Review Article

Penile traction therapy for Peyronie’s disease—what’s the evidence?

Mustafa Faruk Usta1, Tumay Ipekci2
1
Department of Urology, Section of Andrology, Akdeniz University School of Medicine, Antalya, Turkey; 2Department of Urology, Başkent
University Alanya Research Hospital, Antalya, Turkey
Contributions: (I) Conception and Design: MF Usta; (II) Administrative support: All authors; (III) Provision of study materials or patients: MF Usta; (IV)
Collection and Assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VII) Manuscript Writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Prof. Mustafa Faruk Usta, MD. Department of Urology, Section of Andrology, Akdeniz University School of Medicine,
Dumlupinar Bulvari Kampus 07070 Antalya, Turkey. Email: [email protected].

Abstract: Penile traction therapy (PTT) is a new therapeutic option for men with Peyronie’s disease
(PD). However, it has a long history of use in other fields of medicine including bone, skin, skeletal muscle,
and Dupuytren’s. Mechanotransduction, or gradual expansion of tissue by traction, leads to the formation
of new collagen tissue by cellular proliferation. As a molecular result, continuous extension of the fibrous
plaque causes significant increases in collagenase and metalloproteinases, and, ultimately, to fibrous
plaque softening and extension. This hypothetical knowledge has been supported by recent well designed
experimental studies. Furthermore, several clinical papers have provided promising results on the use of
PTT in PD patients. It has been shown in some series that the use of PTT significantly increases flaccid
and stretched penile lengths and results in significant penile curvature improvement when compared to
baseline. Furthermore, the use of PTT concomitantly with either verapamil or interferon α-2b has also
been shown to be an effective therapy. Additionally, the beneficial effect of PTT on penile length before
or after penile surgery in men with corporal fibrosis has been described. Finally, as a minimally invasive
alternative treatment option to penile augmentation surgery in men with dysmorphophobia, PTT use has
shown promising results by several experts. Studies have shown that PTT provides an acceptable, minimally
invasive method that can produce effective and durable lengthening of the penis in men complaining of a
small/short penis. There are, however, several criticisms related to the designs of the reported studies, such
as small sample size and selection bias. Well-designed studies with larger numbers of patients and longer
follow-up periods are, however, needed to establish the true benefits of PTT.

Keywords: Peyronie’s disease (PD); penile traction therapy (PTT); penile shortening

Submitted Feb 18, 2016. Accepted for publication Mar 02, 2016.
doi: 10.21037/tau.2016.03.25
View this article at: http://dx.doi.org/10.21037/tau.2016.03.25

Introduction options for PD are used to treat patients in the early/

acute phase of the disease. Although several reports in
Peyronie’s Disease (PD) is manifested by the development
the literature exist of penile curvature stabilization and/or
of a fibrous inelastic scar within the tunica albuginea, which improvement in other clinical symptoms, recent guidelines
can lead to penile deformity, penile curvature, shrinkage, describe that the available evidence reveals no significant
narrowing, hinging, shortening, and painful erections. benefit from common medical treatment options, especially
These symptoms subsequently cause painful and/or for reducing penile curvature (3). On the other hand,
unsatisfying sexual intercourse (1-7). according to the recent therapy guidelines, medical
Treatment options range from reassurance to medical, treatment options including either oral or intralesional
mechanical, and surgical options (1). Medical treatment injection therapy have been widely accepted as the standard

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304 Usta and Ipekci. Penile traction therapy in Peyronie’s disease

