Peyronie's disease: penile curvature, plaques, and the AU care pathway

What Peyronie’s disease is

Peyronie’s disease is an acquired fibroproliferative disorder of the tunica albuginea — the fibrous sheath surrounding the erectile tissue of the penis — producing a firm plaque, penile curvature, painful erections during the inflammatory phase, and frequently erectile dysfunction and penile shortening. It is not a sexually transmitted condition, not a malignancy, and not caused by anything the man did wrong. Explaining this clearly at the first consultation is important.

The condition affects an estimated 3–9% of adult men (Healthy Male Andrology Australia), with a peak onset around age 50–60 and increasing prevalence with age. It is substantially under-reported — most men delay seeking care for months to years out of embarrassment or a belief that nothing can be done.

Around 80% of men with Peyronie’s disease experience significant psychological distress — depression, anxiety, body-image disturbance, and relationship strain are common. Around 50% have concurrent erectile dysfunction. These dimensions of the condition are as clinically important as the physical plaque and deserve the same attention.

A. Core clinical — the AU general-practice framework

The two clinical phases

Acute (active) phase — approximately 3–18 months:

• Painful erections; the pain typically resolves spontaneously within 6–18 months.
• Curvature is evolving; the plaque is soft or changing.
• Histology shows inflammatory infiltrate with TGF-beta-driven fibroblast activation.
• Surgery is contraindicated — curvature is still evolving, and operating during the active phase results in higher recurrence and complication rates per AUA guidelines (Nehra 2015, amended 2024).
• Around 50% of men in the active phase stabilise without specific intervention (Mulhall J Urol 2006).

Chronic (stable) phase — curvature unchanged for ≥12 months:

• Pain has resolved.
• Curvature is fixed; plaque often calcified and palpable as a hard nodule.
• This is when active intervention (intralesional injections, traction, surgery) is considered.

Distinguishing Peyronie’s disease from congenital curvature

Congenital penile curvature is present since first erection, involves no palpable plaque, is usually ventral in direction, and is associated with chordee. It is a distinct entity and should not be labelled or managed as Peyronie’s disease. The history — curvature present since adolescence vs acquired in adulthood — is usually sufficient to distinguish them.

History

• Onset — gradual development of curvature, when first noticed, direction.
• Pain — characteristic of the active phase; usually resolves over 6–18 months.
• Curvature — dorsal (most common), lateral, or ventral; angle; stability over time.
• Function — is penetrative intercourse possible? Hourglass deformity or hinge effect (buckling) preventing penetration?
• Erectile function — IIEF-5 questionnaire to quantify ED component.
• Penile shortening — perceived or measured.
• Risk factors — diabetes, hypertension, dyslipidaemia, Dupuytren’s contracture, plantar fibromas, pelvic radiation, transurethral prostate surgery, radical prostatectomy.
• Mental health — depression, anxiety, suicidality, relationship strain; ask directly.
• Treatments tried — including online supplements and devices.

Examination

• Palpate the plaque on the flaccid and gently stretched penis — a firm, well-demarcated thickening of the tunica; document size, location (dorsal/lateral/ventral/septal), and hardness (calcification).
• Stretched penile length — baseline measurement for monitoring.
• Hands — palmar Dupuytren’s nodules or cords.
• Soles — plantar fibromas (Ledderhose disease).
• Knuckles — Garrod’s pads (thickening over PIP joints).
• General — BMI, blood pressure; testicular examination.

A patient-supplied photograph of the erect penis for curvature angle assessment is recommended by both AUA 2024 and EAU 2024 guidelines. This is a practical solution that avoids the need for pharmacological erection in the clinic for initial assessment. Store with appropriate consent documentation per RACGP privacy standards.

GP-level investigations

• IIEF-5 (SHIM questionnaire) — quantifies the erectile dysfunction component.
• Fasting glucose and HbA1c — diabetes is both a risk factor and an important comorbidity to treat.
• Fasting lipids — dyslipidaemia contributes to endothelial and microvascular risk.
• Morning testosterone and SHBG — low testosterone contributes to ED.
• UEC and LFT — baseline before referral.
• Cardiovascular risk calculation — erectile dysfunction is a vascular sentinel; assess absolute CV risk.

Specialist investigations

Duplex penile ultrasound with intracavernosal prostaglandin E1 (alprostadil) injection is the gold standard for full assessment — it quantifies the curvature angle, plaque size and calcification, and peak systolic and end-diastolic velocity (vascular status). This is performed by a urologist and informs surgical and injection planning. It is not required before GP referral but should be arranged by the specialist at first urology appointment.

