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Nonsurgical options

Xiaflex

• Xiaflex (collagenase Clostridium histolyticum): proven to improve curvature, side effects include bruising (80%), swelling (55%), pain (45%), hematoma (3.7%), penile fracture (0.4-1.5%)
• Xiaflex technique: inject two dose (1-3d apart), then in-office modeling (grasp 1cm proximal and distal, bend opposite curvature x30s x3), perform up to 4 cycles, 6wk between cycles, stop once curvature < 15deg
• IMPRESS trial: 8 injections 0.58mg CCH with modeling, 34% average improvement
• Collagenase penile fractures: manage conservatively, likely to heal, hard to repair surgically due to poor tissue quality

Other options

• 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
• Other options:ral 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

Surgical options

General info

• Indications: inability to have satisfactory intercourse, pain to self or partner, or distress due to appearance
• Timing: wait until at least 3-6mo after initial symptoms and pain has resolved
• Consent: penile shortening, decreased sensation, decreased rigidity, persistent curvature, appearance
• Postop care: avoid intercourse for 4-6 weeks, can perform massage/stretching (unclear benefits), consider traction if tolerable

Procedures involving potential shortening

Indications: < 60deg and adequate erection/length, not adequate for severe curvatures or hourglass deformities

Success: fixes curvature in > 80%, > 70% satisfaction

Nesbit: elliptical portion of tunica excised opposite plaque and closed transversely

Yachia corporoplasty: longitudinal incision opposite plaque, closed transversely

Dot plication: imbrication of tunica opposite plaque, no tunical incisions

Grafting

• Indications: better choice for severe curvature or hourglass deformity but more likely to result in inadequate erections
• Options: excision has higher rate of postop ED, incision is preferred
• Graft choices: can use autologous (penile vein, saphenous vein, fascia lata, rectus fascia), allografts (human pericardium), xenografts (bovine pericardium), or synthetic (gortex, dacron)
• Success: fixes curvature in > 80%, > 70% satisfaction

Simultaneous treatment of Peyronie and erectile dysfunction

• Indications: if ED in presence of PD, treat ED w/ IPP and intraop grafting/plication
• Maximal modeling: maximally inflate cylinders, bend penis in direction opposite plaque x90s, can inflate more, may feel plaque "crack"
• Side effects: biggest patient concern is postoperative loss of length, urethral injury occurs 2-3% during modeling