There is no uniformly agreed upon treatment algorithm for males in the acute phase of Peyronie's disease. Similarly, there is a lack of strong evidence supporting oral medication in the treatment of Peyronie's disease. Experts in sexual medicine often prescribe oral medications during the acute phase of Peyronie's disease in hopes of mitigating worsening penile scarring. This practice is often specialist dependent. Penile traction is occasionally used in the acute and chronic phase. The belief is that stretching of the penis facilitates improvement of the penile curvature and decreases penile length loss. Only a few studies have demonstrated this to be true.
Intralesional (into the plaque) injection of medication is another treatment option for males with Peyronie's disease. Currently, collagenase Clostridium histolyticum (Xiaflex®) is the only FDA approved pharmacologic treatment of Peyronie's disease. It is administered as an intralesional injection in a series of 1-4 cycles every 6 weeks. This has been shown to result in a 32-34% decrease in penile curvature. Adverse events are common and include penile pain, bruising, and swelling. There is also a risk of of penile fracture, although this is less than 1%. Other intralesional medications are also used in the acute and chronic phase of Peyronie's disease. These medications include verapamil and interferon.
Patients who fail to respond to drug therapy for Peyronie's disease and who have curvature for longer than 12 months are considered candidates for surgical intervention. Which corrective operation is chosen is based on a number of criteria which include: (i) preoperative erectile function; (ii) preoperative penile length; (iii) the magnitude and complexity of the curvature; and (iv) patient and partner expectations and goals. There are 3 major types of operations for Peyronie's disease.
Penile Plication Procedures
This group of procedures generally involves performing a tuck procedure on the side opposite to the scar (plaque). Its advantages include its simplicity, excellent preservation of preoperative erection ability, and high patient satisfaction. The disadvantages include loss of penile length, which in the medical literature is reported to occur in 46-100% of patients. Patients who are considered excellent candidates for this procedure include those with ample penile length who have a simple curvature without any other associated deformity (i.e. hour-glass).
Plaque Incision/Excision and Grafting
This group of procedures involves the complete or partial excision of the plaque, or its incision with the placement of a graft into the space left by the excision/incision technique. Multiple graft materials have been used, including dermis, cadaveric fascia, cadaveric pericardium, saphenous vein, and intestinal submucosa. The advantage of this approach is that it is typically not associated with loss of penile length. Its disadvantages include the development of postoperative erectile dysfunction in men with poor erectile function preoperatively, and prolonged loss of penile sensation in approximately 10% of men. Ideal candidates for this approach are men with complex penile curvatures who have normal erectile function preoperatively. Men who present with hour-glass deformity are also best served by plaque incision and grafting.
Penile Prosethesis Surgery
The placement of a penile implant allows immediate correction of the penile curvature as well as permitting fully rigid erections. It is associated with excellent postoperative patient satisfaction rates. It is reserved for men with combined erectile dysfunction and penile curvature.
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