Peyronie's Disease (Treatment Algorithm)
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 depends on phase determination (non-surgical therapy in the active phase, surgery reserved for stable disease). Treatment selection also depends on erectile-function status, curvature severity, deformity complexity and length concerns. The guideline sources are the AUA 2015 Peyronie's Disease Guideline, the EAU 2025 Male Sexual and Reproductive Health Update, the revised EAU March 2026 Penile Curvature guideline and the 2026 BJU guideline-of-guidelines synthesis.[1][2][25][3] Among non-surgical options, CCH (Xiaflex) is the only FDA-licensed intralesional therapy.[7] A pooled analysis of prospective studies reported about 35% curvature improvement, and each of the 4 treatment cycles added responders.[5][6][7] The Cochrane review found a small mean difference from placebo in curvature (6.9° at 28 weeks after the end of treatment, moderate certainty).[4] The RestoreX traction device has randomized evidence (n = 110, 3 months) of improved curvature and length, and of erectile function in men with ED, at 30–90 min/day.[9] Surgery is reserved for stable disease with deformity that prevents intercourse. In retrospective plication series, Reddy reported immediate postoperative curvature <20° in 93/102 patients later reached by survey; 62.7% of those respondents perceived shortening at median 59.5 months. Hudak reported perceived curvature improvement in 96% of 132 survey respondents at mean 14 months.[11][15] Plaque incision or excision and grafting (PEG) can limit shortening when length or complex deformity drives the choice, but long-term length gain is uncommon and erectile function can worsen.[2][12] For PD with refractory ED, IPP with adjunctive straightening treats both problems. The observational PROPPER registry reported acceptable satisfaction; self-reported depression was 36/187 (19.3%) at baseline and 6/57 (10.5%) among one-year respondents.[13] A separate multicenter series described adjunctive correction for residual curvature after IPP placement.[13][14]
Determine Disease Phase
| Finding | Phase | Action |
|---|---|---|
| Evolving curvature or other changing deformity; pain often present | Acute (active) | Use nonsurgical therapy for symptoms and defer corrective surgery until deformity is stable; the AUA notes that surgical outcomes in active disease are unknown[1][23] |
| Curvature stable ≥3 months; pain may persist with erection | Chronic (stable) | Consider surgery when stable deformity compromises intercourse, after assessing pain and rigidity[1][23] |
The AUA guideline defines stable disease as symptoms clinically quiescent or unchanged for at least 3 months (pain, if present, is less common and usually occurs with erection). Surgical series most often required at least 12 months of symptoms and 3–6 months of stable curvature, and outcomes of surgery in active disease are unknown.[1]
Non-surgical Treatment by Disease Phase
CCH plus clinician and patient modeling is an AUA Moderate Recommendation (Grade B) for stable PD with curvature >30° and <90° and intact erectile function.[1] Acute-phase injection studies have low-quality, heterogeneous evidence; the options below require phase-specific selection.[1][21]
| Clinical Scenario | First-Line | Alternative(s) | Avoid |
|---|---|---|---|
| Stable PD, curvature >30° and <90°, intact EF | Intralesional CCH (Xiaflex) plus clinician/patient modeling (up to four cycles/eight injections); counsel penile hematoma and corporal rupture (5/1044 [0.5%] confirmed ruptures, 9/1044 [0.9%] possible ruptures, and 39/1044 [3.7%] severe hematomas in the XIAFLEX label). US PD treatment is restricted to the XIAFLEX REMS. The XIAFLEX label contraindicates treatment of plaques involving the penile urethra. It directs no sex between the first and second injections of a cycle and resumption at least four weeks after the second injection only once pain and swelling have subsided[1][2][26] | Penile traction therapy (RestoreX) as monotherapy | Surgery during active disease |
| Considering combined nonsurgical therapy | No established first-line combination. CCH plus RestoreX may be discussed when length gain is a priority. In a nonrandomized prospective registry of 113 men with complete data, the 16 combination users had mean 49% curvature reduction versus 31% with CCH alone, mean +1.9 cm stretched length, and OR 6.9 for ≥20° curvature improvement versus the other groups. A 2024 meta-analysis of seven heterogeneous comparative studies (532 men) found 0.81 cm greater pooled length gain (95% CI 0.17–1.45) with CCH combinations, but no statistically significant curvature difference.[8][27] | CCH alone or RestoreX alone | Vitamin E, tamoxifen (AUA: clinicians should not offer; Moderate Recommendation)[1] |
