I recommend treatment that involves 3 approaches. First is a combination of oral pentoxifylline 400 mg three times a day and
L-arginine 1000 mg twice a day. Although these drugs have not been shown in any large-scale multi-center trials to be effective, there is some evidence that they may reduce the likelihood of progression of scarring and may have some beneficial effects on scar remodeling and resolution. These drugs are relatively inexpensive, non-toxic, and tend to be well tolerated. Therefore I believe are reasonable to take. I inform my patients that if they do experience any side effects, they can simply stop taking the drugs, as there is little evidence of benefit. This combination of drugs should be taken for about 6 months.

The second approach is injection therapy. It is my preference to use verapamil, as it is less expensive and has fewer side effects than interferon. In our experience in over 1700 patients, we found 50%-60% of patients had a reduction in curvature of at least 10 degrees. Verapamil is typically recommended to be injected in the office every 2 weeks for 6 treatments, at which point reassessment is made. If no improvement is noted, then no further therapy is indicated. If there is improvement of curvature, girth, pain, or erection, then it is reasonable to continue with the standard protocol, which includes 12 injections over 6 months. This approach is typically covered by insurance. Verapamil injection should not be considered as a cure, but has been shown to be beneficial. Verapamil may help stabilize the disease and prevent progression of the deformity. When no treatment is given at all, the deformity gets worse in up to 50% of patients.

The third approach is external traction therapy. I prefer external traction devices, as they provide prolonged forces on the penis which activate the chemical processes that result in scar remodeling, elongation of the penis, and correction of deformity. I have not seen beneficial effects with vacuum therapy. I believe the reason for this is that the vacuum cannot be left on for an extended period of time; it really provides nothing more than periodic yanks on the penis, which I do not believe activates those beneficial chemical processes. It is important to use traction therapy carefully, which includes wearing the device for at least 3 hours per day at 2-hour intervals. This means it cannot be worn during extended periods of sleep for fear of injury to the underlying tissue. In over 300 patients treated with traction therapy, I have personally not seen any adverse side effects. Two men have had temporary abrasions of the skin on the edge of the glans penis, but there have been no negative effects on erectile function or sensation.

Initial evaluation at our medical center using this three-approach protocol demonstrated that approximately 60% of patients had measured improvement of at least 10 degrees, and that in those men who were responders, the average curvature reduction was 24 degrees. In men who used oral and injection therapy without traction therapy, only 50% had measured improvement, with an average curvature improvement of less than 20 degrees.

Our hope is that new therapies will emerge. Certainly there is excitement about Xiaflex, a form of injectable collagenase which is currently in phase III clinical trials. It is likely we will not know the results of those trials until late 2011 or early 2012.

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