Hard flaccid syndrome

Last updated
Hard flaccid syndrome
A penis in the "hard flaccid" state.png
A penis in the "hard flaccid" state
Specialty Urology, sexual medicine, neurology, men's health
Symptoms A flaccid penis that remains in a firm, semi-rigid state in the absence of sexual arousal
Usual onsetTypically following a traumatic event (an injury to the erect penis, blunt perineal trauma, cauda equina) though can also appear without an apparent cause
CausesExcessive sympathetic activity in the erectile smooth muscle tissue
Risk factors Aggressive or prolonged masturbation, rough or prolonged intercourse, practicing penis enlargement techniques, high-tone pelvic floor dysfunction, bicycle riding, horseback riding, annular tears, tarlov cysts; other risk factors currently unknown
Diagnostic method Overwhelmingly self-diagnosed
TreatmentDefinitive treatment does not currently exist

Hard flaccid syndrome (HFS), also known as hard flaccid (HF), is a rare, chronic condition characterized by a flaccid penis that remains in a firm, semi-rigid state in the absence of sexual arousal. Patients describe their flaccid penises as being firm to the touch, rubbery, shrunken, and retracted. This may be accompanied by pain, discomfort, and a range of additional symptoms. [1] [2] [3] [4] [5] [6] [7] Though the exact cause is poorly understood, current research suggests that HFS is the result of excessive sympathetic activity in the smooth muscle tissue of the penis that is induced by a pathological activation of a theorized pelvic/pudendal-hypogastric reflex. [1] This reflex is thought to be triggered by an injury to the erect penis, blunt trauma to the perineum, and cauda equina, among others. [1] An emerging theory suggests that the real explanation for HFS is sympathetic nerve sprouting in the dorsal root ganglia following a peripheral nerve injury. [8] [9] The majority of patients are in their 20s–30s and symptoms significantly affect one's quality of life. [1] [2] [4] [3] [5] Treatment usually involves a multi-modal approach utilizing a combination of alpha blockers, PDE5 inhibitors, and specialized pelvic floor physical therapy though there is not much evidence to support their efficacy and most patients reportedly do not benefit from currently available treatment options. [6] [7] Due to limited awareness and understanding of the condition within the scientific and medical communities, definitive treatment for HFS does not exist.

Contents

Signs and symptoms

The most obvious, unmistakable, and defining symptom of hard flaccid syndrome is a penis that remains in a firm, semi-rigid state in the absence of sexual arousal. The flaccid penis will appear shrunken, contracted, and upon palpation will feel hard and non-compressible. [1] This typically worsens when the patient is in a standing position. [1] The skin on the shaft of the flaccid penis may also have folds or wrinkles, resembling gastric and vaginal rugae. [8]

Other signs and symptoms

In addition to a "hard flaccid" penis, patients may also experience erectile dysfunction (difficulty achieving or maintaining an erection; painful or tight erections; penis does not fill up completely when getting an erection; no morning erections; no nocturnal erections; no spontaneous erections; painful nocturnal erections), sensory changes (a persistent feeling of coldness in the glans, shaft, or entire penis; paresthesia or pins and needles in or around the penis; dysesthesia or an unpleasant, abnormal sense of touch in or around the penis; complete or partial loss of erogenous sensation to the penis; complete or partial loss of tactile feeling to the penis including temperature, pressure, vibration, or texture; penis feels "hollow", "disconnected" or unstable, as if it was not a part of the body), physical or structural changes to the penis (an hourglass or bottleneck shape to the penis during the flaccid or semi-erect states; engorged veins or spider veins; discoloration of the skin of the penis; soft glans; "long flaccid", where the flaccid penis is more extended than it should be and either feels firm or like a balloon filled with water; tilt of the penis to one side while flaccid, erect, or both; rotation of the penis when erect), pain (pain in or around the penis; pain in or around the penis or perineum after ejaculation), testicular retraction, urinary issues (incontinence; urgency; duel urine streams; a burning feeling when urinating), pelvic floor dysfunction, and constipation. [1] [2] [3] [4] [5] [6] [7]

Cause

Although the exact cause and mechanism are not fully understood, the general consensus is that hard flaccid syndrome is caused by excessive sympathetic activity, or tone, in the erectile smooth muscle tissue. This heightened activity leads to relentless smooth muscle contraction, which produces the "hard flaccid" state, or the persistent firmness and semi-rigidity of the flaccid penis that is characteristic of the condition. [1] This is supported by the fact that intracavernous injections of phentolamine, an α-adrenergic antagonist, eliminate the "hard flaccid" state, albeit temporarily. [1]

Pathology

The leading theory suggests that HFS is the result of a pathological activation of a theorized pelvic/pudendal-hypogastric reflex with the afferent limb being the dorsal branch of the pudendal nerve. [1]

Needs expansion. Expansion in progress...

