Skip to main content

Peyronie's Disease

Peyronie's disease (PD) is an acquired fibrotic disorder of the tunica albuginea that produces palpable plaque, penile curvature, painful erections, erectile dysfunction, shortening, and substantial psychological morbidity. Prevalence is 1–20% of adult men with mean onset ~53 years; the natural history of untreated curvature is unfavorable — only 3–12% improve spontaneously.[1][2][3][4] The single FDA-approved non-surgical treatment is intralesional collagenase clostridium histolyticum (CCH, Xiaflex); surgery remains the gold standard for stable disease with functionally significant deformity.[5][6][7]

The AUA defines PD as "an acquired penile abnormality characterized by fibrosis of the tunica albuginea, which may be accompanied by pain, deformity, erectile dysfunction, and/or distress." It belongs to a broader family of superficial fibrosing disorders with Dupuytren's contracture, Ledderhose disease, and tympanosclerosis.[6][8][9]

This page covers the disease and its medical management. For the operative atlas, see the Peyronie's Disease Surgery section — Tunica Plication, Plaque Incision/Excision and Grafting, and Prosthesis with Straightening.

Epidemiology​

  • Prevalence 1–20% (likely under-reported)[1]
  • Mean age at onset ~53 years (range 18–79)[1][3]
  • Diabetic men — prevalence up to 20.3%[10]
  • White men over-represented (OR 8.47 in case-control)[11]
  • Strong association with Dupuytren's contracture[11][12]

Pathophysiology​

PD is a penile wound-healing disorder in genetically predisposed men.[2][6][8][13]

  1. Inciting event — microvascular trauma to the tunica from penile buckling during intercourse (often unrecalled)
  2. Inflammatory phase — extravascular protein deposition, fibrin trapping, macrophage recruitment, cytokine overexpression (TGF-β, IL-1, IL-6, PDGF, FGF), elastase release
  3. Fibroproliferative phase — MMP/TIMP imbalance (decreased MMPs, increased TIMPs), excessive collagen deposition, shift from type I to predominantly type III collagen
  4. Plaque maturation — progressive fibrosis, calcification in some, stable scar

TGF-β is the central profibrotic mediator; PAI-1, PTX-3, HIF, and IgG4 also contribute. Oxidative stress links PD to systemic metabolic disease.[13][14]

Risk Factors​

FactorAssociation
Penile trauma / bucklingMost common inciting event[1][2]
Dupuytren's contractureShared fibrotic diathesis[11][12]
Diabetes mellitusUp to 20.3% in T2DM; early-onset and uncontrolled DM correlate with severity[10]
Hypertension, hyperlipidemia, smokingCommon comorbidities; mostly tied to concurrent ED rather than PD severity[15]
NAFLD / insulin resistanceIndependent predictor of PD[14]
Prior urologic instrumentationTURP, cystoscopy[2]
Thiazide diureticsOR 2.29 in case-control[12]
White raceOR 8.47[12]

Notably, comorbidity burden does not correlate with curvature severity — these comorbidities track with concurrent ED rather than PD pathogenesis itself.[15]

Disease Phases​

PhaseDurationFeaturesImplications
Acute (active)Typically 12–18 months from onsetPainful erections (~42%), evolving deformity, plaque maturationPain resolves spontaneously in 64–89%; non-surgical interventions favored[1][6][16]
Chronic (stable)After active phaseFibrosis stabilizes, pain typically gone, fixed deformitySurgery appropriate after ≥ 3 mo (AUA) or 3–6 mo (EAU) stability[6][51]

Natural History​

OutcomeRate
Curvature worsened30–48%[3][4]
Curvature stable37–67%[3][4]
Curvature spontaneously improved3–12%[3][4]
Pain resolution64–89%[4][16]
Penile shortening65–89%[16]
Erectile function worsened54–60%[3][4]
Negative psychological impact~50%[4][17]

A median 8.4-year follow-up of conservatively managed patients showed that, although 43% reported curvature resolution, the majority lost length and experienced worsening sexual function and psychosocial distress.[16]

