Hard flaccid syndrome
Other names	Hard flaccid
Specialty	Men's health
Symptoms	Semi-rigid penis at the flaccid state, flaccid glans at the erect state, pelvic/erectile pain and dysfunction, low libido, penile numbness, frequent/urgent urination
Risk factors	Trauma, Antidepressants

Hard flaccid syndrome (HFS), also known as hard flaccid (HF), is a chronic painful condition characterized by a semi-rigid penis at the flaccid state, a soft glans at the erect state (cold glans syndrome), pelvic pain, low libido, erectile dysfunction, erectile pain, pain on ejaculation, penile sensory changes (numbness or coldness), lower urinary tract symptoms, contraction of the pelvic floor muscles, and psychological distress.^[1] Other complaints include rectal and perineal discomfort, cold hands and feet, and a hollow or detached feeling inside the penile shaft. The majority of HFS patients are in their 20s–30s and symptoms significantly affect one's quality of life.^[2]

Sufferers typically report the onset of symptoms after trauma due to a mishap during sexual intercourse or tough masturbation, specifically a traumatic injury at the base of the erect penis,^[3] possibly affecting the dorsal artery of the penis, the bulbourethral and the pudendal arteries, as well as the pudendal and dorsal nerve of the penis.^[4] Penile sensory and textural changes, as well as changes in appearance, are hallmarks of the condition and serve to distinguish HFS from classic chronic pelvic pain syndrome or BPH.^[1]

Both biological and psychological influences contribute to the condition by altering the neurovascular supply to the muscles of the pelvic floor and penis. One theory proposes that HFS is a result of an initial stress which triggers an abnormal fight or flight response resulting in increased sympathetic stimulation to the muscles of the pelvis via the perineal branch of the pudendal nerve. In turn, a surge of adrenaline, noradrenaline and cortisol is released from the efferent nerve fibers promoting increased blood flow to the bulbospongiosus, ischiocavernous and levator ani muscles as well as sustained muscle contraction which results in obstructed venous outflow from the penis via compression of the deep dorsal vein and pelvic myoneuropathy secondary to neurogenic inflammation.^{[medical citation needed]}

Pathophysiology

The pathophysiology of HFS is not well understood, but it is often associated with traumatic events such as vigorous sexual activity or use of vacuum devices, with varying onset times. A key factor is traumatic injury at the base of an erect penis, affecting neurovascular structures supplying the pelvic floor and penile muscles, leading to vascular and sensory changes, partial penile engorgement, and unusual sensations. Emotional distress and sympathetic stimulation trigger prolonged pelvic floor muscle spasms, which further compress these neurovascular structures, leading to penile hypoxia, neuropraxia, sensory alterations, and pelvic muscle impairment. Persistent muscle contractions in various pelvic muscles contribute to penile venous outflow obstruction, causing the semi-hardness state of the flaccid penis. Subsequently, a secondary myoneuropathy develops, leading to erectile and ejaculatory dysfunctions.^[3]

Treatment

Treatment may include medications for pain management, pelvic floor physical therapy, biofeedback, and stress reduction techniques. Men experiencing anxiety or depression may benefit from counseling.^[5]

Hard flaccid relief comes also from:

• Penile Rehab Exercises - Specialized exercises follow pelvic floor relaxation to encourage healthy engorgement. Sequential tension and release along the shaft removes dense built up collagen improving tissue oxygenation. Prescribed routines promote elasticity.
• Shock Wave Therapy - Low intensity sound waves send pulsating vibrations deep into penile tissue to drive angiogenesis and break up fibrotic plaques. Clinical shock wave therapy performed once weekly restarts micro blood flow critical for engorgement. In office procedures last under 30 minutes.^[6]