of care at the first presentation of men with PD (8). In reorganization and remodeling of collagen fibers into
addition to oral and intralesional injection therapy, several uniform, densely packed fibrils that are parallel to the
authors have also used other non-surgical treatment axis of mechanical strain (16). Chung et al. performed
modalities to treat patients with PD, including topical the first experimental study related to the efficacy of
therapy, extracorporeal shockwave therapy, iontophoresis, tissue traction therapy in PD in a rigorously designed
and penile traction therapy (PTT) (1-4). PTT, which model (5). Briefly, using a cyclic strain culture system, the
produces gradual mechanical traction to the penis, has been authors investigated the cellular changes to the tunical
described as an efficient, nonsurgical treatment option for tissue following equibiaxial traction forces. The authors
men with PD. It has been suggested that application of hypothesized that the observed protein alteration following
PTT results in an enhancement in the length of the penis in mechanical traction should replicate the changes seen in
both erect and flaccid forms (6,7). tunical tissue following PTT. In this study, both qualitative
In this article, we aim to review the current literature [immunohistochemistry (IHC)] and quantitative (Western
regarding the use of PTT in men with PD, and, additionally, Blot assay) measurements were examined, hence increasing
its use in specific patient subgroups, including men with the value and reliability of the study. The results of this
shortened penis prior to penile prosthesis placement. excellent study revealed that there was a significant increase
in smooth muscle α-actin, β-catenin, and Hsp-47 protein
contents measured in PD patients, as compared with the
Penile traction therapy (PTT) and Peyronie’s control group. Changes in IHC and Western immunoblot
disease (PD): assays were seen after exposure to cellular equibiaxial
Experimental data tractional forces. IHC staining revealed a decrease in α-actin
staining while Western Blot assay showed a prominent
Several studies have revealed that there are many similarities increase in metalloproteinase-8 expression with no measured
between PD and Dupuytren’s contracture (5,9). The most change in β-catenin level in the stained PD group (5).
important finding was that several genes associated with This interesting study of cells obtained from PD and
collagen degradation, such as matrix metalloproteinases and normal human tunica albuginea cultured in a mechanical
those related to myofibroblast differentiation, were similar in strained environment provided important and promising
both diseases, suggesting that the two conditions may share evidence for the use of PTT in men with PD for plaque
a common pathophysiological pathway (5,10). Therefore, remodeling. Evidence obtained from these basic science
investigators suggested that both conditions may potentially experiments lends support to the clinical use of PTT. It is
respond to similar therapeutic modalities (5). It has been expected that PTT use in PD should yield similar outcomes
previously shown that the use of mechanical traction and as those seen with Dupuytren’s disease or any other similar
tissue expansion therapy leads to an alteration of connective clinical conditions.
tissue by cellular proliferation and expansion of the
extracellular matrix (5). Tissue traction, or the use of tension
to evoke a biologic response, has been investigated in Clinical data
numerous other clinical conditions and in several disciplines. There are several commercially available penile stretching
The mechanism, namely “mechanotransduction”, has been or traction devices for PD, including FastSize Penile
described as a process that converts mechanical stimuli to Extender device (FastSize Medical, Aliso Viejo, CA, USA),
cellular biochemical responses (5). Although the concept of Andro-Penis (Andromedical, Madrid, Spain), Golden
‘tissue traction therapy’ had not been studied in the penis or Erect extender device (Ronas Tajhiz Teb, Tehran, Iran),
PD models until the early 2000s, the biochemical response SizeGenetics (GRT Net Services Inc., Gresham, OR,
to tissue traction has previously been investigated in skin, USA), Vimax Extender (OA Internet Services, Montreal,
bone, skeletal muscle and Dupuytren’s models (11-14). In Canada) and ProExtender (Leading Edge Herbals, Greeley,
Dupuytren’s contracture, a pro-fibrotic clinical condition CO, USA). These devices consist of parallel rods connected
similar to PD, continuous and prolonged mechanical to two padded rings, one proximally at the base of the
tension on the fibrotic tissue may cause collagen remodeling penis and a second distally underneath the corona. PTT
and tendon healing (15). Additionally, histological staining is performed by holding the penis in a small frame and
studies have shown that, after traction therapy, there is applying a gentle, but progressive, traction force on it,

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Translational Andrology and Urology, Vol 5, No 3 June 2016 305

