Successful Treatment of Hard Flaccid Syndrome: A case report

Abstract

ABSTRACT Introduction Hard flaccid syndrome (HFS) is a chronic, painful condition cited in several patient online forums but poorly defined in literature. Gul and Towe were the first to report on cases of HFS with symptoms including a semi-rigid penis in the flaccid state, erectile dysfunction, penile sensory changes of numbness and coldness, and incomplete voiding. These symptoms have a rapid onset, typically following a traumatic event during sexual intercourse or masturbation. The leading hypothesis regarding the pathophysiology of HFS involves physical or psychological stress which injures the pelvic floor neurovasculature leading to prolonged contraction of the pelvic floor muscles and subsequent pelvic floor dysfunction. Though there is no standardized treatment for HFS, patients have been treated, largely unsuccessfully, with analgesics for the neuropathic pain, phosphodiesterase 5 inhibitors for the erectile dysfunction, and pelvic floor relaxation exercises for the overactive pelvic floor muscles. Objective We present a case of a patient diagnosed and successfully treated for HFS. Methods A 16-year-old male patient presented to the emergency room with penile and testicular pain and numbness after masturbation and other associated HFS symptoms. Laboratory and imaging tests were normal. He underwent a circumcision for phimosis which did not relieve his symptoms. His symptoms persisted for several months until seeking a sexual medicine trained urologist. The patient was referred to pelvic floor physical therapy and through a series of exercises targeting abdominal and gluteal muscles he became symptom free. Results We found that specialized pelvic floor physical therapy can relieve the overactive pelvic floor and entrapped penile neurovasculature, supporting and supplementing the leading theory on the pathophysiology of HFS. The patient, like many of the others cited in forums and case reports, also had an inciting traumatic stressor, masturbation, for his HFS. This physical trauma to the pelvic neurovasculature partially explains the contraction of pelvic and penile musculature and resultant erectile and ejaculatory dysfunction; however, it does not provide a full picture of the pathophysiology of HFS. In this case study, physical activity level, social factors, changes in muscle strength and coordination, and postural changes may have all played a role in the development of this chronic condition. Conclusions HFS is a rare condition that requires further research. A multidisciplinary approach including individualized pelvic floor physical therapy that addresses impairments beyond the pelvic floor may be a key in treatment. Disclosure No