SYNOPSIS

Hard flaccid syndrome

BY KAYLIE HUGHES, ARIE PARNHAM AND MARC LUCKY

hronic pelvic pain is defined as can remain flaccid during erection. sustained muscle contraction. pain present below the level of • Pain on ejaculation and urination with a • Sustained contraction of the the umbilicus with a duration reduction in urinary flow. ischiocavernosus and bulbocavernosus of more than six months [1,2]. At presentation, psychological symptoms muscle results in obstructed venous C are usually simultaneously present, such as outflow from the penis via compression of Chronic pelvic pain syndromes (CPPS) are highly prevalent in Western society, insomnia, anxiety, depression, feelings of the deep dorsal vein. This process is likely affecting both males and females. Studies low self-worth leading to social isolation and to be responsible for the semi-engorged have shown that CPPS significantly impacts suicidal thoughts. penis in the flaccid state. upon a person’s quality of life because of • Prolonged contraction of the muscles debilitating physical symptoms along with Clinical signs results in pelvic myoneuropathy secondary the psychological burden of the condition Abdominal and digital rectal examination are to neurogenic inflammation. The muscles physically lose their ability to [1-5]. unremarkable. Examination of the penis in relax, remaining contracted. The severe Until recently, non-bacterial chronic the flaccid state can reveal engorged corpora cramping, clenching sensation men prostatitis has been widely accepted as the cavernous muscles like a semi-erect penis, describe in their pelvis, penile shortening, leading cause of chronic pelvic pain in men with a rubbery texture. In the erect state, the erectile and urinary dysfunction is likely [4]. However, a new phenomenon, known as penis feels very tight, with men reporting increasing levels of pain. The glans penis can attributed to this. hard flaccid syndrome, is being recognised remain flaccid unlike a normal erection. • Myofascial syndrome then occurs. Multiple as an alternative cause of unremitting painful trigger points develop in the pelvic pain in men by specialist pelvic floor muscles, resulting in the area becoming physiotherapists and some urologists. Aetiology hypersensitive. Slight stimulation to the Currently, no published literature exists of The true aetiology of this condition is penis / pelvis results in a complex cascade the syndrome. Using observed information unknown. Like many CPPS the development of afferent and efferent nerve impulses, obtained from men’s health and pelvic floor of hard flaccid syndrome is thought to resulting in the secretion of neuropeptides physiotherapy forums (www.allthingsmale. be multifactorial in nature. Biological, which consequentially cause severe pain com, https://yourbrainrebalanced.com, psychological and social influences all contribute to the development and severity and inflammation disproportionate to the https://pelvicpainrehab.com/, https:// of the condition by altering the neurovascular initial stimulus. curehardflaccid.wordpress.com/) we aim to supply to the muscles of the pelvic floor and The psychosocial factors contributing to the raise awareness of this condition. We present penis. development of this syndrome are related the common signs and symptoms men exhibit Stress is a key risk factor for the to the psychosexual nature of the condition. and discuss how a multimodality holistic development of this condition by way of Men report deterioration or recurrence of approach is the gold standard management. causing prolonged contraction of the muscles symptoms at times of elevated stress. It is not uncommon at presentation for men to What is hard flaccid syndrome? of the pelvic floor. Stress can be triggered by an injury directly to the penis during be trapped in a vicious cycle. They can often Hard flaccid syndrome is a type of CPPS. The sexual intercourse or masturbation, or stress agonise about the future leading to extreme true prevalence is unknown, but cases have secondary to psychosocial distress in the levels of stress and anxiety, triggering more been reported in forums from men aged from absence of injury. sympathetic stimulation to the pelvis. Men their late teens to the seventh decade of life. Within the body, psychological stress can become fixated, performing regular Symptoms can be present for many years triggers the release of adrenalin with a attentive self-examination to the area before correct diagnosis occurs. primitive fight or flight response. The body which may be hypersensitive. This results goes into high alert; blood is directed away in further muscle spasm and exacerbation Clinical features from certain visceral organs like the stomach of symptoms. A possible explanation why Patients usually seek medical advice because to the muscles of the limbs and pelvis, so men catastrophise is that they frequently of the following symptoms: danger can be avoided. blame themselves for past events such as • Penile and perineal pain. This is most One of the biological theories proposed to excessive masturbation or sexual techniques, severe in the standing position, less so explain the relationship between stress and which may be totally unrelated. Their in the sitting position and absent when the development of hard flaccid syndrome is overall perception of body image changes supine. The pain regresses when urinating. as follows: as they become hyperaware of their sexual • Patients report shortening of the penis • Initial stress, be it physical or psychological, organ. They feel suboptimal and this in turn associated with a constant cramp / triggers an abnormal fight or flight response results in altered libido and an aversion to clenching sensation in the pelvis. resulting in increased sympathetic sexual encounters. Over time chronically • Penile sensory changes can be reported stimulation to the muscles of the pelvis via elevated levels of cortisol can lead to lowered with the penis feeling numb to touch. the perineal branch of the pudendal nerve. testosterone levels which can alter libido • Erectile dysfunction. There can be loss of • A surge of adrenaline, noradrenaline and and sexual performance. This can lead to the morning and nocturnal erections. Excessive cortisol is released from the afferent nerve perception of loss of masculinity [6-11]. physical stimulation is often required to fibres promoting increased blood flow to obtain an erection, in addition to visual the bulbospongiosus, ischiocavernous Investigation / diagnosis stimulus or cognitive thought. The glans muscle and levator ani muscles as well as As with all chronic pain syndromes hard

urology news | NOVEMBER/DECEMBER 2018 | VOL 23 NO 1 | www.urologynews.uk.com SYNOPSIS