B. Evidence — what works and what does not

What does not work

Vitamin E — the most persistently promoted and firmly disproven oral therapy. The Brant J Urol 2004 RCT found no benefit over placebo. The Cochrane systematic review (Russell 2005) confirmed absence of evidence for vitamin E and most other oral agents. The AUA 2024 guidelines explicitly recommend against vitamin E. Patients who ask should be told clearly: vitamin E is disproven; continuing it delays appropriate management.

Colchicine, tamoxifen, coenzyme Q10 — all assessed in the Cochrane review with no evidence of meaningful benefit. Pentoxifylline has mixed observational signal and is not routinely recommended.

PRP, stem-cell injections, unregulated online shockwave clinics — AUA and EAU explicitly recommend against these outside formal clinical trials. Many private clinics market these aggressively; document the discussion and counsel patients about the lack of supporting evidence and the commercial exploitation involved.

Acute phase — current clinical approach

The active phase approach is supported by Mulhall J Urol 2006 natural history data showing 50% spontaneous stabilisation:

• Watchful waiting — reassurance and three-monthly photographic monitoring.
• Simple analgesia — paracetamol and NSAIDs for pain.
• Intercourse rest if penetration is painful; avoid positions causing buckling.
• Mental Health Care Plan — refer to psychology early; most men benefit from psychological support in the active phase.
• Do not operate.

Stable phase — established interventions

Intralesional clostridial collagenase histolyticum (CCH / Xiaflex) — the only non-surgical intervention with phase-3 RCT evidence. The IMPRESS I and II trials (Gelbard J Urol 2013) demonstrated approximately 17° (34% relative) curvature improvement over placebo. Indications: stable disease ≥12 months, curvature 30°–90°, palpable plaque, intact erectile function. Administered as paired intralesional injections per cycle with concurrent penile modelling by the patient. TGA-approved (2017) but NOT PBS-listed in Australia — private cost approximately AUD $5,000–10,000 per cycle. Risks include penile haematoma and the rare (0.5%) risk of corporal rupture.

Intralesional verapamil (10 mg in 10 mL) — off-label specialist treatment; approximately 30–50% curvature improvement in observational series; substantially less expensive than collagenase; an AUA 2024 conditional recommendation. A pragmatic alternative when collagenase cost is prohibitive.

Penile traction therapy (PTT) — daily 3–9 hours for 12–24 weeks; modest curvature gains and length preservation in small RCTs (Yafi J Sex Med 2020). Private device cost AUD $300–1,500. Adherence is the limiting factor.

Surgical correction — indicated for severe (>60°) or hinge/hourglass deformity, or stable disease refractory to other options:

• Tunical plication (Nesbit/Yachia/16-dot) — shortens the convex side; simple, reliable; best for moderate dorsal curvature without ED; results in predictable length loss.
• Plaque incision and grafting — preserves length; for severe curvature; higher risk of post-operative ED.
• Penile prosthesis — for severe ED combined with Peyronie’s disease; high satisfaction in selected patients; can include intraoperative modelling to correct curvature simultaneously.

C. Erectile dysfunction and Peyronie’s disease

Approximately 50% of men with Peyronie’s disease have concurrent erectile dysfunction. PDE5 inhibitors (sildenafil, tadalafil) are first-line for the erectile dysfunction component — see the erectile dysfunction article for full management details. Tadalafil 5 mg daily has a theoretical anti-fibrotic signal through PDE5-inhibition-mediated cGMP pathway effects, though clinical evidence for this specific benefit in Peyronie’s disease is limited.

Note that PDE5 inhibitors are not PBS-listed for erectile dysfunction in Australia — they are purchased privately, though generic sildenafil and tadalafil are now affordable. Tadalafil 5 mg daily has a PBS Authority listing for benign prostatic hyperplasia with lower urinary tract symptoms when there is significant overlap.

D. Australian operations

MBS items

• Standard GP consultations — items 23 / 36 / 44.
• Telehealth — items 91790 / 92029 (video); appropriate for ongoing review and mental health once the initial examination is complete.
• Mental Health Care Plan — items 2715 / 2717; the threshold for initiating an MHCP should be low given the 80% prevalence of significant psychological distress.
• GP Chronic Condition Management Plan — items 965 / 967; appropriate when Peyronie’s disease coexists with diabetes, cardiovascular disease, or depression.
• Pathology — HbA1c 66551; lipids 66536; testosterone + SHBG rebatable under specialist pathology items.
• Urology referral — MBS 105 / 106.
• Penile duplex ultrasound — specialist-billed under genitourinary ultrasound items.
• Surgical items — penile plication and Peyronie’s corrective surgery in the 36000-series urology operative item range; confirm with the operating urologist.

