"No two patients with hard flaccid are the same. We must treat every patient as an individual".
Adrian Wagstaff, Male Pelvic Physio
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Hard Flaccid Syndrome is a condition affecting the penis and is of unknown aetiology among men. However, our observations suggest hard flaccid syndrome to be more prevalent between the ages of 18 and 35. It is characterised by a change in penis size, shape and feel. Penile stiffness or swelling when the penis is in a flaccid state and flaccid size is a common characteristic. The penis is sometimes firmer 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. There is often a loss in libido and a shattering of confidence. However, the most common reason for someone seeking help when suffering from hard flaccid is because of alarming changes in penile shape and size. Patients often self-diagnose hard flaccid from reading online forums. It is different from peyronnie’s disease because there are no visible signs of tissue scarring and plaque formation. Nevertheless, hard flaccid is a distressing and poorly understood condition. At Core Body clinic, our pelvic physiotherapists are experts in the treatment of Hard Flaccid syndrome.
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. Seeing a male pelvic physiotherapist who has expertise in male pelvic pain and pelvic dysfunction is the starting point. It is often useful to be assessed by a urologist prior to booking.
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 understanding has been developed which has enabled us to provide treatment solutions.
Injury to the penis and stress are likely drivers for this condition. Our own practice at Core Body Clinic 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.
It has been suggested that 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.
However, tightness can often be confused with strong muscles and to further confound diagnosis patient often present with voiding complications. They may dribble after micturition, finish toileting only to feel like their bladder has not fully emptied or experience pain after voiding. While there may be tension in the pelvis, we have found the strength of the pelvic floor to be poor and on testing using our diagnostic ultrasound scanning we find movement of the pelvic floor is often limited.
What can we do about it?
At Core Body Clinic we have a lot of success in treating this condition with all our patients achieving a greater than 75% improvement**
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 may help some patients by providing 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. However, there may be no tension at all. We also use diagnostic ultrasound to examine the pelvic floor and determine whether movements are limited and whether this is a result of tension or trigger points. We must stress that trigger points merely relate to painful areas in the pelvic floor. The key to successful trigger point diagnosis is the reproduction of the patients pain. True trigger points in the pelvis are rare, we have found, in the case of hard flaccid
Exercises to restore normal pelvic floor control is essential. Quite often online forums encourage the ‘Kegal’ exercises to strengthen the pelvic floor for enhancing sexual performance and many men attend the practice having done these only to end up in a worse state. The confusion is that they have over exercised using kegals. It is often found that they have injured themselves and blamed the kegals. One would then tend to focus on the ‘reverse kegal’. This differs from the kegal by pushing the pelvic floor down rather than lifting it up. It aims and is believed to de-tension the pelvic muscles. However, we must restore balance in the pelvis to ensure reciprocal operation of the pelvic muscles and therefore using diagnostic ultrasound feedback we teach the patients how to balance the normal rhythm of the pelvic floor muscles. We want them to do kegals and reverse kegals. These movements are normal for the pelvic floor and are often dysfunctional in hard flaccid states Using diagnostic Ultrasound s a highly effective technique for such conditions and at Core Body Clinic it is Gold Standard for treating the pelvis.
Hard flaccid is also thought to occur with weight lifting and patients believe 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 our therapy is to coach the patient about normal lifting practices and ensure their breathing pattern and pelvic muscle control is appropriate. It is often they have injured themselves and then find weight training exacerbates their symptoms rather than a cause. Assessment of the pelvic muscles during exercise is key.
We also direct the patient through a set routine of stretches and loading activities to rehabilitate the pelvis. We look at hip, knee, ankle and spinal ranges of movement. Our aim it to get the body back to physical prime. That way patients are mentally and physically confident in their bodies. We also want to reduce as far as possible the facial interplay of connective tissue tension across the pelvis. While there is little evidence to support the concept that fascia in the body causes hard flaccid, getting our patients back to sound physical conditioning is well known to help mental wellness and pain. Our experience is that is hugely helps reduce symptoms in pelvic pain patients and also the symptoms of hard flaccid.
Hard flaccid is a difficult condition to treat. Specific men’s health physiotherapy is highly successful in resolving this condition. More importantly having a physiotherapist that understands the condition and knows how to treat an individual is key.
Core Body Clinic is specialist center for the treatment of Hard Flaccid.
** time frame to achieving outcomes varies considerably.