Clinical Presentation​

  • Penile curvature — dorsal (45–72%), lateral (11–29%), ventral (~17%)[3][4]
  • Palpable plaque
  • Painful erection — acute phase
  • ED in 32–54% at diagnosis; probability rises with age > 60, duration > 12 mo, and ≥ 1 vascular risk factor (86.7%)[3]
  • Penile shortening — 65–89%[16]
  • Hourglass deformity / hinge effect — buckling instability that defeats penetration
  • Substantial psychological distress — 81% emotionally distressed; ~50% depression; 54% relationship difficulties[1][6][18]

Psychological burden​

A Swedish 3.5-million-man cohort:[18]

OutcomeHR (vs general population)
Depression1.7
Anxiety disorder1.9
Self-injurious behavior2.0

5-year cumulative depression risk 7.0% vs 4.4%; 10-year 12.5% vs 8.7%.[18][20] An online-forum thematic analysis reported depressed mood in 33% and feelings of isolation in 18%, with substantial partner impact (sexual dissatisfaction 21%, dyspareunia 7.7%, relationship disruption 8.7%).[19] The AUA recommends explicitly discussing the psychological impact and offering referral for psychological support — see the canonical Psychosexual Therapy page for the sensate-focus / CBT / MBI / couples-therapy framework.[6]

Diagnostic Evaluation​

All four major guidelines (AUA, EAU, CUA, ISSM) converge on the workup.[6][7][21]

StepRole
History (with genital examination)Onset, duration, deformity, pain, shortening, erectile function, prior treatment, sexual / psychological impact
Photographs of erect penis (patient-provided)Document deformity for objective comparison[22]
Physical examStretching and palpation of flaccid penis — plaque size, location, calcification
Intracavernosal injection (ICI) testAUA recommends before invasive intervention (with or without duplex); documents curvature, hinge effect and erectile response[6][7]
Penile duplex Doppler ultrasound (optional)Calcified vs non-calcified plaque; vascular integrity (PSV, EDV); identifies vasculogenic ED that changes the operation[6][22][23][24]
PDQ and IIEF questionnairesSymptom bother and erectile function domains

Management​

Treatment is dictated by disease phase, deformity, erectile function, and patient goals. A 2026 Guideline of Guidelines comparison found broad consensus across AUA, EAU, CUA, and ISSM.[7][21]

Important caveat on non-surgical evidence​

The 2023 Cochrane systematic review found substantial uncertainty for many non-surgical therapies; treatment-specific estimates and patient-important outcomes require careful interpretation.[1]

A. Oral therapies​

The AUA position:[6]

  • Should not offer vitamin E or tamoxifen
  • Evidence for pentoxifylline, potassium para-aminobenzoate (Potaba), and colchicine is insufficient even for a conditional AUA recommendation
AgentMechanismEvidenceAUA
Vitamin EAntioxidantNo benefit over placebo[25]Should not offer
TamoxifenAnti-fibroticNo benefit over placebo[25]Should not offer
PentoxifyllinePDE inhibitor / anti-inflammatoryInsufficient evidence[6]No recommendation
PotabaAnti-fibroticUncertain benefit[1][6]No recommendation
ColchicineAnti-inflammatoryInsufficient evidence[6]No recommendation

B. Intralesional injection therapies​

Collagenase clostridium histolyticum (CCH, Xiaflex) — only FDA-approved option[5][6][26][27][28]​

  • US label: Adult men with palpable plaque and curvature ≥ 30° at treatment initiation; plaque involving the urethra is contraindicated. AUA selection is narrower: stable disease, curvature >30° and <90°, and intact erectile function with or without medication.[5][6]
  • Protocol (IMPRESS): Up to 4 cycles (8 injections total); each cycle = 2 injections of 0.58 mg separated by 24–72 h, with clinician modeling after each cycle and patient home modeling between cycles
  • IMPRESS I & II (n = 832): Mean curvature improvement 17° (34%) vs 9.3° (18.2%) placebo — net benefit ~7.7°; PDQ bother score significantly improved[26]
  • Real-world multi-institutional (n = 918): Mean curvature 48.2° → 32.9° (30.1% improvement); 68.7% achieved ≥ 20% improvement; completing ≥ 4 cycles predicted better outcomes[27]
  • Meta-analysis (n = 1,480): 35% pooled curvature improvement; 41% bother improvement[28]
  • AEs: Bruising, swelling and pain are common; corporal rupture and severe hematoma are important risks. Follow REMS requirements and label counseling, including no sexual activity between injections or for at least 4 weeks after the second injection and until pain/swelling resolve.[5][27][28][29]
  • No significant penile shortening[29][30]
  • Available in the US; withdrawn from Europe[25]