Table 1 Clinical data published on PTT

Author Number of patients Patient group Duration of treatment Efficacy
Levine et al., 2008 10 PD patients 2–8 h/day; 6 months CI: 10°–40°; SPL: 0.5–2 cm
Gontero et al., 2008 15 ‘Short penis’ 4 h/day; 6 months FPL: 2.3 cm; SPL: 1.7 cm
Levine et al., 2011 10 ‘Short penis’ before IPP 2–4 h/day; 4 months SPL: 0.5–3 cm
Nikoobakht et al., 2011 23 ‘Short penis’ 4–6 h/day–2 weeks; FPL:1.7 cm; SPL: 1.7 cm
9 h/day up to 3 months
Rybak et al., 2012 TAP: 52; PTT(+): 27; PD patients after TAP or >2 h/day; 3 months SPL; TAP (PTT+): 0.85 cm;
PTT(−): 25; PEG: 59; PEG surgery TAP (PTT−): −0.53 cm;
PTT(+): 36; PTT(−): 23 PEG (PTT+): 1.48 cm;
PEG (PTT): 0.24 cm
Abern et al., 2012 IVI: 35; IVI+PTT: 39 PD patients after IVI 2–8 h/day; 6 months EPC (IVI): −20.9°;
EPC (IVI+PTT): −26.9°;
SPL (IVI): −0.74 cm;
SPL (IVI+PTT): 0.6 cm
Martinez-Salamanca PTT(+): 55; PTT(−): 41 Acute phase PD patients 6–9 h/day; 6 months EPC (PTT+): −20°;
et al., 2014 EPC (PTT−): +23°
Nowrozzi et al., 2015 54 Penile dysmorphophobia 4–6 h/day; 6 months SPL: 1.3 cm; FPL: 1.7 cm
Yafi et al., 2015 INF: 78; INF+PTT: 34 PD patients with previous Daily use of less or SPL (<3 h PTT): 1.3 cm;
INF α-2b treatment greater than 3 h (>3 h PTT): 4.4 cm
PTT, penile traction therapy; PD, Peyronie’s disease; CI, curvature improvement; SPL, change in streched penile length; FPL, Change
in Flaccid Penile Length; TAP, tunica albuginea plication; PEG, plaque excison and grafting; EPC, change in erect penile curvature; IVI,
ıntralesional verapamil ınjection; INF, ınterferon α-2b.

which can be accomplished by the addition of small metal Life Specific to Male Erection Difficulties (QOL-MED)
extensions to the parallel dynamic rods and frame for questionnaires. At the end of the study, all men reported
certain time periods (5,7). Available data related to PTT reduced curvature (10–40°), increased penile length
treatment is summarized in Table 1. (1–2.5 cm), and increased erect penile girth (0.5–1 cm),
The first report for the use of PTT in men with PD with correction of hinge effect in four out of four men.
was presented at the 4th annual meeting of the European However, there was no significant change in quality of
Society for Sexual and Impotence Research (ESSIR) in life by QOL-MED in this series. The authors of this pilot
2001. In this small study, eight men with at least a 3 months study concluded that, even though the study included small
history of PD without ED underwent PTT for 4 h per day number of patients, early results suggested that prolonged
for a total of 3–6 months. The authors reported a 4.1-cm daily use of PTT treatment should be considered as a new
increase in mean penile length (P˂0.05) and a 14° decrease approach for the nonsurgical treatment of PD. Additionally,
in mean erect penile deviation (from 34° to 20°; P˂0.05) in the authors noted the need for further well designed,
this series (17). randomized studies with larger numbers of patients (18).
Levine et al. evaluated the efficacy of prolonged external One year later, Gontero et al. (19) reported the results
PTT as a nonsurgical treatment option in 10 men with PD. of PTT use in men with a minimum of 12 months history
In this non-controlled pilot study of PTT, patients were of PD and penile curvature of less than 50°. In this study,
treated using the FastSize penile extender. Traction was penile measurements were obtained by photographs taken
applied as the only treatment for 2–8 h per day for 6 months. by the researchers after a vasoactive agent induced an
Penile curvature, and stretched penile length and girth were artificial erection. The patients were instructed to use the
measured before and after treatment. Additionally, erectile PTT for a minimum of 5 h per day, up to a maximum of 9 h.
and sexual function was assessed using the International The results of this study showed that, in PD patients who
Index of Erectile Function-5 (IIEF-5) and Quality of completed the study, penile curvature decreased without

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306 Usta and Ipekci. Penile traction therapy in Peyronie’s disease