Diagnosis

At the moment, there is no established schema or procedure for diagnosing hard flaccid syndrome in a clinical setting. [8] [10] Due to the condition's relative obscurity within the medical community, the majority of HFS patients diagnose themselves. [1]

Treatment

Definitive treatment for hard flaccid syndrome does not exist and current methods often fail to relieve symptoms for most patients. [6] [7] The complexity and poorly understood nature of HFS makes it very difficult to treat. [11] As a result, there is a growing need for more research that can provide better outcomes for those suffering from this challenging condition.

Current treatment options

Potential treatment options

At present, the following treatment options have not been explored in scientific or medical literature in relation to HFS directly, though they could yield positive outcomes in the future.

See also

Related Research Articles

Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity. It is the most common sexual problem in males and can cause psychological distress due to its impact on self-image and sexual relationships.

<span class="mw-page-title-main">Peyronie's disease</span> Abnormal growth of scar tissue within the penis

Peyronie's disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis. Specifically, scar tissue forms in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa, causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening.

<span class="mw-page-title-main">Pudendal nerve</span> Main nerve of the perineum

The pudendal nerve is the main nerve of the perineum. It is a mixed nerve and also conveys sympathetic autonomic fibers. It carries sensation from the external genitalia of both sexes and the skin around the anus and perineum, as well as the motor supply to various pelvic muscles, including the male or female external urethral sphincter and the external anal sphincter.

<span class="mw-page-title-main">Penis enlargement</span> Technique aimed to increase the size of a human penis

Penis enlargement, or male enhancement, is any technique aimed to increase the size of a human penis. Some methods aim to increase total length, others the shaft's girth, and yet others the glans size. Techniques include surgery, supplements, ointments, patches, and physical methods like pumping, jelqing, and traction.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

Pudendal nerve entrapment (PNE), also known as Alcock canal syndrome, is an uncommon source of chronic pain in which the pudendal nerve is entrapped or compressed in Alcock's canal. There are several different types of PNE based on the site of entrapment anatomically. Pain is positional and is worsened by sitting. Other symptoms include genital numbness, fecal incontinence and urinary incontinence.

Sexual medicine or psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.

<span class="mw-page-title-main">Pelvic pain</span> Medical condition

Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis.

Nocturnal penile tumescence (NPT) is a spontaneous erection of the penis during sleep or when waking up. Along with nocturnal clitoral tumescence, it is also known as sleep-related erection. Colloquially, the term morning wood, or less commonly, morning glory is also used, although this is more commonly used to refer specifically to an erection beginning during sleep and persisting into the period just after waking. Men without physiological erectile dysfunction or severe depression experience nocturnal penile tumescence, usually three to five times during a period of sleep, typically during rapid eye movement sleep. Nocturnal penile tumescence is believed to contribute to penile health.

Venous leak, also called venogenic erectile dysfunction and penile venous insufficiency, is one category of vasculogenic impotence — a cause of erectile dysfunction in males. It affects all ages, being particularly awkward in young men. Much about venous leaks has not reached a consensus among the medical community, and many aspects of the condition, particularly its treatment strategies, are controversial. The prevalence of the condition is still unknown, although some sources claim it to be a common cause of erectile dysfunction.

The cavernous nerves are post-ganglionic parasympathetic nerves that facilitate penile erection and clitoral erection. They arise from cell bodies in the inferior hypogastric plexus where they receive the pre-ganglionic pelvic splanchnic nerves (S2-S4).

<span class="mw-page-title-main">Penile implant</span> Medical device

A penile implant is an implanted device intended for the treatment of erectile dysfunction, Peyronie's disease, ischemic priapism, deformity and any traumatic injury of the penis, and for phalloplasty or metoidioplasty, including in gender-affirming surgery. Men also opt for penile implants for aesthetic purposes. Men's satisfaction and sexual function is influenced by discomfort over genital size which leads to seek surgical and non-surgical solutions for penis alteration. Although there are many distinct types of implants, most fall into one of two categories: malleable and inflatable transplants.

