Hard Flaccid: Beyond The Edge Of Science?
Pegasus acknowledges the assistance of Hans and Al in the creation of this article.
PEGym deals with issues of male sexuality covering a number of areas. A difficult, frustrating and somewhat mysterious issue has been Hard flaccid (HF). This covers a wide range of symptoms:
– Pelvic pain
– Pain on ejaculation
– Retracted penis
– A “rubbery” feeling to the penis
– Flaccid glans during an erection
– Changes in penis shape and size
– Loss of libido
– Difficulty getting an erection.
Over time, the mods onsite have recommended 2 main courses of action: stress reduction/dealing with stress anxiety, and on the physical side pelvic floor work to relax the pelvic floor. Our working theory was that on the physical level spasm /tension within the pelvic floor interfered with blood flow and nerve conduction. We also believed stress to be frequently causal in both the difficulty getting erect development and maintain of this syndrome.
Problem was we got a lot of blowback from members with HF on a number of fronts. The most common was the assertion that the problem was totally physical and stress was just a side effect and our view on mental states was demeaning and a distraction. However we also were told hey the problem is in my penis not my pelvis and the cure lies elsewhere. Now the view from actual suffers on what treatment should be was all over place the importance of the mental side was variously dismissed or regarded as central or indeed the only factor. On the physical side a wide range of approaches from NoFap/chastity through fasting through a wide range of physical therapies to just forgetting about it and getting on with life.
So I have been interested in the male pelvic floor and it’s effect on male sexuality for some time. It has been of great interest to me to see the development of mainstream medical views on this relationship in recent years. The development in male pelvic floor physio has been of particular interest. So early in the piece I went looking for the science on HF and found uuummm well nothing. However very recently hallelujah I see the start of discussion about what HF is and a move to recognise it. Some uros have begun the process to recognise it as a condition. More importantly some brave physio are going beyond the science to look at actual treatment.
From urology news:
Hard flaccid syndrome
By Kaylie Hughes, Arie Parnham and Marc Lucky
“However, a new phenomenon, known as hard flaccid syndrome, is being recognised as an alternative cause of unremitting pelvic pain in men by specialist pelvic floor physiotherapists and some urologists. Currently, no published literature exists of the syndrome”
Later they say:
“Hard flaccid syndrome is a type of CPPS.”
“The true aetiology of this condition is unknown. Like many CPPS the development of hard flaccid syndrome is thought to be multifactorial in nature. Biological, psychological and social influences all contribute to the development and severity of the condition by altering the neurovascular supply to the muscles of the pelvic floor and penis.
“Stress is a key risk factor for the development of this condition by way of causing prolonged contraction of the muscles of the pelvic floor. Stress can be triggered by an injury directly to the penis during sexual intercourse or masturbation, or stress secondary to psychosocial distress in the absence of injury.”
Entropy Physio speculates it is a form of CPPS and has this to say:
“First things first: there is nothing wrong with your/your client’s penis. Often, clients have been to many providers and have been given clean bills of health He is shooed away with pharmaceuticals and no explanation why his friend is under the weather. Ruminating on the issue can precipitate a key ingredient to the problem: stress. Stress causes activation of your sympathetic nervous system which in turn releases adrenaline throughout your body.”
So they believe it is physically pelvic and that mental factors are central.
Urologist K .Hughes believes:
“Hard flaccid syndrome is difficult to treat due to the fact it is poorly understood and not yet widely recognised as a condition by urologists. Like with any CCPS, adoption of a multimodality holistic approach is paramount when managing these men. The most important step in the management of this condition is continued reassurance that physically there is nothing functionally wrong with the penis and that this is a chronic pain syndrome.”
The physio at Core Body Clinic’s view is:
“Hard Flaccid syndrome has largely been the subject of discussion and debate on male pelvic pain forums with little or no clinical information about the condition. Therefore, diagnosis is difficult to the untrained eye and often clinicians are often at a loss about treatment.”
“With little by way of clinical research concerning hard flaccid, much of the theories relating to the pathophysiology are based on our observations of the patients who present in clinic. However, in combination with the knowledge of anatomy and pain mechanisms an understanding has been developed which has enabled us to provide treatment solutions.