statistical significance (31° to 27°; P=0.056); however, length improvement was related to the duration of traction
there was a significant improvement in the mean flaccid device use (20).
and stretched penile length measurements (1.3 and 0.8 cm, More recently, in a similar study by Yafi et al., the
respectively). More importantly, the authors reported benefit and duration of daily PTT was assessed in men
that there was no further change in penile curvature or with PD who underwent interferon α-2b therapy. A total
length even 6 months after PTT. The results of this study of 112 patients underwent a median of 12 interferon
suggested that, although the use of a penile extender device α-2b injections, with daily use of PTT reported by 31%
provided minimal improvements in penile curvature, there of patients. The results of this study showed that the use
was a reasonable level of patient satisfaction, most probably of penile traction did not affect change in penile girth.
because of increased penile length. However, men who used PTT 3 or more hours per
Recently, in a nonrandomized prospective controlled day gained significantly greater stretched penile length
trial, investigators specifically assessed the efficacy of a penile compared to those who did not undergo PTT (21).
traction device for the treatment of men in the acute phase of
PD. In this study, 55 patients underwent PTT for 6 months,
The use of penile traction therapy (PTT) before
and were compared with 41 patients with acute phase of
penile surgery
PD who did not receive active therapy. The results of the
study showed that penile curvature decreased from 33° at Inflatable penile prosthesis (IPP) implantation is the
baseline to 15° at 6 months and 13° at 9 months with a mean standard of care for the treatment of patients with advanced
decrease of 20° (P˂0.05) in the PTT group. Additionally, ED, and/or is unresponsive to nonsurgical therapy. In most
pain scores significantly decreased after 6 months series, though the patient/partner satisfaction rates are
while erectile function and erection hardness also improved generally high, concerns remain about penile length after
significantly in the PTT group, compared to the no IPP placement amongst a considerable group of patients. In
intervention group. Furthermore, PTT was associated with a non-controlled pilot study, the effect of PTT in men with
the disappearance of sonographic penile plaques in 48% a shortened penis before IPP placement was investigated.
of PD patients, and the need for surgery was eliminated in This study included 10 patients who were instructed to
40% of patients who were, otherwise, good candidates for wear the device for 2–4 h daily for 2–4 months before IPP
surgery. Altogether, these results suggested that PTT is an placement. Baseline stretched penile length (SPL) was
effective treatment option for the acute phase of PD, with compared with post-traction SPL and post-implant inflated
significant decreases in pain and penile curvature, and an erect length. None of the patients complained about penile
improvement in erectile function (6). loss postoperatively, while 70% of men had measured
Abern et al. also described the use of PTT as a part length gain of up to 15 cm, compared with the baseline
of a combination treatment modality for men with PD. pre-traction SPL (22).
This study aimed to investigate the benefit of PTT when Similarly, in men who underwent IPP placement
combined with intralesional verapamil injections and after radical prostatectomy, and were dissatisfied with
oral L-Arginine 1 g b.i.d. and pentoxifylline 400 mg t.i.d. post-significant loss of penile length post-operatively,
in men with PD. Briefly, 74 men with PD completed authors recommended PTT for 6 months before IPP
12 intralesional verapamil injections. Patients who opted for revision surgery in order to increase penile length. After
PTT used the device for 2–8 h daily. Stretched penile length 6 months of therapy, there was a 2.3-cm increase in SPL,
and erect penile curvature using penile ultrasonography which enabled the placement of a prosthesis that was 20%
were measured. A ≥10° improvement in penile curvature was longer in length (15 to 18 cm), and erect penile length
considered a clinically significant response to therapy. Men increased by 4.4 cm. These results suggested that the use of
who used the device more than 3 h per day gained 0.6 cm PTT increases penile corporal length, and, thus, the length
in stretched penile length vs. 0.07 cm when used less than 3 h of an IPP in a patient unsatisfied with his current IPP (23).
per day, while men who did not use the device lost 0.74 cm In another study conducted by Moncada-Iribarren et al.,
of stretched penile length on average. In summary, this PTT was used in men who underwent PD surgery. In this
study showed that better curvature improvement and series, 12 men had plaque incision + graft placement while
stretched penile length gain was seen in the combination 28 underwent penile plication. Patients were randomized
group. Additionally, multivariate analysis revealed that to PTT vs. observation. PTT was applied for 8–12 h per

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Translational Andrology and Urology, Vol 5, No 3 June 2016 307

day for at least 4 months. Penile shortening for both groups in another series, 54 men with a ‘short penis’ underwent
was from 0.5 to 4 cm. The use of PTT led to an increase in PTT 4 to 6 h per day for 6 months. Flaccid, stretched,
SPL, which ranged from 1 to 3 cm. Additionally, sustained and erect penile length measurements were performed at
treatment with PTT for 4 months caused an increase in baseline and again after 1, 3, 6 and 9 months. Additionally,
SPL from 1 to 4 cm (24). erectile function was assessed at baseline and at 9 months
In a more recent study, authors have assessed patient after treatment by IIEF-5. A significant increase in flaccid,
outcomes with regards to SPL change and penile stretched, and erect penile length was observed at the 6th
satisfaction after penile plication and partial plaque excision month follow-up, when compared to baseline values. On
and grafting with or without postoperative application of the other hand, no significant change was seen in penile
PTT. The results of this study showed that, in patients who girth after PTT treatment. Nine out of 13 patients with
used PTT, there was no perceived length loss, while 58% mild baseline ED reported normal erectile function after
reported a mean erect length gain of 1.1 cm, suggesting that 9 months of PTT (25).
postoperative PTT can result in length preservation, and, in Altogether, the results of these studies suggest that
most cases, measured and perceived length gain is possible PTT should be considered as a noninvasive and effective
after correction of the curvature (11). treatment modality to increase penile length in patients
seeking treatment for a ‘Short/small penis’.