<span class="mw-page-title-main">Human penis</span> Human male external reproductive organ

In human anatomy, the penis is an external male sex organ that serves as a passage for excretion of urine and ejaculation of semen. The main parts are the root, body, the epithelium of the penis including the shaft skin, and the foreskin covering the glans. The body of the penis is made up of three columns of tissue: two corpora cavernosa on the dorsal side and corpus spongiosum between them on the ventral side. The urethra passes through the prostate gland, where it is joined by the ejaculatory ducts, and then through the penis. The urethra goes across the corpus spongiosum and ends at the tip of the glans as the opening, the urinary meatus.

<span class="mw-page-title-main">Erection</span> Physiological phenomenon involving the hardening and enlargement of the penis

An erection is a physiological phenomenon in which the penis becomes firm, engorged, and enlarged. Penile erection is the result of a complex interaction of psychological, neural, vascular, and endocrine factors, and is often associated with sexual arousal, sexual attraction or libido, although erections can also be spontaneous. The shape, angle, and direction of an erection vary considerably between humans.

<span class="mw-page-title-main">Human penis size</span> Measurement of the human penis

Human penis size varies on a number of measures, including length and circumference when flaccid and erect. Besides the natural variability of human penises in general, there are factors that lead to minor variations in a particular male, such as the level of arousal, time of day, ambient temperature, anxiety level, physical activity, and frequency of sexual activity. Compared to other primates, including large examples such as the gorilla, the human penis is thickest, both in absolute terms and relative to the rest of the body. Most human penis growth occurs in two stages: the first between infancy and the age of five; and then between about one year after the onset of puberty and, at the latest, approximately 17 years of age.

<span class="mw-page-title-main">Clitoral erection</span> Physiological phenomenon involving the engorgement of the clitoris

Clitoral erection is a physiological phenomenon where the clitoris becomes enlarged and firm.

<span class="mw-page-title-main">Nerve compression syndrome</span> Symptoms resulting from chronic, direct pressure on a peripheral nerve

Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by chronic, direct pressure on a peripheral nerve. It is known colloquially as a trapped nerve, though this may also refer to nerve root compression. Its symptoms include pain, tingling, numbness and muscle weakness. The symptoms affect just one particular part of the body, depending on which nerve is affected. The diagnosis is largely clinical and can be confirmed with diagnostic nerve blocks. Occasionally imaging and electrophysiology studies aid in the diagnosis. Timely diagnosis is important as untreated chronic nerve compression may cause permanent damage. A surgical nerve decompression can relieve pressure on the nerve but cannot always reverse the physiological changes that occurred before treatment. Nerve injury by a single episode of physical trauma is in one sense an acute compression neuropathy but is not usually included under this heading, as chronic compression takes a unique pathophysiological course.

<span class="mw-page-title-main">Buried penis</span> Male congenital condition

Buried penis, also called hidden penis or retractile penis, is a congenital or acquired condition in which the penis is partially or completely hidden below the surface of the skin. A buried penis can lead to urinary difficulties, poor hygiene, infection, and inhibition of normal sexual function.

<span class="mw-page-title-main">Penile artery shunt syndrome</span> Medical condition

Penile artery shunt syndrome (PASS) is an iatrogenic clinical phenomenon first described by Tariq Hakky, Christopher Yang, Jonathan Pavlinec, Kamal Massis, and Rafael Carrion within the Sexual Medicine Program in the Department of Urology, at the University of South Florida, and Ricardo Munarriz, of Boston University School of Medicine Department of Urology in 2013. It may be a cause of refractory erectile dysfunction in patients who have undergone penile revascularization surgery.

<span class="mw-page-title-main">Glans insufficiency syndrome</span> Medical condition