Other intralesional agents​

  • Interferon-α2b — historical curvature/pain benefit, but EAU 2026 no longer recommends it given limited evidence and withdrawal from US/European markets.[31][51]
  • Verapamil — intralesional evidence is weak and inconsistent; AUA recommends against electromotive delivery.[6][25][31]
  • Hyaluronic acid — EAU offers a weak acute-phase option with limited evidence; this is not an FDA-approved PD indication.[5][51]

C. Mechanical therapies​

Penile traction therapy (PTT)​

Mechano-transduction increases MMP activity and remodels collagen.[25]

  • RestoreX — the most studied modern device; only 30–90 min/day required (vs 3–8 h for older devices)[32]
    • RCT (n = 110): 3-month curvature −11.7° vs +1.3° in controls (p < 0.001)[32]
    • 6-month open-label: 95% length gains (mean 2.0–2.2 cm); 61% curve improvements (16.8–21.4°)[33]
    • Combined with CCH: RestoreX + CCH 49% curvature improvement vs 31% with CCH alone; 6.9× more likely to achieve ≥ 20° improvement[34]
  • Penimaster PRO — also well-studied with comparable efficacy[35]

Other modalities​

  • Extracorporeal shockwave therapy (ESWT) — may relieve acute-phase pain; do not offer to correct curvature.[6][51]
  • Vacuum erection device — limited evidence; modest benefits in small series[31][35]

D. Surgical treatment — gold standard for stable PD with functional deformity​

All guidelines: surgery for stable disease (≥ 3–6 months) by experienced surgeons.[6][7]

Levine surgical algorithm (widely adopted; angular cutoffs guide discussion rather than determine the operation):[2][36][37]

  • Adequate rigidity, mild–moderate curvature (< 60°), no hourglass/hinge → Tunical plication
  • Adequate rigidity, severe curvature (> 60–70°), hourglass/hinge, significant shortening → Plaque incision/partial excision and grafting
  • Refractory ED ± curvature → Inflatable penile prosthesis ± modeling, plication, or grafting

1. Tunical plication (Nesbit / 16-dot / modified Yachia)​

  • The most common PD operation (~50% of all PD surgery)[6]
  • Curvature correction ≥ 90%[6]
  • Penile shortening — mean −1.0 cm is the trade-off[38]
  • Best candidate: intact erectile function, curvature < 60°[6][37]
  • Lower risk of de novo ED than grafting; no graft required
  • Wound complications ~6.3% — no difference between ventral and subcoronal incisions[39]

2. Plaque incision (or partial excision) and grafting​

  • Curvature correction 80–98.6% depending on graft and technique[6][38][40]
  • Length gain was reported in one comparative cohort (mean +0.9 cm); preservation or gain is not guaranteed[38]
  • Best candidate: intact erectile function, severe curvature (> 60–70°), hourglass / hinge / significant shortening[2][37]
  • De novo ED varies substantially; counsel that risk can reach 50% in some grafting series.[40][41][51]
  • Compound curvature — PEG plus supplemental TAP achieves 79% penetrative intercourse with 12.4% recurrence at 61 months[42]

Graft materials:

MaterialTypeNotes
Buccal mucosa graft (BMG)AutologousFavorable pooled outcomes in selected series; no established superiority[40][43]
Tunica vaginalisAutologous90% technical success at 24 mo; comparable to BMG[43]
Bovine pericardiumXenograftOff-the-shelf; widely used; good results[41][45]
TachoSil (collagen fleece)Hemostatic patchReported operative-time advantages; no proven best graft[38][45]
DermisAutologousHistorical standard[41]
Small intestinal submucosa (SIS)XenograftVariable[38]

