Peyronie Disease

Symptoms: pain, deformity, palpable plaque, and erectile dysfunction
ED vs PD: ask, "if your penis was straight with the same quality of rigidity you have now, do you think it would be adequate for penetrative sexual activity?"
Assess ED risk factors: DM, HTN, HLD, smoking
50% see worsening curvature 12-18 months after presentation, 13% or less see some improvement
1/3 PD patients have diabetes
ED treatments unlikely to cause Peyronie, but more likely to expose patients who would otherwise not notice
Associated with depression, anxiety, and other psychosocial issues
Some association with Dupuytren disease (hand/foot contractures)
Assess severity with the PDQ (PDF here)
Potential risk factors: prior trauma, sexual microtrauma, DM, low T, smoking, alcohol, ED

Ask to bring picture from home of erection from above and from the side
Examine penis on stretch and palpate for plaques
Stretched penile length: pubis to corona dorsally
Can use goniometer to accurately measure curvature severity
No benefit to US or lab evaluation
Intracavernosal injection in-office recommended prior to any invasive therapies
Differentiate from congenital penile curvature (CPC), which shows smooth curvature on exam without plaques

Peyronie treatment algorithm, from Campbell's

Peyronie consent tips, from Campbell's

Xiaflex (collagenase Clostridium histolyticum): proven to improve curvature, side effects include bruising (80%), swelling (55%), pain (45%), penile fracture (0.4%)
IMPRESS trial: 8 injections 0.58mg CCH with modeling, 34% average improvement
Intralesional verapamil: unclear dosing and frequency, some proven treatment benefit, side effects include bruising, dizziness, nausea, pain
Intralesional IFN-a: can offer (per guidelines), side ffects include sinusitis, flu symptoms, penile swelling
Oral agents, topical agents, XRT, and shock wave therapy have not been shown to provide a treatment benefit
Traction: small improvement in curvature and length, 85% satisfaction, need to wear for 3+hr daily
Acute setting: manage pain with NSAIDs

Indications: inability to have satisfactory intercourse, pain to self or partner, or distress due to appearance
Consent: discuss risk of shortening, decreased sensation, decreased rigidity, persistent curvature, appearance
Plication: not adequate for severe curvatures or hourglass deformities, can use Nesbit, Yachia, or dot techniques
Grafting: more likely to result in inadequate erections, better choice for severe curvature or hourglass deformity, can use autologous, xenografts, or synthetic grafts
IPP: place for PD + ED, perform modeling while placing device to avoid tunical tearing, biggest patient concern is postoperative loss of length, urethral injury occurs 2-3% during modeling
Complications: persistent pain, indentation, curvature, hematoma, infection, loss of length, palpable sutures
Postop care: avoid intercourse for 4-6 weeks, can perform massage/stretching (unclear benefits), consider traction if tolerable

AUA Core Curriculum
Nehra, Ajay, et al. "Peyronie’s disease: AUA guideline." The Journal of urology 194.3 (2015): 745-753.
Seftel, A. and H. Yang. "Diagnosis and Management of Peyronie's Disease." Campbell-Walsh Urology 12 (2020).

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