Peyronie's Disease
This page hosts the operative decision support for Peyronie's disease (PD): phase determination, intralesional and mechanical therapies, and the surgical algorithm (plication vs. plaque incision/grafting vs. prosthesis with adjunctive straightening). For pathophysiology, evaluation, and natural history, see Peyronie's Disease in Clinical Conditions. For technique-specific operative deep-dives, see the Peyronie's Disease subsection.
Decision Framework
PD management hinges on accurate phase determination — non-surgical therapy in the acute phase, surgery reserved for stable disease — with treatment selection further driven by erectile-function status, curvature severity, deformity complexity, and length concerns. The contemporary anchors are the AUA 2015 Peyronie's Disease Guideline, the EAU 2025 Male Sexual & Reproductive Health Update, and the 2026 BJU Guideline-of-Guidelines synthesis.[1][2][3] Among non-surgical options, CCH (Xiaflex) is the only FDA-approved intralesional therapy (~35% curvature improvement, with incremental benefit through all 4 cycles).[5][6][7] The RestoreX traction device is the only PTT modality with RCT evidence of curvature, length, and EF improvement at practical daily-use times (30–90 min/day).[8][9] Surgical correction remains the most rapid and reliable approach: plication achieves ≥90% straightening even for severe deformities at minimal de novo-ED risk; plaque incision/excision + grafting (PEG) provides superior length outcomes at the cost of higher complexity and de novo ED.[10][11][12] For PD with refractory ED, IPP with adjunctive straightening addresses both problems with >80% satisfaction.[13][14]
Determine Disease Phase
| Finding | Phase | Action |
|---|---|---|
| Penile pain present, curvature changing/worsening, symptom duration ≤18 months | Acute (active) | Non-surgical therapy only; surgery contraindicated |
| No pain, curvature stable ≥3 months | Chronic (stable) | Candidate for surgical correction if deformity prevents coitus |
Stability is defined clinically as: (1) no curvature change for 3–6 months, (2) absence of pain on erection, and (3) time-from-onset beyond 12 months — all three should be present before offering surgery.[1]
Acute-Phase Treatment
| Clinical Scenario | First-Line | Alternative(s) | Avoid |
|---|---|---|---|
| Acute PD, curvature 30–90°, intact EF | Intralesional CCH (Xiaflex) + modeling (up to 4 cycles / 8 injections) | Penile traction therapy (RestoreX) as monotherapy | Surgery (contraindicated in active phase) |
| Acute PD, prefers maximum non-surgical effect | CCH + RestoreX combination (49% curvature reduction vs 31% CCH alone; +1.9 cm length; 6.9× more likely to achieve ≥20° improvement)[8] | CCH alone or RestoreX alone | Vitamin E, tamoxifen (AUA: should NOT be offered) |
| Acute PD, intralesional alternative to CCH | Interferon α-2b (~12–14° curvature improvement) | Verapamil — AUA/ISSM see potential role; EAU recommends against | Corticosteroids; IL-hyaluronic acid (insufficient evidence) |
| Acute PD, oral therapy preferred | No oral monotherapy has robust evidence; consider pentoxifylline (off-label) or coenzyme Q10 — modest/uncertain benefit | Tadalafil daily (mechanism-based; Spirito 2024 disease-modifying signal) | Vitamin E and tamoxifen — AUA: should NOT be offered (Strong, Grade B) |
| Acute PD, pain predominant | Li-ESWT for pain only (no curvature benefit); penile traction; tadalafil | NSAIDs / pain-directed pharmacotherapy | ESWT for curvature reduction (Cochrane: no curvature benefit;[4] AUA: should NOT be used for curvature/plaque reduction) |
Stable-Phase Surgical Decision Algorithm
The critical branch point is erectile-function status. The matrix below operationalizes the AUA / EAU / ISSM / CUA guideline consensus.[1][2][3]
| Clinical Scenario | First-Line | Alternative(s) | Avoid |
|---|---|---|---|
| Adequate EF + curvature ≤60° + simple deformity + adequate length | Tunical plication (Nesbit, 16-dot, 8-dot, parallel rows) — ≥90% straightening, minimal de novo ED[10][15] | PEG (length-preserving but higher de novo ED risk) | Plication in patient unwilling to accept perceived shortening |
| Adequate EF + curvature ≤60° + complex deformity (biplanar, hinge) | Tunical plication (expanded indication) — 91% straightening even for severe / complex deformities at long-term follow-up (Reddy 2018)[11] | PEG | "Hinge effect = automatic graft" — long-term data show plication works |
| Adequate EF + curvature >60° or hourglass / indentation deformity | PEG (plaque incision/excision + grafting) — 80–98.6% straightening, +0.9 to +1.99 cm length[12][16] | Plication with patient counseled on additional shortening | PEG in patient unable to tolerate 5–15.7% de novo ED risk |
| Adequate EF + severe shortening as primary concern | PEG — only surgical option that provides length gain | Plication only if shortening is acceptable | Plication when length preservation is the explicit goal |
| ED refractory to PDE5i/ICI + any curvature | IPP with adjunctive straightening — addresses both problems; >80% satisfaction; depression decreases (PROPPER 19.3% → 10.5%)[13][14] | (No alternative with both EF and curvature reliably addressed) | IPP alone without curvature management |
| Residual curvature >15–20° after IPP inflation | Stepwise adjunct ladder: manual modeling (Wilson; ~75% of cases; median 26° correction) → tunical plication (~5%; median 40°) → plaque incision/grafting (~2%; median 55°)[14] | Scratch technique + postoperative VED (Antonini 2018; residual 17–21° → 8–9°)[17] | Skipping adjunctive straightening when residual curvature is functionally significant |
