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Penile Traction Therapy (PTT)

Penile traction therapy (PTT) is a non-invasive mechanical treatment that applies controlled longitudinal force to the penis. It has been studied mainly in Peyronie's disease (curvature improvement, length preservation, and as an adjunct to intralesional therapy). Other uses are post-radical-prostatectomy penile rehabilitation, pre- and post-penile-prosthesis length optimization, and cosmetic penile lengthening (penile dysmorphophobia).[1][2]

Mechanism of action​

PTT is proposed to act through mechanotransduction, the cellular process by which mechanical stimuli are translated into biochemical responses. Proposed effects of continuous longitudinal traction include:

  • Increased matrix metalloproteinase (MMP) activity within treated tissue, driving collagen degradation and scar remodeling.
  • Re-orientation of collagen fibrils along the direction of applied force.
  • In a rat model of Peyronie's disease, traction and vacuum devices both reduced curvature compared with controls (15.3° and 28.4° vs 38.6°). The vacuum group had more preserved smooth-muscle actin and less TGF-β1 and SMAD 2/3 staining, and the authors propose antifibrotic, antiapoptotic and smooth-muscle-preserving mechanisms.[4]

Devices​

DeviceMechanismDaily durationNotes
RestoreX (PathRight Medical)Rod-based traction with counter-bending30–60 min/day per 2025 IFUShortest listed wear time; counter-bend feature for curvature; developed with Mayo Clinic. The Peyronie's RCT tested 30–90 min/day, and randomized data also exist after radical prostatectomy.[1][2][9][12][27]
Penimaster PRO (MSP Concept)Vacuum-adhesion + traction3–8 hoursDose-dependent response in a randomized trial in stable PD; vacuum grip avoids strap compression.[5]
Andropenis / Andropeyronie (Andromedical)Strap-based traction4–6 hoursStudied for cosmetic lengthening and as an adjunct to collagenase.[6]
Golden Erect (Ronas Tajhiz Teb)Strap-based traction4–9 hoursLimited data.[7]

Randomized data in Peyronie's disease exist for RestoreX and Penimaster PRO.[5][9]

Clinical indications and evidence​

Peyronie's disease — strongest evidence base​

Guideline endorsement of PTT in Peyronie's disease varies by society. The Cochrane review rated the certainty of the traction evidence as very low.[3] PTT has been used alone and as an adjunct to CCH, interferon α-2b, verapamil, or surgery.[8] The EAU 2026 guideline notes that responses in calcified plaques and hourglass or hinge deformities have not been studied systematically.[25]

TrialDevice / ProtocolKey outcome
Ziegelmann 2019 J Urol RCT (n=110, Mayo; 3:1 randomization to PTT or no therapy; primary outcome safety)[9]RestoreX 30–90 min/day × 3 moAt 3 mo vs controls (62 traction and 27 control men with objective data): +1.5 cm vs 0 cm stretched length (p < 0.001), −8.5° vs −1.1° primary curvature (p < 0.001), and −11.7° vs +1.3° composite curvature (p < 0.01); IIEF-EF improved in men with ED (+4.3 vs −0.7, p = 0.01)
Joseph 2020 RestoreX open-label and follow-up phases[10]Open-label use after the randomized phase (mean use 31 min/day; n = 64 at 6 mo)Among 37 original traction-arm men using RestoreX ≥15 min/day for 6 mo, 95% had length gains and 61% had curvature improvements; no controlled comparison after 3 months
Moncada 2019 BJU Int Penimaster PRO RCT (93 randomized; 41/47 traction and 39/46 control completed at 12 weeks; stable unidirectional PD ≥45°, without ED or significant pain; hourglass/complex deformity, indentation, and prior intralesional therapy excluded)[5]3–8 h/day × 12 wkAmong completers, mean curvature fell 31.2° (41.1%) and stretched length increased 1.8 cm in the traction arm; controls had no significant curvature change. Use >6 h/day was associated with a 38.4° (51.4%) mean reduction, versus 19.7° (28.8%) with <4 h/day.
Cochrane 2023 (Rosenberg)[3]SROne traction trial (about 90 men); curvature MD −7.4° with very low certainty; no evidence on ability to have intercourse

