Guideline sources The following summarized guidelines for the evaluation and management of Peyronie's disease are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023), the European Society for Sexual Medicine (ESSM 2022), and the American Urological Association (AUA 2015). 1 2 3 Guidelines 1. Diagnostic investigations History and physical examination: As per EAU 2023 guidelines, elicit a medical and sexual history in patients with Peyronie's disease, including duration of the disease, pain on erection, penile deformity, difficulty in vaginal/anal intromission due to disabling deformity, and erectile dysfunction. A Show 2 more As per AUA 2015 guidelines, elicit a careful history to assess penile deformity, interference with intercourse, penile pain, and/or distress, and perform a physical examination of the genitalia to assess for palpable abnormalities of the penis, to document the signs and symptoms that characterize Peyronie's disease. B Diagnostic imaging: https://web.pathway.md/diseases/recVbYF1qm6x53nTS 1/6 6/29/23, 11:08 PM Peyronie's disease Pathway Diagnostic imaging: Do not obtain ultrasound, CT, or MRI to assess plaque size and deformity in everyday clinical practice. D Obtain penile Doppler ultrasound in the diagnostic evaluation of erectile dysfunction, to evaluate penile hemodynamic and vascular anatomy, and to assess the location and calcification of plaques, especially before surgery. B 2. Diagnostic procedures Intracavernous injection test: As per EAU 2023 guidelines, perform intracavernous injection testing in the diagnostic evaluation of Peyronie's disease to provide an objective assessment of penile curvature with an erection. B As per AUA 2015 guidelines, perform an in-office intracavernosal injection test, with or without Doppler ultrasound, before an invasive intervention. E 3. Medical management Management of pain: As per EAU 2023 guidelines, consider offering NSAIDs B and extracorporeal shockwave therapy for the treatment of penile pain in the acute phase of Peyronie's disease. C As per AUA 2015 guidelines, consider prescribing oral NSAIDs in patients with active Peyronie's disease requiring pain management. E Management of erectile dysfunction: consider offering PDE5 inhibitors to treat concomitant erectile dysfunction or to optimize penetration when the deformity results in difficulty in penetrative intercourse. C Agents with no evidence for benefit: As per EAU 2023 guidelines, do not use oral therapy with vitamin E, potassium para- aminobenzoate, tamoxifen, pentoxifylline, colchicine, and acetyl esters of carnitine for the treatment of Peyronie's disease. D As per AUA 2015 guidelines, do not offer the following oral medications in patients with Peyronie's disease: vitamin E D tamoxifen D procarbazine D omega-3 fatty acids D combination of vitamin E with L-carnitine. D 4. Therapeutic procedures Indications for conservative treatment: offer conservative treatment in patients not fit for surgery or when surgery is not acceptable to the patient. A https://web.pathway.md/diseases/recVbYF1qm6x53nTS 2/6 6/29/23, 11:08 PM Peyronie's disease Pathway Intralesional injections, collagenase clostridium histolyticum: As per EAU 2023 guidelines, consider administering intralesional collagenase injections in patients with stable Peyronie's disease with dorsal or lateral curvature > 30 degrees requesting nonoperative management. B As per AUA 2015 guidelines: Consider performing intralesional collagenase clostridium histolyticum injections in combination with modelling by the clinician and by the patient for the reduction of penile curvature in patients meeting the following criteria: stable Peyronie's disease penile curvature > 30 degrees and < 90 degrees intact erectile function (with or without the use of medications). C Counsel patients with Peyronie's disease before beginning treatment with intralesional collagenase about potential occurrence of adverse events, including penile ecchymosis, swelling, pain, and corporal rupture. B Intralesional injections, interferon alpha-2b: As per EAU 2023 guidelines, consider administering intralesional interferon alpha-2b injections in patients with stable Peyronie's disease with dorsal or lateral curvature > 30 degrees requesting a minimally invasive procedure. B As per AUA 2015 guidelines: Consider performing intralesional interferon alpha-2b injections in patients with Peyronie's disease. C Counsel patients with Peyronie's disease before beginning treatment with intralesional interferon alpha-2b about potential adverse events, including sinusitis, flu-like symptoms, and minor penile swelling. B Intralesional injections (verapamil): Consider performing intralesional verapamil injections in patients with Peyronie's disease. C Counsel patients with Peyronie's disease before beginning treatment with intralesional verapamil about potential adverse events, including penile bruising, dizziness, nausea, and pain at the injection site. B Intralesional injections (corticosteroids): do not use intralesional corticosteroids in patients with Peyronie's disease as it is not associated with a significant reduction in penile curvature, plaque size, or penile pain. D Intralesional injections (platelet-rich plasma and hyaluronic acid): do