| PD without ED but prefers prosthesis (emerging indication) | IPP in selected men — Moncada 2025 reports 87.9% satisfaction; mechanical failure was actually lower in non-ED group[18] | Plication or PEG (standard non-ED algorithm) | Routine IPP in PD without ED — emerging indication; warrants further research |
| Recalcitrant complex PD with ED + severe shortening | IPP + multiple corporeal incisions + collagen-fleece grafting (mean +2.5 cm length; 94.9% satisfaction with straightness; 89.7% would recommend) | Standard IPP + manual modeling | Acceptance of major shortening as inevitable |
Plication vs Grafting Sub-Comparison
| Factor | Favors Plication | Favors PEG |
|---|---|---|
| Curvature severity | Any (even ≥60° at long-term follow-up) | Traditionally >60–70%; meaningful overlap |
| Deformity complexity | Simple, biplanar | Hourglass, severe focal indentation |
| Penile length concern | Adequate length, accepts modest shortening | Length preservation / gain is priority |
| Operative complexity | Simpler, shorter OR time, can be done without degloving | More complex, graft harvest required |
| De novo ED risk tolerance | Minimal (0–5%) | Accepts 5–15.7% risk |
| Surgeon experience | Widely reproducible | Requires grafting expertise |
| Yafi 2018 head-to-head[16] | Plication +92.2% curvature correction; −1.0 cm length; +4.9 IIEF-5 | PEG +94.9% curvature correction; +0.9 cm length; +2.2 IIEF-5 |
Graft-Material Selection (When PEG Is Chosen)
| Graft | Type | Curvature Success | De Novo ED | Length Change | Best Evidence |
|---|---|---|---|---|---|
| Buccal mucosa graft | Autologous | 98.6% | 1.7% | +1.99 cm (affected side) | Badr 2026 SR/meta of 17 studies — highest success, lowest de novo ED, lowest shortening[19] |
| Collagen fleece (TachoSil) | Xenograft | 91–94% at long-term | 15.7% worsened EF | +1.1 cm | Hatzichristodoulou 2021 — 319 pts, 47-mo follow-up, suture-free sealing, 79-min OR, 87.8% satisfaction[20] |
| Tunica vaginalis | Autologous | ~90% at 24 mo | Rare | Significant gain | Same operative field; readily available |
| Small intestinal submucosa (SIS) | Xenograft | >80% | 5–15% | Variable | Off-the-shelf; no donor-site morbidity |
| Pericardium (bovine / human cadaveric) | Xeno- / allograft | >80% | 5–15% | Variable | Off-the-shelf; good handling |
| Saphenous vein | Autologous | >80% | 5–20% | Variable | Historical gold standard |
| Dermis | Auto- / allograft | >80% | Variable | Variable | Less commonly used today |
Treatment Database
| Treatment | Tier |
|---|---|
| Oral Agents | Oral |
| Intralesional Agents | Intralesional |
| Penile Traction Therapy | Mechanical / Device |
| Vacuum Erection Device (no constriction ring) | Mechanical / Device |
| Extracorporeal Shockwave Therapy (ESWT, pain-only) | Mechanical / Device |
| Tunical Plication | Surgical — Plication |
| Plaque Incision / Excision and Grafting (PEG) | Surgical — Grafting |
| IPP with Adjunctive Straightening | Surgical — Prosthesis |
See Also
- Peyronie's Disease (Clinical Conditions) — disease phases, natural history, comparative outcomes
- Peyronie's Disease subsection — technique-specific operative pages
- Erectile Dysfunction — operative decision support
- Pharmacology — Peyronie's Disease Agents hub
References
1. 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
2. Salonia A, Capogrosso P, Boeri L, et al. European Association of Urology guidelines on male sexual and reproductive health: 2025 update on male hypogonadism, erectile dysfunction, premature ejaculation, and Peyronie's disease. Eur Urol. 2025;88(1):76–102. doi:10.1016/j.eururo.2025.04.010
3. 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
4. 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
5. 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
6. Ziegelmann M, Hu Y, Xiang Q, et al. Incremental treatment response by cycle with collagenase clostridium histolyticum for Peyronie's disease: a pooled analysis of two phase 3 trials. Urology. 2023;175:126–131. doi:10.1016/j.urology.2023.02.019
7. 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
8. 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
9. 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
10. Demzik A, Ehlers M, Brems J, Figler BD. Penile plication for Peyronie's disease: the iterative 8-dot technique. Urology. 2022;164:e307. doi:10.1016/j.urology.2022.03.005
11. Reddy RS, McKibben MJ, Fuchs JS, et al. Plication for severe Peyronie's deformities has similar long-term outcomes to milder cases. J Sex Med. 2018;15(10):1498–1505. doi:10.1016/j.jsxm.2018.08.006
12. 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
13. 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
14. 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
15. Hudak SJ, Morey AF, Adibi M, Bagrodia A. Favorable patient reported outcomes after penile plication for wide array of Peyronie disease abnormalities. J Urol. 2013;189(3):1019–1024. doi:10.1016/j.juro.2012.09.085
16. 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
17. 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
18. 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
19. 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. 2026:00129336-990000000-00391. doi:10.4103/aja202543
20. Hatzichristodoulou G, Fiechtner S, Pyrgidis N, et al. Suture-free sealing of tunical defect with collagen fleece after partial plaque excision in 319 consecutive patients with Peyronie's disease: the sealing technique. J Urol. 2021;206(5):1276–1282. doi:10.1097/JU.0000000000001933