Post-radical-prostatectomy penile rehabilitation​

Radical prostatectomy commonly causes penile shortening, ED, and corporal fibrosis.[11]

  • Toussi 2021 J Urol RestoreX RCT (n = 82 randomized to control or one of two PTT protocols; 6-month data in 25 controls and 30 PTT men): stretched length to corona +1.6 cm in 26 PTT men vs +0.3 cm in 25 controls (p < 0.01), median IIEF-EF change 0 in 29 PTT men vs −6.5 in 24 controls (p = 0.03), and intracavernosal injection use 4/21 (19%) vs 8/16 (50%).[12] In men with baseline ED, the IIEF-EF contrast did not reach significance (+5 vs −6, p = 0.28).[12] The 2023 open-label extension had 9-month data for 45/82 men: the 13 men initially assigned to traction who averaged <15 min/day in the open-label phase retained a mean 1.8-cm stretched-length gain to the corona, while erectile-function change did not differ significantly between the initially treated men averaging >15 min/day in that phase and initial controls averaging <15 min/day (P = .16).[26]

Pre- and post-penile-prosthesis length optimization​

PTT has been used to optimize penile length before IPP placement, particularly in men with shortening from prior surgery, explantation, or PD.[13][14]

  • Levine 2011 pilot (n = 10, 2–4 h/day × 2–4 mo before IPP): no measured or perceived length loss after implant; 70% had a measured erect length gain of up to 1.5 cm over baseline stretched length.[14]
  • Moskovic 2011 case report: one post-prostatectomy patient with an existing IPP used a vacuum erection device twice daily for approximately 1 year and traction for 8 h/day for 8 months. Stretched length increased by 2.3 cm after 6 months of traction; subsequent revision allowed a 20% longer prosthesis (15 to 18 cm).[15]
  • Evidence in this indication is limited to a small pilot and a case report.

Cosmetic / aesthetic penile lengthening (penile dysmorphophobia)​

Men seeking penile enhancement may have normal dimensions, micropenis, or adult-acquired buried penis; size measurement and psychosexual assessment help distinguish these from penile dysmorphic disorder.[6][29] The Fifth ICSM consultation reports about 2 cm average length gain after at least 3 months of daily traction, while noting small heterogeneous studies and uncertain durability.[29]

  • AndroPenis (Nowroozi 2015): 54 of 163 counseled men with penile dysmorphophobia were willing to use the device; four were excluded and 44 completed treatment. In this uncontrolled series, use was prescribed for 4–6 h/day × 6 mo; among completers, mean gains at 6 mo were +1.7 cm flaccid, +1.3 cm stretched, and +1.2 cm erect (all p < 0.001); no effect on girth was observed.[6]
  • Golden Erect (Nikoobakht 2011): n = 23 (mean age 26.5 years), uncontrolled, 4–6 h/day for 2 weeks and then 9 h/day to 3 months: flaccid length 8.8 to 10.5 cm and stretched length 11.5 to 13.2 cm (p < 0.05); proximal girth did not change, while glans circumference decreased from 9.3 cm at 1 month to 8.8 cm at 3 months (p < 0.05).[7]
  • Oderda and Gontero 2011 review: penile extenders were the only non-invasive lengthening method with some scientific support, and the authors judged their results not inferior to surgery.[16]
  • Romero-Otero 2021 SR (BJU Int): non-invasive interventions, including traction therapies, were safe and mostly efficacious in 57 studies, but study quality was low and the authors could not make evidence-based recommendations for aesthetic or therapeutic indications.[17]
  • Structured psychosexual counseling should precede any intervention in men with cosmetic concerns; many can be reassured without treatment.[6] See Small Penis Syndrome / PDD and Cosmetic Genital Surgery.

