Hard Flaccid Syndrome: A Biopsychosocial Management Approach with Emphasis on Pain Management, Exercise Therapy and Education

Abstract

Hard flaccid syndrome (HFS) is a rather rare, acquired clinical entity affecting young men’s well-being, sexual and social life. HFS presents with a cluster of symptoms including penile-specific somatosensory disturbances, a semi-rigid penis at the flaccid state without any stimulation or desire, erectile dysfunction, perineal and/or penile pain, associated urinary symptoms, emotional distress as well as other psychosocial and stress-related manifestations. Although its pathophysiology is still not well understood, initial penile trauma causing minor nerve and vascular disturbances to the penis and associated pelvic floor musculature is suggested to trigger the syndrome. Despite the scarcity of research on HFS, the present report describes a case of a young male clinically diagnosed with HFS, who benefited from a biopsychosocial management strategy, focusing on pain management, therapeutic exercise approaches, such as pelvic floor exercise re-education, graded exposure to activity as well as education on lifestyle and stress-related modifications. This holistic management approach has been clinically reasoned in this case report, and the need for more evidence-based studies developing diagnosing criteria, elaborating pathophysiological mechanisms and testing the efficiency of different therapeutic options is highlighted.

Hard-Flaccid syndrome: a survey of sexual medicine practitioners’ knowledge and experience

“…Similarly, there was a wide variety of diagnostic modalities utilized. There does seem to be a general consensus that either pelvic floor therapy in isolation or combined with other modalities such as medical and/or behavioral therapy is the optimal treatment approach which has been also described in the literature through the use of biopsychosocial treatment approaches, however with spotty success [4].…”

“…Interestingly, there are also reports of having the pain exacerbated during ejaculation and micturition. Additionally, this painful and psychologically worrisome condition results in significant anxiety and depression with significant impacts on quality of life [1,3,4].…”

“…Specifically, damage to the neurovascular bundles that supply innervation to the penis and pelvic floor. The pathophysiologic process is thought to be an emotional reaction following injury and noticing the sensory changes on the penis which then causes a feedback loop where this reaction triggers a hypersympathetic response leading to extensive pelvic floor muscle spasms which ultimately causes additional extrinsic damage to the penile neurovascular bundles [1,4]. Work-up including cross-sectional imaging, penile ultrasound doppler, and labs tests tend to be completely normal [1,5].…”