Glans insufficiency syndrome, also known as the soft glans, cold glans, or glans insufficiency, is a medical condition that affects male individuals. This condition is characterized by the persistent inability of the glans penis to achieve and maintain an erect or turgid state during sexual arousal, remaining soft and cold. This condition can have an impact on a person's sexual function, including decreased sensitivity, difficulty in maintaining an erection, and overall quality of life.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 "Hard Flaccid Syndrome Proposed to Be Secondary to Pathological Activation of a Pelvic/Pudendal-Hypogastric Reflex - American Urological Association". auanews.net. Retrieved 2024-08-09.
  2. 1 2 3 Abdessater, Maher; Kanbar, Anthony; Akakpo, William; Beley, Sebastien (2020). "Hard flaccid syndrome: state of current knowledge". Basic and Clinical Andrology. 30: 7. doi: 10.1186/s12610-020-00105-5 . ISSN   2051-4190. PMC   7271516 . PMID   32518654.
  3. 1 2 3 Gül, M.; Serefoglu, E.C. (2019-05-01). "PO-01-037 Hard Flaccid: Is It a New Syndrome?". The Journal of Sexual Medicine. 16 (Supplement_2): S58. doi:10.1016/j.jsxm.2019.03.194. ISSN   1743-6109.
  4. 1 2 3 Gul, Murat; Towe, Maxwell; Yafi, Faysal A.; Serefoglu, Ege Can (March 2020). "Hard flaccid syndrome: initial report of four cases". International Journal of Impotence Research. 32 (2): 176–179. doi:10.1038/s41443-019-0133-z. ISSN   1476-5489. PMID   30890780.
  5. 1 2 3 Gul, Murat; Huynh, Linda M.; El-Khatib, Farouk M.; Yafi, Faysal A.; Serefoglu, Ege Can (September 2020). "A qualitative analysis of Internet forum discussions on hard flaccid syndrome". International Journal of Impotence Research. 32 (5): 503–509. doi:10.1038/s41443-019-0151-x. ISSN   1476-5489. PMID   31175339.
  6. 1 2 3 4 Gryzinski, Gustavo; Hammad, Muhammed Moukhtar; Alzweri, Laith; Azad, Babak; Barham, David; Lumbiganon, Supanut; Serefoglu, Ege Can; Yafi, Faysal (2024-06-19). "Hard-Flaccid syndrome: a survey of sexual medicine practitioners' knowledge and experience". International Journal of Impotence Research: 1–2. doi: 10.1038/s41443-024-00917-3 . ISSN   1476-5489. PMID   38898174.
  7. 1 2 3 4 Niedenfuehr, Jenny; Stevens, David M. (2024-02-28). "Hard flaccid syndrome symptoms, comorbidities, and self-reported efficacy and satisfaction of treatments: a cross-sectional survey". International Journal of Impotence Research. doi:10.1038/s41443-024-00853-2. ISSN   1476-5489. PMID   38418867.
  8. 1 2 3 4 UroChannel (2024-06-22). DON'T JELQ before you've watched THIS! | UroChannel . Retrieved 2024-08-09 via YouTube.
  9. Chung, K.; Lee, B. H.; Yoon, Y. W.; Chung, J. M. (1996-12-09). "Sympathetic sprouting in the dorsal root ganglia of the injured peripheral nerve in a rat neuropathic pain model". The Journal of Comparative Neurology. 376 (2): 241–252. doi:10.1002/(SICI)1096-9861(19961209)376:2<241::AID-CNE6>3.0.CO;2-3. ISSN   0021-9967. PMID   8951640.
  10. "Hard-Flaccid Syndrome: Definition, Diagnosis and Management - American Urological Association". auanews.net. Retrieved 2024-08-13.
  11. 1 2 3 Yazar, R. Omer; Hammad, Muhammed A. M.; Barham, David W.; Azad, Babak; Yafi, Faysal A. (2024-07-25). "Successful treatment of hard flaccid syndrome with multimodal therapy: a case report study". International Journal of Impotence Research: 1–3. doi: 10.1038/s41443-024-00955-x . ISSN   1476-5489. PMID   39054358.
  12. Giammusso, Bruno; Gattuso, Ugo; Vanaclocha, Vicente; Saiz-Sapena, Nieves; Falsaperla, Mario; Burrello, Maurizio; Motta, Mario (March 2005). "Percutaneous lumbar sympathectomy in the treatment of erectile dysfunction secondary to cavernous adrenergic hypertone: initial results of an original technique". Archivio Italiano di Urologia, Andrologia: Organo Ufficiale [di] Societa Italiana di Ecografia Urologica e Nefrologica. 77 (1): 5–9. ISSN   1124-3562. PMID   15906781.
  13. Sverrisdottir, Yrsa B.; Martin, Sean C.; Hadjipavlou, George; Kent, Alexander R.; Paterson, David J.; FitzGerald, James J.; Green, Alexander L. (2020-09-16). "Human Dorsal Root Ganglion Stimulation Reduces Sympathetic Outflow and Long-Term Blood Pressure". JACC: Basic to Translational Science. 5 (10): 973–985. doi:10.1016/j.jacbts.2020.07.010. ISSN   2452-302X. PMC   7591825 . PMID   33145461.
  14. Guagnini, Fabio; Ferazzini, Mara; Grasso, Marco; Blanco, Salvatore; Croci, Tiziano (2012-03-23). "Erectile properties of the Rho-kinase inhibitor SAR407899 in diabetic animals and human isolated corpora cavernosa". Journal of Translational Medicine. 10: 59. doi: 10.1186/1479-5876-10-59 . ISSN   1479-5876. PMC   3328245 . PMID   22444253.