Combination therapy​

PTT can be combined with intralesional injections or as adjunct to surgical correction of PD.[8]

CCH + RestoreX​

The Alom 2019 J Sex Med three-arm comparison is a nonrandomized, single-site analysis of a prospective CCH registry (113 men completing therapy):[19]

OutcomeCCH alone (n=52)CCH + other PTT (n=45)CCH + RestoreX (n=16)
Curvature improvement20.3° (31%)19.2° (30%)33.8° (49%)
Length change−0.7 cm (−4%)−0.4 cm (−2%)+1.9 cm (+17%)
Subjective curvature improvement44%32%63%
Daily PTT use—1.9 h0.9 h
≥ 20° curvature improvementpart of pooled comparatorpart of pooled comparator; NS vs CCH aloneOR 6.9 vs other two groups
≥ 50% curvature improvementpart of pooled comparatorpart of pooled comparator; NS vs CCH aloneOR 3.5 vs other two groups
≥ 20% length improvementpart of pooled comparatorpart of pooled comparator; NS vs CCH aloneOR 10.7 vs other two groups

Results. In this nonrandomized registry, CCH plus RestoreX was associated with greater mean curvature correction and length gain than CCH alone among 113 men with complete posttreatment data (of 287 with traction-use data).[19] CCH with other PTT devices showed no benefit over CCH alone, including in the subset using other devices ≥ 3 h/day. RestoreX was used less (0.9 versus 1.9 h/day), and adverse events were similar across arms.[19] In a later single-center prospective database of 826 men receiving CCH, RestoreX use was associated with the largest curvature improvement of any factor assessed (5–20° depending on the test).[20]

In a 2017 prospective database of 51 men completing CCH, 69% used the Andropenis device (mean 9.8 h/week) and curvature improved a mean of 20.9° overall.[21] Curvature improvement did not differ by frequency or duration of PTT, and stretched length changed by +0.4 cm with PTT and −0.35 cm without (p = 0.21).[21] A 2024 meta-analysis of seven comparative studies (532 men with curvature data) found, in four length-reporting studies (346 men), 0.81 cm more length gain with heterogeneous CCH combinations than with CCH alone (95% CI 0.17–1.45), without a significant curvature difference.[30]

CCH + PTT (IMPRESS-extension protocol — García-Gómez 2021)​

Prospective multicenter single-arm study (n = 87) using the IMPRESS protocol plus a penile extender ≥ 4 h/day starting 24–48 h after injection: mean curvature fell from 57° to 34° (−23.3°, −41%) with a mean of 2 cycles. Without a control arm, the authors suggest that PTT may limit the number of cycles needed.[22]

IFN α-2b + PTT​

  • Yafi 2015 J Urol: in a retrospective review of 112 men receiving interferon α-2b, PTT use overall did not change curvature or stretched length. Men using PTT ≥ 3 h/day gained more stretched length (+4.4 mm versus +1.3 mm, p = 0.04) without a curvature effect.[18]

Emerging "3 Ts" multimodal protocol (Hatzichristou 2026)​

The 3Ts protocol is a proposed multimodal framework: daily Tadalafil (proposed to improve cavernosal oxygenation and counteract hypoxia-driven fibrosis), Tunneling with intralesional biologics (delivers growth factors directly into or around the plaque), and daily Traction (mechanotransductive realignment). The paper is a protocol description, and prospective randomized studies are needed.[23]

Treatment protocols​

No universally standardized protocol exists.[11][8] General principles:

  • Duration: ranges from 30 min/day (RestoreX) to 3–8+ hours/day (traditional devices). In the Penimaster PRO trial, longer daily use was associated with greater curvature improvement, and in the interferon series ≥ 3 h/day was associated with greater length gain.[5][18]
  • Treatment course (RestoreX in Peyronie's disease): After 3 months of randomized treatment and 3 months of open-label use, men who used PTT throughout gained an additional 0.6–0.8 cm of length during months 3–6.[10]
  • Force and breaks: increase traction progressively per device instructions. In the Penimaster PRO trial, men were told not to wear the device during sleep and to remove it every 2 hours for 30 minutes, or sooner for discomfort or numbness.[5]