PBS medicines

• Clostridial collagenase (Xiaflex) — NOT PBS-listed for Peyronie’s disease (as at October 2026). Private cost is approximately AUD $5,000–10,000 per treatment cycle.
• Pentoxifylline — PBS general schedule; off-label weak evidence for Peyronie’s.
• Colchicine — PBS Authority Streamlined for gout; off-label weak evidence for Peyronie’s.
• Sildenafil/tadalafil (PDE5i) — NOT PBS-subsidised for erectile dysfunction; private purchase; generic versions affordable.
• Antidepressants (SSRIs/SNRIs) — PBS general schedule for comorbid depression and anxiety.
• Paracetamol and NSAIDs — general schedule / OTC for acute-phase pain management.

Medico-legal considerations

Document the following at every consultation:

• Realistic expectation counselling — most men do not regain a fully straight penis; failure to set this expectation is a common source of medico-legal complaint after surgery.
• Advice against vitamin E, PRP, stem-cell injections, and predatory online clinics.
• Mental health screen — risk of self-harm exists in men with severe untreated distress.
• Cost discussion for Xiaflex — informed financial consent before referral.
• Photograph storage — secure, consent-documented; treat as a sensitive medical record.

E. Special populations

Post-prostatectomy patients — radical prostatectomy and external beam radiation are recognised risk factors for Peyronie’s disease. The condition is common in this population but often missed; ask directly. Management is complicated by the typically co-existing vascular erectile dysfunction, which may require penile prosthesis with intraoperative Peyronie’s correction.

Younger men — though peak onset is 50–60 years, Peyronie’s disease does occur in younger men, sometimes with more aggressive progression. Genetic or connective tissue predisposition is more likely in this group; check for Dupuytren’s and plantar fibromas.

Men with Dupuytren’s contracture — the overlap with Dupuytren’s disease in 10–15% of cases is not coincidental. Shared pathophysiology means these men may also develop plantar fibromas and knuckle pads. Hand therapy and orthopaedic referral for the Dupuytren’s is managed separately but should be coordinated.

Patients with diabetes — uncontrolled glycaemia worsens fibrosis, erectile dysfunction, and wound healing. Optimising glycaemic control is an integral part of managing the whole patient. Refer to the type 2 diabetes management article for the GP diabetes pathway.

When to escalate

Refer or escalate when:

• Any confirmed or suspected Peyronie’s disease — routine urology referral for duplex ultrasound and specialist assessment.
• Urgent urology same week — severe curvature preventing intercourse, hourglass or hinge deformity, suspected penile fracture, suspected penile malignancy.
• Mental health — depression, anxiety, suicidality, relationship breakdown — Mental Health Care Plan with psychology; low threshold.
• Endocrinology — low testosterone contributing to severe erectile dysfunction.
• Vascular assessment — significant vascular erectile dysfunction component requiring further workup.

What this article is and is not

This is general health information drawn from current urology guidelines and evidence — AUA Peyronie’s Disease Guideline (2015/2024), EAU Sexual and Reproductive Health Guideline 2024, eTG Genitourinary, USANZ, and Healthy Male Andrology Australia. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about investigation, treatment, and specialist referral are made with your own GP and treating clinicians.

For consumer-friendly information: HealthDirect — Peyronie’s disease, Healthy Male, and Beyond Blue for mental health support.

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Sources cited

1. AUA — Peyronie’s Disease Guideline (Nehra 2015, amended 2024)
2. EAU — Sexual and Reproductive Health Guideline 2024 (Salonia)
3. Healthy Male (Andrology Australia) — Peyronie’s disease
4. Therapeutic Guidelines (eTG) — Genitourinary
5. USANZ — Andrology and men’s health
6. Gelbard et al — IMPRESS I and II collagenase RCT (J Urol 2013)
7. Russell et al — Cochrane review: non-surgical therapies for Peyronie’s disease (2005)
8. Mulhall et al — Natural history of Peyronie’s disease (J Urol 2006)
9. Yafi et al — RestoreX penile traction RCT (J Sex Med 2020)
10. HealthDirect — Peyronie’s disease
11. Beyond Blue — mental health support
12. PBS — pharmaceutical benefits schedule