| Other intralesional agents | No current first-line agent listed | Verapamil (AUA 2015: clinicians may offer; Conditional Recommendation, Grade C; EAU 2026 finds evidence insufficient for clinical use)[1][25]; intralesional hyaluronic acid [25] | Interferon α-2b (historical AUA 2015: clinicians may administer; Moderate Recommendation, Grade C; EAU 2026 does not recommend it because evidence is limited and the drug was withdrawn from European and US markets in 2021)[1][25]; corticosteroids (poor evidence)[25] |
| Oral therapy preferred | No oral drug has established benefit for PD curvature; pentoxifylline and coenzyme Q10 remain unproven.[1][25] | Use an NSAID for active-phase pain when appropriate or a PDE5 inhibitor for concomitant ED ; tadalafil is not established as curvature treatment.[25] | Vitamin E and tamoxifen (AUA: clinicians should not offer; Moderate Recommendation, Grade B for vitamin E and C for tamoxifen)[1] |
| Pain predominant in active disease | NSAIDs for pain when appropriate [25] | Li-ESWT for pain only ; penile traction for deformity and tadalafil for concomitant ED [1][25] | ESWT for curvature reduction (Cochrane: little to no difference versus sham, low certainty[4]; AUA: clinicians should not use it for curvature or plaque size, Moderate Recommendation, Grade B[1]) |
Stable-Phase Surgical Decision Algorithm
The branch point is erectile-function status. The matrix below summarizes the AUA, EAU, ISSM and CUA guidelines together with the cited series.[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) (mixed-deformity retrospective series: 91% reported straight erections at mean 4.5 months after 8-dot plication; 96% of 132/154 respondents reported curvature improvement at mean 14 months in Hudak)[10][15] | PEG (length-preserving but higher de novo ED risk) | Plication in patient unwilling to accept perceived shortening |
| Adequate EF + complex deformity (biplanar curvature, hourglass or hinge) | For a true hourglass or hinge deformity, consider tunical lengthening or extra-tunical grafting; plication alone does not restore girth at the narrowed segment[2] | Selected biplanar curvature may be plicated if length and rigidity are adequate; Reddy 2018 studied severe curvature defined by ≥60° or biplanar ≥35°, with 102/327 survey responders[11] | Applying the Reddy result to hinge deformity |
| Adequate EF + severe curvature or hourglass / indentation deformity[25] | PEG (plaque incision/excision + grafting) (buccal mucosa pooled success 98.6% and de novo ED 1.7%; in a separate PEG cohort, mean stretched length gained 0.9 cm, while a buccal mucosa meta-analysis found +1.99 cm affected-side length)[12][16][19] | Plication with patient counseled on additional shortening | PEG in patient unwilling to accept possible erectile-function worsening |
| Adequate EF + severe shortening as primary concern | PEG aims to limit shortening relative to plication; selected cohorts reported mean postoperative length gains near 1 cm, while long-term gain is uncommon[16][20][25] | 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 — treats both problems; acceptable satisfaction in PROPPER; self-reported depression was 36/187 (19.3%) among baseline respondents and 6/57 (10.5%) among one-year respondents[13][14] | (No alternative with both EF and curvature reliably addressed) | Leaving functionally significant residual curvature after prosthesis inflation |
| Residual curvature after IPP inflation | EAU 2026 suggests observation for <30° and manual modeling for >30°; if >30° persists, consider plication or incision/grafting. Counsel that urethral perforation was reported in 3% with modeling over an inflated prosthesis.[25] In a retrospective IPP cohort, manual modeling with or without scratch was used in ~75% of patients (median 26° correction), tunical plication in ~5% (median 40°), and plaque incision/grafting in ~2% (median 55°); these were separate patient groups.[25][14] | Scratch technique + postoperative VED (Antonini 2018; mean residual curvature 14.1–21.5° after surgery by plaque location, falling to 7.7–9.1° after 24 weeks of VED)[17] | Skipping adjunctive straightening when residual curvature is functionally significant |