Safety​

Short trials of specific traction devices reported mostly mild, transient adverse events; the 2023 Cochrane review rated traction adverse-event evidence very low certainty and found no long-term data.[9][8][5][6][3]

  • RestoreX IFU safety: the August 2025 Rev G instructions contraindicate use within six weeks of penile, scrotal, or pelvic surgery unless a medical provider indicates otherwise, with chronic penile pain unrelated to Peyronie's disease, chronic testicular or scrotal pain, or open penile sores or wounds. They do not recommend use in severe vascular disease with absent limb or digit sensation from ischemia or neuropathy, or with penile skin infection; stop use and consult a clinician for new or worsening pain or deformity, persistent skin discoloration or injury, reduced sensation, or worsening sexual function.[27]

  • Adverse events are transient and mild (erythema, local discomfort, skin irritation, temporary glans numbness), typically resolving within minutes of device removal.[10]

  • Serious adverse events: penile fracture, permanent numbness and vascular compromise were not reported in the cited traction-monotherapy trials. In the nonrandomized CCH registry, suspected fractures occurred in 1/52 CCH-only, 2/45 CCH plus other-traction and 0/16 CCH plus RestoreX patients.[9][5][19]

  • RestoreX post-prostatectomy trial: 87% would choose to repeat therapy and 93% would recommend it.[12]

  • In the Penimaster PRO trial, adverse events occurred in 43% of users (mainly local discomfort and glans numbness); 3/47 assigned to traction (6.4%) stopped: two because of glans edema and one because of significant shaft pain after stretching beyond the prescribed limit.[5]

Limitations​

  • Compliance limits efficacy; daily use for extended periods is demanding, and adherence is highly variable.[1][11]
  • No standardized protocols across devices and indications.[8]
  • Penile girth did not increase in the cosmetic-lengthening series (glans circumference did in one).[6][7]
  • Limited long-term data. The RestoreX Peyronie's trial reported outcomes at 3, 6, and 9 months; durability beyond 9 months was not assessed.[10]
  • Overall quality of evidence is low, with small samples and heterogeneous designs.[3][17]
  • Cost and availability vary regionally; not typically covered by insurance.[1]

Guideline positioning​

Guideline endorsement of PTT in Peyronie's disease varies by society, and the Cochrane review rates the certainty of the traction evidence as very low.[3] The 2015 AUA guideline makes no recommendation for or against traction: three observational studies of 4.5–5.0 hours a day reported curvature improvement, and the panel classed traction among unproven "Other Treatments" needing replication in adequately powered randomized designs.[24] The International Consultation on Sexual Medicine report (2015 meeting, published 2016) concluded that PTT is "a viable therapy to modestly improve penile length" as primary therapy, before prosthesis placement in men with decreased length, or after surgery for Peyronie's disease. It may have a role in the acute phase of Peyronie's disease but has inconsistent outcomes in the long-term phase.[2] The Fifth ICSM Peyronie's consensus, published in 2026, conditionally recommends penile extenders or vacuum devices to reduce deformity, alone or in multimodal care (moderate-quality evidence).[31] For cosmetic lengthening, systematic-review evidence is of low quality and does not support graded recommendations.[17] The EAU 2026 limited update offers traction and vacuum devices to reduce deformity or within multimodal therapy for Peyronie's disease , while noting limited data: a meta-analysis of five randomized and nonrandomized trials of penile traction therapy found about 15° of curvature improvement; traction devices were worn two to eight hours daily, with no serious adverse effects reported.[25] As an adjunct to surgery or injection therapy, traction was associated with about 1 cm more stretched length without a significant curvature difference.[25] In a separate meta-analysis, adding traction or vacuum to CCH showed no statistically certain extra benefit for curvature (mean additional decrease 0.3°, 95% CI −3.97° to 4.49°) or length (+0.5 cm, 95% CI −0.32 to 1.4 cm).[28] For short penile size it considers traction as conservative treatment to increase length (weak; level 3).[25]