The 2026 BMG meta-analysis: 98.6% straightening, 92.1% satisfaction, 1.7% de novo ED, 1.1% shortening, from selected studies; limited comparisons do not establish equivalence or superiority over other grafts.[40]

3. Inflatable penile prosthesis (IPP)​

  • Indication: PD with refractory ED (failed PDE5i, VED, ICI) ± deformity[6][46]
  • Addresses both ED and curvature in a single operation[2][6]
  • Multicenter cohort (499 PD-IPP patients):[47]
    • Mean preop curvature 39.4°
    • 17.6% straightened with IPP alone
    • 82.4% needed adjuncts — manual modeling ± scratch (74.7%, median 26° correction); plication (4.8%, 40°); grafting (2%, 55° for the most severe)
  • Satisfaction > 80% at 1–2 yr; device use > 88%[48][49]
  • Self-reported depression decreased from 19.3% preop to 10.5% at 1 yr (p = 0.02)[49]
  • Selected series describe IPP for complex deformity without ED (87.9% satisfaction in one study); limited evidence does not make it a routine first-line operation for preserved erections.[48][51]
  • Scratch technique + postoperative VED — combined approach achieving residual curvature of 7.7–8.7° at 1 yr with excellent IIEF improvement[50]

E. Comparative outcomes​

Prospective nonrandomized multi-institutional comparison of CCH vs plication vs PEG; selection and baseline deformity differ, limiting causal treatment comparisons:[38]

OutcomeCCHTunical plicationPEG
Mean curvature correction23.3° (34.4%)72.0° (92.2%)71.8° (94.9%)
Penile length change−0.2 cm−1.0 cm+0.9 cm
IIEF-5 change+5.7+4.9+2.2

In patients who fail CCH, surgical correction (grafting ± IPP or Nesbit) is technically feasible and safe — 95.6% no complications; recurrence only 4.4%.[44]

Algorithm Summary​

  1. Active phase (evolving symptoms): Treat pain with NSAIDs when appropriate; discuss traction and its limitations, erectile function, and psychological support. Defer corrective surgery until stable. Do not present unproven oral antifibrotics as standard therapy.[6]
  2. Stable phase (≥ 3–6 mo):
    • Curvature < 60°, no hourglass/hinge, intact rigidity → Plication
    • Curvature > 60°, hourglass/hinge, or shortening, intact rigidity → Plaque incision/excision + graft (BMG, bovine pericardium, TachoSil, or tunica vaginalis)
    • Refractory ED → IPP ± modeling, plication, or grafting
    • Patient prefers non-surgical → CCH (curvature 30–90°, palpable plaque, intact erection) ± RestoreX PTT
  3. All patients: shared decision-making; counsel about expected outcomes (shortening with plication, de novo ED with grafting, modest CCH benefit ~7.7° net); screen for and address psychological distress.[7][18][20]

Guideline Principles​

  • History and genital examination are the minimum evaluation; document erect deformity before treatment.[6]
  • Shared decision-making and thorough counseling are universally emphasized
  • Plication and grafting reserved for patients with preserved erectile function
  • Penile prosthesis is the preferred surgical option for PD with refractory ED
  • CCH is an established option for appropriately selected patients; current guidance differs from older recommendations for IFN-α2b
  • Vitamin E and tamoxifen should not be offered
  • Further pathophysiology and rigorous outcomes research are needed

See Also​

Videos​

Peyronie's Disease Surgery: Considerations, Tips, and Pitfalls
Grand Rounds in Urology (2025)

References​

1. Rosenberg JE, Ergun O, Hwang EC, et al. "Non-surgical therapies for Peyronie's disease." Cochrane Database Syst Rev. 2023;7:CD012206. doi:10.1002/14651858.CD012206.pub2

2. Ziegelmann MJ, Bajic P, Levine LA. "Peyronie's disease: contemporary evaluation and management." Int J Urol. 2020;27(6):504–516. doi:10.1111/iju.14230

3. Kadioglu A, Tefekli A, Erol B, et al. "A retrospective review of 307 men with Peyronie's disease." J Urol. 2002;168(3):1075–1079. doi:10.1016/S0022-5347(05)64578-8

