What is hard flaccid and how can pelvic floor PT help treat it?
Doug is a 25-year-old male who has enjoyed a history of rather rigorous masturbation and partner intimacy. He has always strived to achieve the firmest erection and most intense orgasm possible. About 6 months ago, Doug noticed difficulty with achieving a full erection. That progressed to an increased firmness in the penis when he was not aroused along with reduced sensation and “coldness” in his penis. He went to multiple doctors who ran every test possible, including blood work and blood flow imaging, and all came back “normal”. Doug began to do his own research and came across a condition called hard-flaccid syndrome or HFS for short.
Hard-flaccid syndrome (HFS) is a relatively new condition. While there is not a significant amount of research regarding HFS, a review of the current available research was developed in 2020.1 HFS is an acquired condition, meaning you are not born with it, that is characterized by a semi-rigid penis at the flaccid state and a loss in erectile rigidity with penile sensory changes, erectile dysfunction (ED), pelvic floor muscle contraction and psychological distress. Sensory changes can include numbness or coldness with reduced sensitivity specifically at the head of the penis. HFS can also result in decreased number of morning or nocturnal erections. Pain in the penis and perineum (or taint) are often worse in standing. Men can be affected from late teens to their 70s, but it most commonly occurs in men in their 20s and 30s.1
The cause of HFS is not well known; however, most report symptoms occurring after a traumatic event like the use of a vacuum, touch masturbation or sex, jelqing or excessive squatty with delay of symptoms anywhere from minutes to weeks.1 The idea is that the arteries and nerves that begin at the base of the penis are injured, which will affect blood flow and sensation to the area. Anxiety, depression, decreased libido, and insomnia are often involved with HSF due to the emotional toll. This can trigger an increase in the sympathetic nervous system, which is our fight-or-flight response. Our sympathetic nervous system can further exacerbate symptoms due to the reflective contraction or spasming of the pelvic floor muscles that can continue to reduce blood flow and nerve sensitivity.1 Imagine the penis, including the arteries and the nerves, receives a big, prolonged bear hug. Most of us ask to breath after a second or two of a big squeeze like that right? Another example is when we sit on the toilet for a long period of time and our legs fall asleep. When the pelvic floor muscles are in an overly contracted or tense state, it is difficult for blood flow to exit the penis which can create the semi-firmness during a flaccid penis. The “tight” muscles also reduce the ability for blood flow to enter the penis to allow for a full erection.
Unfortunately, there is no one test that can confirm HFS.1 Typically, imaging, doppler studies and blood tests come back normal, including hormone assessment, which allows medical professionals to ensure that another cause is not contributing the symptoms. Much of the diagnosis stems from a person’s description of their symptoms and the history of those symptoms.1
A team approach is most recommended for successful treatment of HFS, including psychological support for the stress and anxiety that is often present. Those with HFS often need to include multiple treatment approaches, including good sleep, excellent nutrition, regular exercise, breathing exercises, yoga to reduce stress, possible medications, and decrease pelvic floor muscle contractions.1
Physical therapy, specifically a pelvic floor specialist, should be part of that team approach as “Physical therapy seems to play important role in the relaxation of the pelvic floor muscles”.1 Your physical therapist (PT) should do a full assessment including asking you questions about your symptoms and assessing both the pelvic area and surrounding areas like your back and hips. Don’t be surprised if your treatment plan includes multiple interventions, including sleep education, breathing techniques, stress reduction activities, stretches, and possibly strengthening. Your PT should explain the purpose of each technique and its role in your healing journey. If you feel you are experiencing the symptoms of hard-flaccid syndrome, reach out to healthcare professionals in your area including a pelvic floor physical therapist to assess and address your concerns!
Written by Jordan Schmidt, PT, DPT
References
- Abdessater, M., Kanbar, A., Akakpo, W., & Beley, S. (2020). Hard flaccid syndrome: state of current knowledge. Basic and Clinical Andrology, 30,
