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What is Hard Flaccid Syndrome?
Hard Flaccid Syndrome is a condition affecting the penis and is of unknown aetiology among men. It is a hugely distressing condition and at Core Body Clinic our age range is18 to 40. It is characterised by penile stiffness when the penis is in a flaccid state and flaccid size. The penis is essentially stiff to the touch, it is engorged and rubber in texture, and is often accompanied by a change in size or shape of erection. There may be a loss in nocturnal erections and it may require a greater degree of stimulation to achieve an erection. However, the most common reason for someone seeking help is because of alarming changes in penile shape and size. There is a feeling of embarrassment, loss of confidence and often deep anxiety. It is different from peyronines disease because there are no visible signs of tissue scarring and plaque formation. Nevertheless, it is a distressing and poorly understood condition.
Until recently any male pelvic pain syndrome would fall under the umbrella term of Chronic non-bacterial prostatitis often leaving men in the no-man’s land of diagnostic labelling and therefore at a loss as to how their pain and symptoms could be rectified.
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.
What causes it?
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 expert consensus has been developed from which we hope to understand more.
Injury to the penis and stress are likely drivers for this condition. Our own practice has observed many patients who present having engaged in excessive masturbation, exhaustive sex or who have attempted penis enhancement stretching. Such situations see the penile muscles in sustained contractile states leading to venous compression in the penis. The blood vessels therefore failing to empty when in a flaccid state with blood remaining in the erectile tissue. Erectile tissue fatigue occurs, as one would see in many other muscle tissues in the body. An almost spasm like behaviour where the regulatory control of erectile function is lost and the erectile tissue fails to disengage fully. Likewise, in a continued semi stimulated state, the tissue struggles to fully erect because it has lost the normal feedback mechanism. Autonomic and central nervous systems control erectile function and in states of fatigue the central and parasympathetic nervous system can no longer regulate this function. Pain is common due to tissue injury and chemical irritation of nerve endings, caused by fatigue chemicals. This further results in anxiety and distress. We know that psychological drivers transfer into biological processes. Stress causes the release of cortisol, adrenaline and no-adrenaline resulting in increased blood flow to the pelvic area. Exposing already traumatised blood vessels to increased blood flow only helps to drive the process and maintain a hard flaccid state.
Tension in the pelvis is strongly linked to stress and this in turn will help to maintain the poor regulation of blood flow in the pelvic floor. The origin of the penile muscles from within the pelvis allows for easy influence of the tight pelvic muscles on the penile erectile tissue. There is often associated tension over the perineal and anus regions. What we see in the clinic are cases where men cannot select and activate the pelvic floor muscles. A change in posture can place addicitonal stress on the pelvic floor muscles. In normal situations the pelvic muscles react and contract. In Hard Flaccid they may already be tense and fatigued, and therefore the patient cannot distinguish relaxed from tensed states. The loss in function weakens the pelvic muscles and there function during sex becomes hampered.
Retraining these muscles are essential to regaining normal function.
What can we do about it?
Understanding the patient’s drivers and educating our patients about their condition helps with anxiety about the condition. Information concerning the onset of symptoms is essential in removing any harmful behaviours or practices and emotional drivers. Often this is a distressing and difficult time for the patient, and in some cases the cause is elusive and requires careful history taking to unpick the possible triggers.
Relaxation plays a significant role in re-establishing normal breathing patterns thereby facilitating appropriate abdominal movement. Interruption of the normal diaphragmatic excursions during breathing is closely associated with pelvic tension. Hard flaccid is distressing and leaves the patient in a state of anxiety causing shallow breathing, abdominal bracing and abdominal muscle fatigue.
Physical therapies such as trigger point release and massage to the perienal area and internally within the pelvic floor helps to provide feedback to patient and clinician about tension in the pelvis. With careful and skilled practice it is possible to remove this tension to alleviate pain and tissue tension. Immediate changes are often reported.
Spinal manual therapy has a clear role by re-establishing normal spinal mechanics. There is clear evidence of reduced muscle tension with spinal manual therapy and this extends to the pelvic region. External muscle release technqiues will also have a cross over and can be helpful with both pain and relaxation for HF patients.
Exercises to restore normal pelvic floor control is essential. Quite often online forums encourage the ‘Kegal’ exercise and many men attend the practice having done these only to end up in a worse state. We tend initially focus on the ‘reverse kegal’. This differs from the kegal by pushing the pelvic floor down rather than lifting it up. It aims to de-tension the pelvic muscles. We call this down training. It is essential patients learn to perform a kegal once the initial phase of rehab is complete. The kegal is a normal function of the pelvic floor. It must be retrained so the pelvic muscles can react normally to postural change.
Hard flaccid can also occur with weight lifting with patients believing that they have lifted excessively as the cause for the initial onset of symptoms. Therefore, there is a reluctance to get back to training and part of therapy is to coach the patient about normal lifting practices and ensure their breathing pattern and pelvic muscle control is appropriate.
Sexual coaching and pacing is vital so there is no pressure or expectation placed on the patient. Positioning to allow greatest chance of successful and maintained erection is key to rehabilitate the pelvic floor and graduated postition must be done in realistic progressions so not to cause distress and disappointment.
Hard flaccid is a difficult condition to treat. Specific men’s health physiotherapy is highly successful in resolving this condition.
Core Body Clinic is specialist center for the treatment of Hard Flaccid.