Peyronie’s disease (PD) is a wound healing disorder characterized by scar tissue (“plaque”) formation within the penile tunica albuginea. Patients present with penile pain, deformity (curvature, indentation, shortening) and sexual dysfunction. Treatments are aimed at relieving pain, enhancing sexual function and improving psychological bother. Most authorities consider surgery as the gold standard therapy for correcting bothersome penile curvature. However, patients with milder symptoms may desire less invasive treatments. Most oral agents are recommended against due to the lack of proven efficacy.¹ Intralesional injections with verapamil, interferon α-2B, and collagenase Clostridium histolyticum (CCH) provide modest yet meaningful improvements. However, these agents require frequent visits and have the potential for rare but serious side effects.

During the last 2 decades penile traction therapy (PTT) for PD has garnered significant interest. With this approach, longitudinal stretching forces are applied to the flaccid penis via a mechanical device. Chung et al showed that traction applied to PD plaques results in cellular-level changes (collagenase activation and upregulation of matrix metalloproteinases among other mechanisms) with resultant plaque remodeling.² Several clinical studies support potential benefits for penile curvature and penile shortening, the latter of which is an area of significant bother with few reliable treatments. Furthermore, PTT is performed in the comfort of a patient’s home, making it an appealing option for those men who desire less invasive therapy. Please see the Appendix for an overview of the available literature.

Scroppo et al first reported on PTT monotherapy in 8 men with PD in 2001.³ They found significant improvements in curvature (–14 degrees; p=0.05) and nonsignificant increases in stretch penile length (SPL; mean +4.1 mm; p >0.05) when PTT was used for ≥4 hours daily for at least 3 months. Levine et al similarly reported curvature improvements of 10 to 40 degrees, and increases in SPL of 0.5 to 2.0 cm in a small pilot study.⁴ Martínez-Salamanca et al subsequently evaluated PTT in men during early (acute) phase PD in a nonrandomized, prospective controlled trial.⁵ In those patients who performed daily PTT (6 to 9 hours/day) for a period of 6 to 9 months, the mean curvature improvement was –20 degrees compared to a mean +23 degree (worsening) in the nontraction group (p <0.05). SPL also increased by a mean +1.5 cm in the PTT group versus –2.5 cm (loss) in the nonintervention group (p=0.03). Improvements were more common in men with curve <45 degree. The amount of PTT also played a role, as all those who achieved >10 degrees of curve improvement reported using the PTT system for >6 hours daily.

The majority of available traction devices use some variation of a constrictive band applied over the coronal sulcus to secure the distal penis. A series of modifiable rods allow the user to apply greater forces based on penile length and elasticity. Recently, 2 trials have assessed newer generation devices. The Penimaster PRO (MSP Concept, Berlin, Germany) uses a vacuum cup on the glans, which is thought to spread force across the entire glans, thereby enhancing comfort. Traction is applied using a series of rods, a belt (worn around the waist, leg or shoulder) or weight system. Moncada et al studied 93 patients with chronic phase PD (≥45 degrees) who were randomized to PTT or no intervention.⁶ Patients with hourglass deformity, complex curvatures and indentation were excluded. Following 3 months of PTT for 3 to 8 hours/day, patients demonstrated a mean curvature improvement of –31.2 degrees vs –2.4 degrees in the nonintervention group (p <0.0001). Patients using PTT >6 hours/day demonstrated a mean improvement of –38.4 degrees compared to –19.7 in patients using the device for <4 hours/day. SPL increased by +1.8 cm (p=0.03) in the traction group. In all, 43% of patients experienced an adverse event such as local discomfort or glans numbness, and 3 patients prematurely discontinued the study (6.5%).

In 2019 our group evaluated outcomes with another new PTT system known as the RestoreX (PathRight Medical, Plymouth, Minnesota).⁷ This has several novel design elements such as a novel glans clamp design, ability to bend the penis in the direction opposite the curvature for counter traction and dynamic traction adjustments without the need to remove the device. In this single-blind, randomized-controlled trial (ClinicalTrials.gov NCT03389854), 110 patients with PD and curve >30 degrees were randomized to 3 months of PTT for 30 to 90 minutes/day vs nonintervention. Unlike previously mentioned study protocols, patients with compound curvature, indentation/hourglass deformity or prior intralesional injections were not excluded. At 3 months >75% of PTT patients demonstrated improvements in curvature (mean –11.7 degrees or 18%; p <0.01) and 95% achieved an increases in SPL (mean +1.5 cm; p <0.001). Subjectively, 75% of patients considered the treatment “meaningful” and two-thirds were somewhat or very satisfied with the treatment. Adverse events such as pain or glans discoloration were mild and transient. Positive benefits were similarly seen in the open-label and long-term followup phases of the trial at 6-month and 9-month followup.⁸ Notably, this was the first and only study to demonstrate benefit of PTT with therapy <3 hours/day, which may allow for enhanced patient compliance.

PTT has also been studied as an adjunct to intralesional injections, although the data are somewhat mixed and suffer from significant methodological limitations. Even less has been reported on the use of adjunctive PTT with PD surgery, with a single study supporting improvements in penile length after plication and grafting approaches for PD.⁹ PTT may be considered in this setting for those men who are highly motivated to optimize penile length and curvature concurrently.

PTT is a noninvasive treatment for PD. It can be used as primary monotherapy or in combination with other approaches. High level evidence is lacking, but the available literature supports possible modest improvements in penile curvature and length. It is one of the only nonsurgical therapies shown to improve penile length. Patient compliance is a limiting factor, but newer PTT systems with novel attributes may enhance outcomes.