A Multimodal Approach to Peyronie's

Peyronie’s disease is one of those conditions where the gap between what we understand pathologically and what we offer therapeutically is genuinely uncomfortable. We know it starts as inflammation, progresses to fibrosis, and ends in a structurally remodelled tunica. We know the molecular drivers. And yet for most patients the pathway is still: reassure, maybe try pentoxifylline or tadalafil, wait for stabilisation, then discuss surgery if the curve is bad enough.

A perspective article by Hatzichristou in IJIR (April 2026) proposes something different. Not a trial result, not a guideline update. A fully specified multimodal protocol designed to intervene at the biology rather than around it. It’s called the 3Ts Protocol, and it’s worth knowing about even if the evidence base is still early.

What the 3Ts Actually Are

Three components, used one after another.

Tadalafil 5mg daily. Started before sleep to coincide with nocturnal erections. The framing here is different from how we usually use it: not to treat the ED that sits alongside the Peyronie’s, but to create a less hostile tissue environment before you do anything else. Sustained PDE5 inhibition improves cavernosal oxygenation and suppresses the hypoxia-driven TGF-beta1 pathways that feed tunical fibrosis. That framing matters.

Tunneling with intralesional biologics. The procedural core. Under local anaesthetic, multiple longitudinal and oblique micropunctures are made through the plaque using a 27G needle (roughly four tunnels per centimetre of fibrotic tissue). PRP and hyaluronic acid are injected through those channels. The mechanical disruption is part of the point: it may convert a stable fibrotic plaque back into a more biologically responsive state, while the biologics deliver growth factors directly into a matrix that would otherwise block their diffusion. A single session of low-intensity shockwave therapy is given just before injection, timed to transiently increase tissue permeability.

Traction therapy. Starting the same evening as the first injection, patients use a penile traction device for 90 minutes daily over three months. After tunneling softens the plaque, traction preserves those micro-spaces, limits re-adhesion of collagen, and nudges the tissue into better alignment.

Four injection sessions over two to three week intervals. The full cycle runs three months, with reassessment at the end. A second cycle can follow if response is suboptimal.

What’s Genuinely Interesting

It’s completely new to me.

It’s fully specified. Most multimodal Peyronie’s protocols don’t give enough detail. This one does: needle gauge, tunnel density, shockwave parameters, traction schedule, timing of each phase. Whether or not you agree with the approach, you could reproduce it. That’s rarer than it should be.

It challenges the active-versus-stable model. The traditional model says active phase is the intervention window, stable phase means surgery if needed. If tunneling can mechanically revert a stable plaque to a more responsive state, that distinction becomes less of a treatment gate and more of a tissue description. Not proven yet, but a reasonable hypothesis. And it changes how you think about the disease.

It addresses ED as a contributor, not just a co-morbidity. For men with vascular risk factors, partial erections may generate inadequate axial rigidity and increased tunical stress. The protocol can be modified to add revascularisation-focused shockwave sessions across the treatment period. More thoughtful than most guidelines on the ED-Peyronie’s overlap.