Penile traction therapy (PTT) and penile

dysmorphophobia Conclusions

Penile dysmorphophobia has been defined as a body PTT is a relatively new area of interest for the nonsurgical
dysmorphic disorder. Body dysmorphia is a somatoform treatment of men with PD. Additionally, PTT has been
disorder conferred by preoccupation with an imaginary used in patients with postoperative loss of penile length, and
or trivial flaw in the physical appearance, which leads to for the management of men complaining of a small penis
deficiency in several areas of functioning. This problem can despite an objectively normal size. In the literature, there
cause major depression and social dysfunction, which may are an increased number of articles reporting promising
ultimately lead to social isolation (25). Small penis syndrome results after the use of PTT. It is, however, important
has been described as an anxiety related to the external to consider several issues regarding PTT, including the
genitalia with the penile length being shorter than normal efficacy of this therapy in the different subgroups of PD
size for a normal adult (25). Studies have actually shown patients. Another important point is that, in comparison
that, while there is an increase in men who are concerned to PTT for the treatment of dysmorphophobia and
about their penile length, most men complaining of short postsurgical short penises, the lengthening benefit of this
penis have, in fact, a normal sized penis (25,26). Real ‘Short intervention in PD patients has been found to be inferior.
penis-micropenis’ is defined as penile lengths of less than Therefore, realistic expectations, especially in men with
4 and 7.5 cm, respectively in the flaccid and stretched PD, should be discussed before recommending PTT. It
configurations (26). According to recent literature, the use should also be kept in mind that PTT requires a committed
of PTT in men with a ‘normal sized’ penis is suggested as and compliant patient who is willing to devote time to a
an alternative option against several surgical interventions relatively long treatment period. Studies have shown that
which actually may cause devastating results (27). when used concomitantly with intralesional injection of
In a phase-II prospective study conducted by Gontero, both verapamil and INF α-2b, PTT provided a significant
the efficacy of PTT was assessed in 15 men. After a 6-month increase in stretched penile length when compared to no
treatment period, there was a significant gain in penile length PTT. Therefore, it seems that PTT, in combination with
(2.3 and 1.7 cm flaccid and stretched, respectively (28). intralesional plaque therapy, represents a good nonsurgical
In a similar study of 23 patients, PTT was applied for 4–6 h therapeutic option for men with PD.
per day for the first 2 weeks and then 9 h per day until the In conclusion, level 2b evidence (according to the
end of the third month. Both flaccid and stretched penile Oxford Centre for Evidence-based Medicine) suggests
sizes increased significantly during the first and second that PTT is a tolerable, minimally invasive method for
follow-up. Additionally, the circumference of the glans men with PD. However, most of the studies related to this
penis significantly increased after PTT (29). More recently, treatment option are not well designed and have a limited

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308 Usta and Ipekci. Penile traction therapy in Peyronie’s disease

number of patients. Another important issue is that the and grafting for Peyronie's disease: measured lengths and
time of device application (3 to 6 h) and treatment duration patient perceptions. J Sex Med 2012;9:2396-403.
(3 to 6 months) remain to be defined. Further prospective, 12. Ilizarov GA. The tension-stress effect on the genesis and
randomized, controlled studies with a larger number of growth of tissues. Part I. The influence of stability of
patients and longer follow-up periods are needed. fixation and soft-tissue preservation. Clin Orthop Relat
Res 1989;(238):249-81.
13. Molea G, Schonauer F, Blasi F. Progressive skin extension:
Acknowledgements
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14. Sun JS, Hou SM, Hang YS, et al. Ultrastructural studies
on myofibrillogenesis and neogenesis of skeletal muscles
Footnote
after prolonged traction in rabbits. Histol Histopathol
Conflicts of Interest: The authors have no conflicts of interest 1996;11:285-92.
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continuous elongation technique for severe Dupuytren's
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Cite this article as: Usta MF, Ipekci T. Penile traction therapy
for Peyronie’s disease—what’s the evidence. Transl Androl Urol
2016;5(3):303-309. doi: 10.21037/tau.2016.03.25

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