4. Mulhall JP, Schiff J, Guhring P. "An analysis of the natural history of Peyronie's disease." J Urol. 2006;175(6):2115–2118. doi:10.1016/S0022-5347(06)00270-9

5. Endo. Xiaflex (collagenase clostridium histolyticum): prescribing information, Medication Guide and safety information. Prescribing information (March 2026)

6. Nehra A, Alterowitz R, Culkin DJ, et al. "Peyronie's disease: AUA guideline." J Urol. 2015;194(3):745–753. doi:10.1016/j.juro.2015.05.098

7. Chierigo F, Fallara G, Tozzi M, et al. "Guideline of guidelines: Peyronie's disease." BJU Int. 2026;137(5):770–782. doi:10.1111/bju.70201

8. Patel DP, Christensen MB, Hotaling JM, Pastuszak AW. "A review of inflammation and fibrosis: implications for the pathogenesis of Peyronie's disease." World J Urol. 2020;38(2):253–261. doi:10.1007/s00345-019-02815-6

9. Swislocki ALM, Eisenberg ML. "Peyronie disease as a marker of inflammation — is there hope on the horizon?" Am J Med. 2021;134(10):1218–1223. doi:10.1016/j.amjmed.2021.06.015

10. Karakus S, Unal S, Dai D, et al. "Early-onset and uncontrolled diabetes mellitus factors correlate with complications of Peyronie's disease." J Sex Med. 2024;21(8):716–722. doi:10.1093/jsxmed/qdae069

11. Rhoden EL, Riedner CE, Fuchs SC, et al. "A cross-sectional study for the analysis of clinical, sexual and laboratory conditions associated to Peyronie's disease." J Sex Med. 2010;7(4 Pt 1):1529–1537. doi:10.1111/j.1743-6109.2009.01584.x

12. Bjekic MD, Vlajinac HD, Sipetic SB, Marinkovic JM. "Risk factors for Peyronie's disease: a case-control study." BJU Int. 2006;97(3):570–574. doi:10.1111/j.1464-410X.2006.05969.x

13. Şahin A, Babayev H, Cirigliano L, et al. "Unveiling the molecular hallmarks of Peyronie's disease: a comprehensive narrative review." Int J Impot Res. 2024;36(8):801–808. doi:10.1038/s41443-024-00845-2

14. Crocetto F, Barone B, Manfredi C, et al. "Are insulin resistance and non-alcoholic fatty liver disease associated with Peyronie's disease? A pilot study." J Physiol Pharmacol. 2022;73(1). doi:10.26402/jpp.2022.1.05

15. Usta MF, Bivalacqua TJ, Jabren GW, et al. "Relationship between the severity of penile curvature and the presence of comorbidities in men with Peyronie's disease." J Urol. 2004;171(2 Pt 1):775–779. doi:10.1097/01.ju.0000097498.34847.7c

16. Ziegelmann M, Bole R, Avant R, et al. "Conservatively managed Peyronie's disease — long-term survey results from patients undergoing nonsurgical and noninjection therapies." Urology. 2018;113:99–104. doi:10.1016/j.urology.2017.11.012

17. Capoccia E, Ziegelmann M, Emmerson J, et al. "Long-term patient-reported outcomes in men with Peyronie's disease undergoing nonsurgical and nonintralesional injection management." Int J Impot Res. 2021;33(1):75–81. doi:10.1038/s41443-020-0231-y

18. Kuja-Halkola R, Henningsohn L, D'Onofrio BM, et al. "Mental disorders in Peyronie's disease: a Swedish cohort study of 3.5 million men." J Urol. 2021;205(3):864–870. doi:10.1097/JU.0000000000001426

19. Low P, Wang L, Li KD, et al. "Thematic analysis of the psycho-sexual symptoms in patients with Peyronie's disease present on online forums." Int J Impot Res. 2023;35(6):533–538. doi:10.1038/s41443-022-00589-x