“Injury to the penis and stress are likely drivers for this condition”
Leading physio Gerard Greene says in a podcast that HF is largely pelvic floor related at a physical level and also talks on the effect of stress . This from a patient of his:
“I had heard of Hard Flaccid before but always wondered if it really existed as I could never find anything on google about it but had seen it mentioned in one forum. Without me mentioning it Gerard thought I had pelvic pain definitely but also Hard flaccid. The way he described it , and I’m not a medical person , is that if there is pain for a long time in the pelvis and nerves get irritated or inflamed ( pudendal & others ) then the tissues those nerves supply can get affected i.e the penis.”
So it seems the mods at PEGym were on the right track. HF at the physical level is a pelvic floor issue and stress is heavily involved.
Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moreira E, et al. Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res. 2005;17:39–57.
Nickel JC, Freedland SJ, Castro-Santamaria R, Moreira DM. Chronic prostate inflammation predicts symptom progression in patients with chronic prostatitis/chronic pelvic pain. J Urol. 2017;198:122–8.
Labat JJ, Robert R, Delavierre D, et al. Anatomy and physiology of chronic pelvic and perineal pain. Prog Urol 2010;20(12):843-52.
Dybowski C, Löwe B, Brünahl C. Predictors of pain, urinary symptoms and quality of life in patients with chronic pelvic pain syndrome (CPPS): A prospective 12-month follow-up study. J Psychosom Res 2018;112:99-106.
Passavanti MB, Pota V, Sansone P, et al. Chronic pelvic pain: assessment, evaluation, and objectivation. Pain Res Treat 2017;9472925.
Sandhu J, Tu HYV. Recent advances in managing chronic prostatitis/chronic pelvic pain syndrome. F1000Res 2017;6.pii:F1000 Faculty Rev-1747.
Quaghebeur J, Wyndaele JJ. Prevalence of lower urinary tract symptoms and level of quality of life in men and women with chronic pelvic pain. Scand J Urol 2015;49(3):242-9.
Jansen AS, Nguyen XV, Karpitskiy V, et al. Central command neurons of the sympathetic nervous system: basis of the fight-or-flight response. Science 1995;270(5236):644-6.
Jantos M. Understanding chronic pelvic pain. Pelviperineology 2007;26:66-9.
Hubbard DR. Chronic and recurrent muscle pain: Pathophysiology and treatment, and review of pharmacologic studies. J Musculoskeletal Pain 1996;4:123-43.
Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical Therapy 2014;94(12):1816–25.
Krsmanovic A, Tripp DA, Nickel JC, et al. Psychosocial mechanisms of the pain and quality of life relationship for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Can Urol Assoc J 2014;8(11-12):403-8.
Montenegro ML, Gomide LB, Mateus-Vasconcelos EL, et al. Abdominal myofascial pain syndrome must be considered in the differential diagnosis of chronic pelvic pain. Eur J Obstet Gynecol Reprod Biol 2009;147(1):21-4.
Tripp DA, Curtis Nickel J, Katz L. A feasibility trial of a cognitive-behavioural symptom management program for chronic pelvic pain for men with refractory chronic prostatitis/chronic pelvic pain syndrome. Can Urol Assoc J 2011;5(5):328-32.
Fry RP, Crisp AH, Beard RW. Sociopsychological factors in chronic pelvic pain: a review. J Psychosom Res 1997;42(1):1-15.
Franco JVA, Turk T, Jung JH. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome: a Cochrane systematic review. BJU Int 2018;doi:10.1111/bju.14492 [Epub ahead of print].
Anderson R, Wise D, Sawyer T, et al. Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome. Clin J Pain 2011;27(9):764-8.
Van Alstyne LS, Harrington KL, Haskvitz EM. Physical therapist management of chronic prostatitis/chronic pelvic pain syndrome. Phys Ther 2010;90(12):1795-806.
Schaffer SD, Yucha CB. Relaxation & pain management: the relaxation response can play a role in managing chronic and acute pain. AJN 2004;104(8):75-82.
Hofmann SG, Sawyer AT, Witt AA, et al. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol 2010;78(2):169-83.
Sutar R, Yadav S, Desai G. Yoga intervention and functional pain syndromes: a selective review. Int Rev Psychiatry 2016;28(3):316-22.
Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. The Journal of Alternative and Complementary Medicine 2009;15(5):593-600.