Current AUA guidelines for Peyronie’s disease published in 2015 recommend that only 2 types of treatments be offered: intralesional injections or surgical therapies (plication, grafting, prosthesis).¹ Numerous factors affect whether patients are candidates for these 2 options, some being patient specific and others being system based. Some of these factors include acute vs chronic phase, degree of curvature, associated deformities (ie indentation or tapering), multiplanar curves, baseline erectile function and presence of calcification. However, 2 overlying factors can affect decisions, cost and access to care.

Patient-centered factors will guide treatment recommendations.² One would not want to perform corrective surgery if the deformity is still in the acute phase and actively changing. Associated deformities like indentation or tapering may cause some to choose surgical grafting rather than plication surgery, and poor baseline erections would push recommendations the opposite way. The presence of large calcifications has been shown to make intralesional collagenase less effective, and providers may choose to recommend penile plication instead.³ Ultimately, an experienced provider can use a detailed history, physical examination and deformity assessment to determine the best course of action with shared decision making. Many patients can be divided into 2 personality groups. The first are those who are averse to surgery and want a more conservative option regardless of the longer treatment cycle and thus choose injections. The other personality group wants the fastest option with the least amount of interruption in their lives, and they often choose surgical repair.

Costs have increased since the release of intralesional collagenase in 2013. A retrospective cohort study conducted using claims data from the Truven MarketScan® database illustrates, in 2018, the mean cost of treatment with intralesional collagenase was substantially higher than surgery ($20,260 and $10,930, respectively).⁴ From 2007 to 2018, the average treatment cost per patient increased almost sixfold from approximately $1,500 to $10,000 per patient. A 2017 cost analysis comparing intralesional collagenase to penile plication found the mean costs for penile plication surgery were approximately $3,000 vs $25,000 for intralesional collagenase.⁵ These costs can be prohibitive for some patients whose insurance does not cover costlier treatments like intralesional collagenase.

Access to care is a growing problem, and with the current physician shortage this is increasingly evident in specialty care. According to the 2020 AUA Census, of the more than 13,000 practicing urologists, only about 5% report having a primary subspecialty area in either erectile dysfunction or male genitourinary reconstruction (the closest subspecialty areas that might include Peyronie’s disease treatment).⁶ This does not fully represent all the urologists who treat Peyronie’s disease, but it does illustrate how difficult it may be for patients to find proper care. This only gets worse in the rural areas. As shown by the Census report, only 10% of practicing urologists report their primary practice location in nonmetropolitan (population less than 50,000) areas while 20% of the population lives in these areas. In addition, 62% of U.S. counties have 0 urologists with a primary practice located within them. Access to care will increasingly be more of a problem as fewer physicians enter rural practice, necessitating patients to travel further for care.⁷

In summary, many factors contribute to the treatment of Peyronie’s disease. With the help of a careful history, focused exam and in-office deformity assessment, a properly experienced provider can navigate the patient through these patient-centered factors. However, some factors are more systems based and rely on major changes to the delivery of health care to decrease costs and increase access to care.