See Also​

Peyronie's Disease (Male Sexual Dysfunction atlas) · Peyronie's Disease Agents (pharmacology) · Penile Implants · Small Penis Syndrome / PDD · Cosmetic Genital Surgery

References​

1. Sultana A, Grice P, Vukina J, Pearce I, Modgil V. Indications and characteristics of penile traction and vacuum erection devices. Nat Rev Urol. 2022;19(2):84-100. doi:10.1038/s41585-021-00532-7

2. Trost LW, Munarriz R, Wang R, Morey A, Levine L. External mechanical devices and vascular surgery for erectile dysfunction. J Sex Med. 2016;13(11):1579-1617. doi:10.1016/j.jsxm.2016.09.008

3. Rosenberg JE, Ergun O, Hwang EC, et al. Non-surgical therapies for Peyronie's disease. Cochrane Database Syst Rev. 2023;7:CD012206. doi:10.1002/14651858.CD012206.pub2

4. Lin H, Liu C, Wang R. Effect of penile traction and vacuum erectile device for Peyronie's disease in an animal model. J Sex Med. 2017;14(10):1270-1276. doi:10.1016/j.jsxm.2017.08.011

5. Moncada I, Krishnappa P, Romero J, et al. Penile traction therapy with the new device 'Penimaster PRO' is effective and safe in the stable phase of Peyronie's disease: a controlled multicentre study. BJU Int. 2019;123(4):694-702. doi:10.1111/bju.14602

6. Nowroozi MR, Amini E, Ayati M, et al. Applying extender devices in patients with penile dysmorphophobia: assessment of tolerability, efficacy, and impact on erectile function. J Sex Med. 2015;12(5):1242-1247. doi:10.1111/jsm.12870

7. Nikoobakht M, Shahnazari A, Rezaeidanesh M, Mehrsai A, Pourmand G. Effect of penile-extender device in increasing penile size in men with shortened penis: preliminary results. J Sex Med. 2011;8(11):3188-3192. doi:10.1111/j.1743-6109.2009.01662.x

8. Bole R, White L, Parikh N, et al. A modern review of penile traction monotherapy and combination therapy for the treatment of Peyronie's disease. Int J Impot Res. 2021;33(3):251-258. doi:10.1038/s41443-020-0247-3

9. Ziegelmann M, Savage J, Toussi A, et al. Outcomes of a novel penile traction device in men with Peyronie's disease: a randomized, single-blind, controlled trial. J Urol. 2019;202(3):599-610. doi:10.1097/JU.0000000000000245

10. Joseph J, Ziegelmann MJ, Alom M, et al. Outcomes of RestoreX penile traction therapy in men with Peyronie's disease: results from open-label and follow-up phases. J Sex Med. 2020;17(12):2462-2471. doi:10.1016/j.jsxm.2020.10.003

11. Shu T, Ren D, Wang R. The role of vacuum erection device and penile traction therapy in the patients after radical prostatectomy: a narrative review. Int J Impot Res. 2025. doi:10.1038/s41443-025-01092-9

12. Toussi A, Ziegelmann M, Yang D, et al. Efficacy of a novel penile traction device in improving penile length and erectile function post-prostatectomy: results from a single-center randomized, controlled trial. J Urol. 2021;206(2):416-426. doi:10.1097/JU.0000000000001792

13. Krishnappa P, Matippa P, Fraile-Poblador A, Lledo-Garcia E, Moncada I. Penile length preservation in penile prosthesis placement: tips & tricks. Int J Impot Res. 2025. doi:10.1038/s41443-025-01123-5

14. Levine LA, Rybak J. Traction therapy for men with shortened penis prior to penile prosthesis implantation: a pilot study. J Sex Med. 2011;8(7):2112-2117. doi:10.1111/j.1743-6109.2011.02285.x