20. Lindhardt-Mejlholm SL, Mortensen KS, Andersen IT, Nørgaard M, Lund L. "Peyronie's disease and risk of depression: a nationwide 25-year cohort study." J Sex Med. 2025;qdaf168. doi:10.1093/jsxmed/qdaf168

21. Manka MG, White LA, Yafi FA, et al. "Comparing and contrasting Peyronie's disease guidelines: points of consensus and deviation." J Sex Med. 2021;18(2):363–375. doi:10.1016/j.jsxm.2020.11.013

22. Chung E, Gillman M, Tuckey J, La Bianca S, Love C. "A clinical pathway for the management of Peyronie's disease: integrating clinical guidelines from the International Society of Sexual Medicine, American Urological Association and European Urological Association." BJU Int. 2020;126(Suppl 1):12–17. doi:10.1111/bju.15057

23. McCauley JF, Dean RC. "Diagnostic utility of penile ultrasound in Peyronie's disease." World J Urol. 2020;38(2):263–268. doi:10.1007/s00345-019-02928-y

24. Pradeep A, Alexander LF, Padilla-Maldonado GW, et al. "Imaging techniques for diagnosing and managing Peyronie disease." Abdom Radiol (NY). 2025;50(1):349–359. doi:10.1007/s00261-024-04521-3

25. Hayat S, Brunckhorst O, Alnajjar HM, et al. "A systematic review of non-surgical management in Peyronie's disease." Int J Impot Res. 2023;35(6):523–532. doi:10.1038/s41443-022-00633-w

26. Gelbard M, Goldstein I, Hellstrom WJ, et al. "Clinical efficacy, safety and tolerability of collagenase clostridium histolyticum for the treatment of Peyronie disease in 2 large double-blind, randomized, placebo controlled phase 3 studies." J Urol. 2013;190(1):199–207. doi:10.1016/j.juro.2013.01.087

27. Hellstrom WJG, Tue Nguyen HM, Alzweri L, et al. "Intralesional collagenase clostridium histolyticum causes meaningful improvement in men with Peyronie's disease: results of a multi-institutional analysis." J Urol. 2019;201(4):777–782. doi:10.1097/JU.0000000000000032

28. Zhang F, Xiong Y, Wang W, et al. "The efficacy and safety of intralesional injection of collagenase for Peyronie's disease: a meta-analysis of published prospective studies." Front Pharmacol. 2022;13:973394. doi:10.3389/fphar.2022.973394

29. Hoy SM. "Collagenase clostridium histolyticum: a review in Peyronie's disease." Clin Drug Investig. 2020;40(1):83–92. doi:10.1007/s40261-019-00867-5

30. Dhillon S. "Collagenase clostridium histolyticum: a review in Peyronie's disease." Drugs. 2015;75(12):1405–1412. doi:10.1007/s40265-015-0441-7

31. Russo GI, Milenkovic U, Hellstrom W, et al. "Clinical efficacy of injection and mechanical therapy for Peyronie's disease: a systematic review of the literature." Eur Urol. 2018;74(6):767–781. doi:10.1016/j.eururo.2018.07.005

32. Ziegelmann M, Savage J, Toussi A, et al. "Outcomes of a novel penile traction device in men with Peyronie's disease: a randomized, single-blind, controlled trial." J Urol. 2019;202(3):599–610. doi:10.1097/JU.0000000000000245

33. Joseph J, Ziegelmann MJ, Alom M, et al. "Outcomes of RestoreX penile traction therapy in men with Peyronie's disease: results from open label and follow-up phases." J Sex Med. 2020;17(12):2462–2471. doi:10.1016/j.jsxm.2020.10.003

34. Alom M, Sharma KL, Toussi A, Kohler T, Trost L. "Efficacy of combined collagenase clostridium histolyticum and RestoreX penile traction therapy in men with Peyronie's disease." J Sex Med. 2019;16(6):891–900. doi:10.1016/j.jsxm.2019.03.007

35. Sultana A, Grice P, Vukina J, Pearce I, Modgil V. "Indications and characteristics of penile traction and vacuum erection devices." Nat Rev Urol. 2022;19(2):84–100. doi:10.1038/s41585-021-00532-7