| PD without ED but prefers prosthesis (emerging indication) | Plication or tunical lengthening according to penile length, curvature, complexity and rigidity .[25] | Penile prosthesis may be discussed in selected men: in Moncada's retrospective subgroup without ED, 29/33 were satisfied at six months and fewer mechanical-failure revisions were reported than in the ED group.[18] | Routine prosthesis with preserved erections; the authors call for further research |
| Recalcitrant complex PD with ED + severe shortening | If ED is unresponsive to pharmacotherapy, penile prosthesis with adjunctive correction as needed for residual curvature .[25] | In selected expert practice, multiple corporeal incisions with collagen-fleece grafting: a single-surgeon series of 43 men reported mean 2.5 cm postsurgical length gain (median follow-up 21 months); among 39 respondents, 94.9% were satisfied with straightness and 89.7% would recommend surgery. One IPP infection and one delayed distal corporal erosion occurred.[24] | Routine length-restoration incisions without complication counseling |
A 2023 randomized comparison of CCH plus RestoreX plus sildenafil versus surgery plus RestoreX plus sildenafil found greater curve improvement after surgery (84% versus 54%) at three months among 38 completers, but less measured length (-0.5 versus +1.0 cm) and more adverse events (50 versus 13 events); 18/19 surgery patients had plication and one had incision/grafting.[22]
Plication vs Grafting Sub-Comparison
| Factor | Favors Plication | Favors PEG |
|---|---|---|
| Curvature severity | Selected cases including ≥60° in a retrospective plication series[11] | Often considered for >60° or complex deformity[2]; 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 placement required; patient tissue harvest only for autografts[2] |
| De novo ED risk tolerance | Lower but nonzero; EAU 2026 simple-plication weighted estimate 8.8% (range 0–38%) | Higher and graft-dependent; EAU 2026 weighted estimates span 11.2–26.5% for the listed tunica vaginalis, vein, dermis, SIS and pericardium grafts (noncomparable studies; updated from EAU 2025).[2][25] |
| Surgeon experience | Widely reproducible | Requires grafting expertise |
| Yafi 2018 nonrandomized prospective comparison (n = 14 plication, 25 PEG)[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% pooled reported success | 1.7% pooled reported de novo ED | +1.99 cm on the affected side | Badr 2026 pooled 17 reports (nine full texts, eight abstracts) and found comparable outcomes in its head-to-head analysis.[19] Natsos 2024 found mostly single-arm studies at high risk of bias.[12] |
| Collagen fleece (TachoSil) | Xenograft | 93.7% immediately after surgery; 91.2% at median 47.2 mo | De novo ED not separately reported; 15.7% worsened EF | +1.1 cm | Hatzichristodoulou 2021 — 319/367 attended long-term evaluation; median 47.2-mo follow-up, suture-free sealing, median 79.8-min OR, 87.8% satisfaction[20] |
| Tunica vaginalis | Autologous | 88.1% weighted success | 11.2% weighted de novo ED | 18.6% reported shortening | EAU 2026 update of the 2025 tabulation: 99 patients in six noncomparable studies, follow-up 12–60 mo; same operative field[2][25] |
| Small intestinal submucosa (SIS) | Xenograft | 83.9% weighted success | 21.9% weighted de novo ED | 19.6% reported shortening | EAU 2025: 429 patients in ten studies, follow-up 9–75 mo; off-the-shelf[2] |
| Pericardium (bovine / human cadaveric) | Xeno- / allograft | Bovine 87.4%; cadaveric 85.1% weighted success | Bovine 26.5%; cadaveric 18.5% weighted de novo ED | Bovine 20.1%; cadaveric 22.1% reported shortening | EAU 2026 update of the 2025 tabulation: bovine 318 patients/6 studies (14–67 mo); cadaveric 463/7 (4.5–63 mo); noncomparable series, off-the-shelf[2][25] |
| Vein grafts (including saphenous) | Autologous | 85.6% weighted success | 14.8% weighted de novo ED | 32.7% reported shortening | EAU 2025 vein-graft data: 690 patients in 17 studies, follow-up 12–120 mo; saphenous is a traditional graft[2] |
| Dermis (autologous; allograft also used) | Auto- / allograft | Autologous: 81.2% weighted success; allograft not summarized | Autologous: 20.5% weighted de novo ED; allograft not summarized | Autologous: 59.9% reported shortening | EAU 2025 autologous-dermis data: 718 patients in 12 studies, follow-up 6–180 mo; less commonly used today[2] |
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
Podcasts
Videos
References
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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
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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
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