15. Moskovic DJ, Pastuszak AW, Lipshultz LI, Khera M. Revision of penile prosthesis surgery after use of penile traction therapy to increase erect penile length: case report and review of the literature. J Sex Med. 2011;8(2):607-611. doi:10.1111/j.1743-6109.2010.02121.x

16. Oderda M, Gontero P. Non-invasive methods of penile lengthening: fact or fiction? BJU Int. 2011;107(8):1278-1282. doi:10.1111/j.1464-410X.2010.09647.x

17. Romero-Otero J, Manfredi C, Ralph D, et al. Non-invasive and surgical penile enhancement interventions for aesthetic or therapeutic purposes: a systematic review. BJU Int. 2021;127(3):269-291. doi:10.1111/bju.15145

18. Yafi FA, Pinsky MR, Stewart C, et al. The effect of duration of penile traction therapy in patients undergoing intralesional injection therapy for Peyronie's disease. J Urol. 2015;194(3):754-758. doi:10.1016/j.juro.2015.03.092

19. Alom M, Sharma KL, Toussi A, Kohler T, Trost L. Efficacy of combined collagenase clostridium histolyticum and RestoreX penile traction therapy in men with Peyronie's disease. J Sex Med. 2019;16(6):891–900. doi:10.1016/j.jsxm.2019.03.007

20. Cahill EM, Trost L. Factors associated with improved curvature outcomes with collagenase clostridium histolyticum for Peyronie's disease: results from a large prospective series. J Sex Med. 2025;qdaf213. doi:10.1093/jsxmed/qdaf213

21. Ziegelmann MJ, Viers BR, Montgomery BD, et al. Clinical experience with penile traction therapy among men undergoing collagenase clostridium histolyticum for Peyronie disease. Urology. 2017;104:102–109. doi:10.1016/j.urology.2017.01.054

22. García-Gómez B, García-Rojo E, Alonso-Isa M, et al. Treatment of Peyronie's disease with combination of clostridium histolyticum collagenase and penile traction therapy: a prospective, multicenter, single-arm study. Int J Impot Res. 2021;33(3):325–331. doi:10.1038/s41443-020-0292-y

23. Hatzichristou D. From fibrosis to restoration: the multimodal 3 Ts protocol for Peyronie's disease. Int J Impot Res. 2026. doi:10.1038/s41443-026-01262-3

24. Nehra A, Alterowitz R, Culkin DJ, et al. "Peyronie's disease: AUA guideline." J Urol. 2015;194(3):745–753. doi:10.1016/j.juro.2015.05.098

25. EAU. Guidelines on Sexual and Reproductive Health, Limited Update March 2026, sections 8.2.3.a.3, 8.2.3.a.4 and 9.3.1.e.

26. Zganjar A, Toussi A, Ziegelmann MJ, et al. "Efficacy of RestoreX after prostatectomy: open-label phase of a randomized controlled trial." BJU Int. 2023;132(2):217-226. doi:10.1111/bju.16033

27. PathRight Medical. "RestoreX Instructions for Use." Model 117, 729-18-420051-01 Rev G. August 2025. Manufacturer PDF

28. Pyrgidis N, Yafi FA, Sokolakis I, et al. "Assessment of conservative combination therapies for active and stable Peyronie's disease: a systematic review and meta-analysis." Eur Urol Focus. 2022;8(5):1520-1530. doi:10.1016/j.euf.2021.12.003

29. Chung E, Jenkins L, Moon DG, et al. "Penile augmentation and cosmetic surgery: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024)." Sex Med Rev. 2026;14(1):qeaf067. doi:10.1093/sxmrev/qeaf067

30. Guo Y, Yang Y, Mao Q, et al. "Efficacy of collagenase Clostridium histolyticum combination therapies for Peyronie's disease: a systematic review and meta-analysis." Sex Med Rev. 2024;12(3):497-504. doi:10.1093/sxmrev/qeae025

31. Chung E, Ziegelmann M, Lin HC, et al. "Management of Peyronie's disease: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024)." Sex Med Rev. 2026;14(1):qeaf068. doi:10.1093/sxmrev/qeaf068