36. Papagiannopoulos D, Yura E, Levine L. "Examining postoperative outcomes after employing a surgical algorithm for management of Peyronie's disease: a single-institution retrospective review." J Sex Med. 2015;12(6):1474–1480. doi:10.1111/jsm.12910

37. Levine LA, Lenting EL. "A surgical algorithm for the treatment of Peyronie's disease." J Urol. 1997;158(6):2149–2152. doi:10.1016/s0022-5347(01)68184-9

38. Yafi FA, Diao L, DeLay KJ, et al. "Multi-institutional prospective analysis of intralesional injection of collagenase clostridium histolyticum, tunical plication, and partial plaque excision and grafting for the management of Peyronie's disease." Urology. 2018;120:138–142. doi:10.1016/j.urology.2018.06.049

39. Seyer A, Piraino J, Lozoya AG, Ziegelmann M. "What is the right approach for Peyronie's disease surgery? Comparing postoperative wound complications between ventral and subcoronal incisions with penile straightening surgery." J Sex Med. 2025;qdaf189. doi:10.1093/jsxmed/qdaf189

40. Badr H, Bettocchi C, Alsalem A, et al. "Surgical treatment of Peyronie's disease by plaque incision and buccal mucosa graft: a systematic review and meta-analysis." Asian J Androl. 2026. doi:10.4103/aja202543

41. Natsos A, Tatanis V, Kontogiannis S, et al. "Grafts in Peyronie's surgery without the use of prostheses: a systematic review and meta-analysis." Asian J Androl. 2024;26(3):250–259. doi:10.4103/aja202358

42. Chow AK, Sidelsky SA, Levine LA. "Surgical outcomes of plaque excision and grafting and supplemental tunica albuginea plication for treatment of Peyronie's disease with severe compound curvature." J Sex Med. 2018;15(7):1021–1029. doi:10.1016/j.jsxm.2018.04.642

43. Ainayev Y, Zhanbyrbekuly U, Gaipov A, et al. "Comparison of technical success and adverse events of plaque incision and grafting methods in patients with Peyronie's disease: tunica vaginalis versus buccal mucosa." Urology. 2022;170:226–233. doi:10.1016/j.urology.2022.07.063

44. Cocci A, Ralph D, Djinovic R, et al. "Surgical outcomes after collagenase clostridium histolyticum failure in patients with Peyronie's disease in a multicenter clinical study." Sci Rep. 2021;11(1):166. doi:10.1038/s41598-020-80551-3

45. Farrell MR, Abdelsayed GA, Ziegelmann MJ, Levine LA. "A comparison of hemostatic patches versus pericardium allograft for the treatment of complex Peyronie's disease with penile prosthesis and plaque incision." Urology. 2019;129:113–118. doi:10.1016/j.urology.2019.03.008

46. Ziegelmann MJ, Farrell MR, Levine LA. "Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review." Asian J Androl. 2020;22(1):51–59. doi:10.4103/aja.aja_81_19

47. Hammad MAM, Barham DW, Simhan J, et al. "A multicenter evaluation of penile curvature correction in men with Peyronie's disease undergoing inflatable penile prosthesis placement." J Sex Med. 2025;22(2):349–355. doi:10.1093/jsxmed/qdae192

48. Moncada I, Krishnappa P, Zaccaro C, et al. "Penile prosthesis implantation is safe and effective in Peyronie's disease patients with and without erectile dysfunction." Int J Impot Res. 2025;37(1):61–65. doi:10.1038/s41443-024-00938-y

49. Khera M, Bella A, Karpman E, et al. "Penile prosthesis implantation in patients with Peyronie's disease: results of the PROPPER study demonstrates a decrease in patient-reported depression." J Sex Med. 2018;15(5):786–788. doi:10.1016/j.jsxm.2018.02.024

50. Antonini G, De Berardinis E, Del Giudice F, et al. "Inflatable penile prosthesis placement, scratch technique and postoperative vacuum therapy as a combined approach to definitive treatment of Peyronie's disease." J Urol. 2018;200(3):642–647. doi:10.1016/j.juro.2018.04.060

51. European Association of Urology. Sexual and Reproductive Health: Penile Curvature. 2026. Guideline chapter