Treatment of Peyronie’s disease does differ if we consider the acute active stage (when the penile curvature is still potentially progressive) or the late stage (the disease is no longer progressive). We offer non-surgical treatments for patients in the acute active stage while we indicate surgery as a treatment of significant stable penile curvature impacting the sexual life.
1. Non-surgical treatments
We do conservative treatment for patients in the early stage of the disease. Several options have been studied, including oral pharmacotherapy, intralesional injection therapy and other topical treatments. Physical treatment based on Shock waves or iontophoresis. are also possible. While the clostridial collagenase is the only drug approved for Peyronie’s disease by the American FDA (Federal Drug Administration), the European Medicines Agency (EMA) still has not approved any treatment. The research results on conservative treatment for Peyronie’s disease are often contradictory, making it difficult to provide good recommendations. The low quality of the studies is related to uncontrolled studies, the limited number of patients treated, the short-term follow-up and different outcome measures.
1.1 Oral treatments
1.1.1 Vitamin E and Colchicine
Vitamin E is commonly prescribed at once or twice daily doses of 400 IU because of its wide availability, low cost and safety. However, the research evidence does not allow to make recommendations. The combination treatment with vitamin E and colchicine (600 mg/day and 1 mg every 12 hours, respectively) in the early stage of disease for six months in patients with early-stage Peyronie’s disease seems to improve the plaque size and curvature. However, the pain relief is less evident.
1.1.2 Potassium Para-aminobenzoate (POTABA)
Potassium para-aminobenzoate is not superior to other oral medications in treating penile pain, plaque size and curvature. It seems it can have a protective effect on the deterioration of penile curvature.
The results are very conflicting, and we cannot make any recommendations.
1.1.4 Acetyl esters of carnitine
The combination of propionyl-l-carnitine with intralesional verapamil might reduce penile curvature, plaque size, and disease progression.
Pentoxifylline seems to stabilize or reduce calcium content in penile plaques.
1.1.6 Phosphodiesterase type 5 inhibitors (Cialis 2.5 mg)
We cannot give well-supported recommendations on the use of PDE5I in patients with Peyronie’s disease.
1.2 Intralesional treatment
Injection of active agents directly into penile plaque delivers higher local concentrations and possible better action against the progression of fibrous tissue. However, dense or calcified plaque might be hard to infiltrate.
We think intralesional steroids can control the inflammation responsible for Peyronie’s plaque progression. However, adverse effects include tissue atrophy, thinning of the skin and immunosuppression. We cannot conclude with a well-supported recommendation.
The intralesional (plaque) verapamil injections might benefit from treating non-calcified acute phase or chronic plaques and stabilize disease progression or possibly reduce the penile deformity. Side-effects are not common (4%). Minor possible side-effects include nausea, light-headedness, penile pain, and ecchymosis.
1.2.3 Clostridium Collagenase (Xiaflex)
The American Food and Drug Administration (FDA) now approved the use of Clostridium collagenase for cases with a palpable fibrous plaque and penile curvature of at least 30°. The most reported side effects are penile pain, penile swelling, and ecchymosis at the injection site. Because of the risks of severe general and penile adverse reactions, Xiaflex should be administered by a healthcare professional only in certified facilities.
Intralesional Interferon injections of Interferon α 2b (two times per week for 12 weeks) seem to improve penile curvature, plaque size and density, and pain. Possible side-effects are general symptoms like myalgias, arthralgia, fever and flu-like symptoms.
1.3 Physical treatments
1.3.1 Topical Verapamil
There is no evidence that topical treatments on the penile shaft allow adequate levels of the active compound within the tunica albuginea. Iontophoresis, known as transdermal electromotive drug administration (EMDA), may overcome the limitations on the local uptake of the drugs. However, we cannot conclude with well-supported recommendations.
1.3.2 Extracorporeal Shock Wave Treatment (ESWT)
It is a treatment using focused shock waves in the plaque in more sessions. The few studies so far have only shown significant improvement only for penile pain. We have not strong support for the effects on the plaque and the penile deformation. .
1.3.3. Traction devices
The FastSize Penile Extender has been studied and applied as the only treatment for 2-8 hours/ day for six months . It seems effective in reducing the penile curvature and allow the patient to avoid the surgery. .
1.3.4 Vacuum Devices
The application of vacuum devices follows the same principles as traction devices, with the drawback of being non-continuous.
2. Surgical Treatments
We do surgery in those patients who have their sexual life affected because of difficult or impossible penetration related to the penile curvature. The penile curvature results from the disease’s early acute stage, which usually lasts 12 to 18 months. We define the chronic, late stage of the illness when the curvature is stable. In fact, at this stage, we do not expect any further changes. Procedures range from the simple straightening penile-plastic (Nesbit Procedure) to plaque excision and substitution procedures. Choosing the most appropriate surgical intervention is based on:
- penile length assessment
- curvature severity
- erectile function status
- patient expectations
According to the postoperative penile length, we distinguish shortening and lengthening procedures. A penile prosthesis is another surgical option.
2.1 Penile Shortening Procedures
Penile shortening procedures are the Nesbit wedge resection and the plication techniques performed on the convex side of the penis. The short and long-term results of the Nesbit procedure are excellent. We achieve complete penile straightening in more than 80% of patients.
A good candidate for this surgery:
- patient with significant curvature affecting the ability to penetrate
- curvature, not more than 30 degrees
- patients who accept 1-1.5 cm penile shortening
Complications are uncommon (about 10%):
- Recurrence of the curvature
- penile hypoesthesia
- the risk of postoperative ED is minimal
2.2 Penile Lengthening Procedures
With tunic lengthening procedures, we make an incision in the tunica’s short (concave) side to increase the length of this side, creating a tunic defect that we cover with a graft (derma, vein, and buccal mucosa graft).
- Curvature more than 30 degrees
- Patients not accepting excessive penile shortening
- Patient assessed and normal erectile function
- Recurrence of the curvature
- Erectile dysfunction
2.3 Penile Prosthesis
A penile implant is a surgically intrapenile placed device to produce a natural-looking and natural-feeling erection. In cases of severe deformity, the surgeon can do intra-operative ‘modelling’ of the penis over the inflated cylinders.
- Severe penile curvature
- Other penile deformities related to the plaque
- Erectile dysfunction
- Urethral perforation
- Prosthesis extrusion