not use intralesional platelet-rich plasma or hyaluronic acid, either alone or in combination with oral treatment, to reduce penile curvature, plaque size, or pain outside of a clinical trial. D Electromotive drug administration: do not offer electromotive therapy with verapamil in patients with Peyronie's disease. D Penile traction and vacuum devices: consider offering penile traction and vacuum devices to reduce penile deformity or as part of a multimodal therapy approach in patients with Peyronie's disease. C Extracorporeal shock wave therapy: As per EAU 2023 guidelines: https://web.pathway.md/diseases/recVbYF1qm6x53nTS 3/6 6/29/23, 11:08 PM Peyronie's disease Pathway Do not offer extracorporeal shock wave therapy to improve penile curvature and reduce plaque size in patients with Peyronie's disease. D Consider offering extracorporeal shockwave therapy for the treatment of penile pain in the acute phase of Peyronie's disease. C As per AUA 2015 guidelines: Do not perform extracorporeal shock wave therapy for the sole purpose of reducing penile curvature or plaque size in patients with Peyronie's disease. D Consider performing extracorporeal shock wave therapy for the improvement of penile pain in patients with Peyronie's disease. C Radiotherapy: do not perform radiotherapy for the treatment of patients with Peyronie's disease. D 5. Surgical interventions Surgical reconstruction: As per EAU 2023 guidelines, perform surgery only when Peyronie's disease has been stable for at least 3 months (without pain or deformity deterioration), usually after 12 months from the onset of symptoms, and intercourse is compromised due to deformity. A Show 5 more As per ESSM 2022 guidelines, perform surgical treatment in patients with Peyronie's disease only when the curvature and/or penile deformity and/or inadequate quality of erections do not allow satisfactory sexual intercourse, or when the deformity causes severe bother. B Show 5 more As per AUA 2015 guidelines, ensure disease stability before consider patients with Peyronie's disease as candidates for surgical reconstruction. B Show 2 more Penile prosthesis: As per EAU 2023 guidelines, perform penile prosthesis implantation, with or without any additional procedure (modeling, plication, incision, or excision with or without grafting), in patients with Peyronie's disease and erectile dysfunction not responding to pharmacotherapy. A As per ESSM 2022 guidelines, reserve penile prosthesis implantation for patients with Peyronie's disease with refractory erectile dysfunction or distal flaccidity not responding to pharmacologic treatment or in patients with complex deformities otherwise requiring plaque incision and grafting or partial plaque excision and grafting procedures. B Show 2 more As per AUA 2015 guidelines, consider performing penile prosthesis implantation in patients with Peyronie's disease with erectile dysfunction and/or penile deformity sufficient to prevent coitus despite pharmacotherapy and/or vacuum device therapy. C Show 2 more 6. Patient education https://web.pathway.md/diseases/recVbYF1qm6x53nTS 4/6 6/29/23, 11:08 PM Peyronie's disease Pathway General counseling: As per EAU 2023 guidelines, discuss with patients all the available treatment options and expected results before starting any treatment. A As per ESSM 2022 guidelines: Counsel patients before surgery discussing benefits as well as side effects and complications of each surgical treatment in detail with the patient to set realistic expectations towards surgical outcomes. B Address psychological, emotional and relationship issues attributable to Peyronie's disease. B As per AUA 2015 guidelines: Discuss the available treatment options and the known benefits and risks/burdens associated with each treatment with patients with Peyronie's disease. B Counsel patients with Peyronie's disease before beginning treatment with intralesional injections about potential adverse effects: Situation Guidance Penile ecchymosis, swelling, pain, and corporal rupture Intralesional collagenase Sinusitis, flu-like symptoms, and minor penile swelling Intralesional interferon alpha-2b Penile bruising, dizziness, nausea, and pain at the injection site. B Intralesional verapamil 7. Follow-up and surveillance Revision surgery: recognize that none of the straightening procedures currently available has proven superior with regards to preventing curvature recurrence. B Show 6 more Clinical findings Symptoms Past medical history Erectile dysfunction Diabetes mellitus Penile deformity Dupuytren's contracture Penile pain Ledderhose disease Past events Genitourinary exam Penile trauma Penile curvature Penile nodule Penile plaque penile length https://web.pathway.md/diseases/recVbYF1qm6x53nTS 5/6 6/29/23, 11:08 PM Peyronie's disease Pathway References 1. A. Salonia, C. Bettocchi, J. Carvalho et al. EAU Guidelines on Sexual and Reproductive Health. EAU. 2023. Open 2. Ajay Nehra, Ralph Alterowitz, Daniel J Culkin et al. Peyronie's Disease: AUA Guideline. J Urol. 2015 Sep;194 3 745 53. Open 3. Daniar Osmonov, Ahmed Ragheb, Sam Ward et al. ESSM Position Statement on Surgical Treatment of Peyronie's Disease. Sex Med. 2022 Feb 1;10 1 100459. Open https://web.pathway.md/diseases/recVbYF1qm6x53nTS 6/6