gold-standard method for correcting deformity.
2. Indicated for men with stable disease for >6 months, painless deformity, compromised ability to engage in coitus secondary to deformity, inadequate rigidity when there is extensive plaque calcification, and for those wanting the most rapid / reliable result.
3. Should discuss risks of recurrent curvature, loss of erect length, diminished rigidity, and decreased sexual sensation.
4. General agreement that for men with <60 degrees and adequate rigidity, tunical plication is preferred.  Those with more severe deformity (hourglass, >60 degrees) and good pre-operative rigidity, incision or partial excision and grafting is recommended.  Penile prosthesis is recommended when there is pre-op erectile dysfunction not responsive to PDE5 inhibitors (Viagra).  

Reference: Montorsi F, et al: 2010 J Sex Med

Last updated 2012 - prior to release of many contemporary therapies (Xiaflex, 2nd generation traction [e.g. RestoreX])

Notes - Specific guideline statements are included below

Congenital Penile Curvature

1. Use Nesbit and other plication techniques for the treatment of congenital penile curvature in patients who undergo surgery. Strong Recommendation.

Diagnosis of Peyronie's Disease

1. In the medical and sexual history of patients with Peyronie's disease, include duration of the disease, penile pain, change of penile deformity, difficulty in vaginal intromission due to deformity, and erectile dysfunction (ED).  Strong Recommendation
2. In the physical examination, include assessment of palpable plaques, penile length, extent of curvature (self-photograph, vacuum-assisted erection test or pharmacological-induced erection) and any other possibly related diseases (Dupuytren's contracture, Ledderhose disease).  Strong Recommendation
3. Do not use Peyronie's disease specific questionnaire in everyday clinical practice.  Weak Recommendation
4. Do not use ultrasound (US) measurement of plaque size in everyday clinical practice.  Weak Recommendation
5. Use Doppler US only in the case of diagnostic evaluation of ED, to ascertain vascular parameters associated with ED.  Weak Recommendation

Non-operative Treatment

1. Use conservative treatment in patients not fit for surgery or when surgery is not acceptable to the patient.  Weak Recommendation
2. Do not use extracorporeal shockwave treatment to improve penile curvature and reduce plaque size.  Weak Recommendation
3. Use penile traction devices and vacuum devices to reduce penile deformity and increase penile length.  Weak Recommendation
4. Do not use intralesional treatment with steroids to reduce penile curvature, plaque size or pain.  Weak Recommendation
5. Do not use oral treatment with vitamin E and tamoxifen for significant reduction in penile curvature or plaque size.  Strong Recommendation
6. Do not offer other oral treatments (acetyl esters of carnitine, pentoxifylline, colchicine) for the treatment of PD.  Weak Recommendation

Surgical Treatment

1. Perform surgery only when Peyronie's disease (PD) has been stable for at least three months (without pain or deformity deterioration), which is usually the case after twelve months from the onset of symptoms, and intercourse is compromised due to deformity.  Strong Recommendation
2. Prior to surgery, assess penile length, curvature severity, erectile function (including response to pharmacotherapy in case of erectile dysfunction (ED)) and patient expectations.  Strong Recommendation
3. Use tunical shortening procedures, especially plication techniques as the first treatment option for congenital penile curvature and for PD with adequate penile length, curvature < 60° and absence of special deformities (hour-glass, hinge).  Strong Recommendation
4. Use grafting techniques for patients with PD and normal erectile function, with no adequate penile length, curvature > 60º and presence of special deformities (hour-glass, hinge).  Strong Recommendation
5. Use penile prosthesis implantation, with or without any additional procedure (modelling, plication or grafting), in PD patients with ED not responding to pharmacotherapy.  Strong Recommendation

Reference: https://uroweb.org/guideline/male-sexual-dysfunction/#3