flaccid syndrome is a diagnosis of exclusion with meditation, yoga or exercise are all 15. Anderson R, Wise D, Sawyer T, et al. Safety and [3,4]. The majority of men will have vital in the successful management of this effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome. seen several doctors and may have been somewhat debilitating condition [17-20]. CBT Clin J Pain 2011;27(9):764-8. misdiagnosed with alternative conditions may also help patients come to terms and 16. Van Alstyne LS, Harrington KL, Haskvitz EM. Physical such as Peyronie’s disease before the correct adapt to life living with a chronic condition. therapist management of chronic prostatitis/chronic diagnosis is made. It is not uncommon for pelvic pain syndrome. Phys Ther 2010;90(12):1795-806. men to have received intensive investigation Conclusion 17. Schaffer SD, Yucha CB. Relaxation & pain management: the relaxation response can play a role in managing such as: blood tests including hormonal Hard flaccid syndrome should be suspected chronic and acute pain. AJN 2004;104(8):75-82. profiling and prostate specific antigen in men of all ages who present with chronic 18. Hofmann SG, Sawyer AT, Witt AA, et al. The effect (PSA), urinalysis and urine culture, sexually pelvic pain associated with urinary and of mindfulness-based therapy on anxiety and transmitted infection screen, flexible erectile dysfunction. At present this condition depression: a meta-analytic review. J Consult Clin Psychol 2010;78(2):169-83. cystoscopy, Doppler ultrasound of the penis in not universally accepted by urologists 19. Sutar R, Yadav S, Desai G. Yoga intervention and and MRI of the pelvis / penis, all of which yield because of the lack of published literature on functional pain syndromes: a selective review. Int Rev normal results. the subject, despite the debilitating physical Psychiatry 2016;28(3):316-22. Clinical history and examination can help and emotional symptoms it may cause. 20. Chiesa A, Serretti A. Mindfulness-based stress reduction direct towards a diagnosis. Key signs and By raising awareness of the syndrome, we for stress management in healthy people: a review symptoms may be shortening of the penis and meta-analysis. The Journal of Alternative and hope to provide a better understanding of Complementary Medicine 2009;15(5):593-600. (although this is highly subjective), chronic the disorder with a view to enabling earlier pain which regresses in the supine position diagnosis, less misdiagnosis and quicker and on micturition, and men typically access to appropriate therapy. describing the penis as “feeling hollow”. As mentioned previously, on examination the AUTHORS penis can be semi engorged in the flaccid References 1. Labat JJ, Robert R, Delavierre D, et al. Anatomy and state and have a rubbery texture. physiology of chronic pelvic and perineal pain. Prog Urol 2010;20(12):843-52. Management 2. Dybowski C, Löwe B, Brünahl C. Predictors of pain, Hard flaccid syndrome is difficult to treat urinary symptoms and quality of life in patients with chronic pelvic pain syndrome (CPPS): A prospective due to the fact it is poorly understood and 12-month follow-up study. J Psychosom Res not yet widely recognised as a condition by 2018;112:99-106. urologists. Like with any CCPS, adoption of a 3. Passavanti MB, Pota V, Sansone P, et al. Chronic pelvic multimodality holistic approach is paramount pain: assessment, evaluation, and objectivation. Pain Res when managing these men [4]. Treat 2017;9472925. 4. Sandhu J, Tu HYV. Recent advances in managing chronic Kaylie E Hughes, The most important step in the prostatitis/chronic pelvic pain syndrome. F1000Res Specialist Registrar in Urology, St Helens and management of this condition is continued 2017;6.pii:F1000 Faculty Rev-1747. Knowsley NHS Foundation Trust, Prescot, Merseyside. reassurance that physically there is nothing 5. Quaghebeur J, Wyndaele JJ. Prevalence of lower functionally wrong with the penis and that urinary tract symptoms and level of quality of life in this is a chronic pain syndrome. The patient men and women with chronic pelvic pain. Scand J Urol 2015;49(3):242-9. should be guided to the conclusion that they 6. Jansen AS, Nguyen XV, Karpitskiy V, et al. Central are not to blame for their symptoms which command neurons of the sympathetic nervous may alleviate some of the anxiety surrounding system: basis of the fight-or-flight response.Science the disorder [12-14]. Simple analgesia and 1995;270(5236):644-6. medication for neuropathic pain such as 7. Jantos M. Understanding chronic pelvic pain. nortriptyline can be used for symptom relief Pelviperineology 2007;26:66-9. [4]. Supervised pelvic floor, biofeedback and 8. Hubbard DR. Chronic and recurrent muscle pain: Pathophysiology and treatment, and review of trigger point physiotherapy with reverse pharmacologic studies. J Musculoskeletal Pain Marc A Lucky, Kegel exercises and Z-wands, allow men to 1996;4:123-43. Consultant Urologist, Aintree University Hospital NHS learn techniques which they can perform and 9. Hannibal KE, Bishop MD. Chronic stress, cortisol Foundation Trust, Liverpool. dysfunction, and pain: a psychoneuroendocrine continue to practise at home to successfully E: [email protected] rationale for stress management in pain rehabilitation. relax their pelvic floor [15,16]. Physical Therapy 2014;94(12):1816–25. As anxiety is the main risk factor for 10. Krsmanovic A, Tripp DA, Nickel JC, et al. Psychosocial Declaration of completing interests: None declared development and persistence of this mechanisms of the pain and quality of life relationship condition, early referral for counselling for chronic prostatitis/chronic pelvic pain syndrome (CP/ SECTION EDITOR and cognitive behavioural therapy (CBT) CPPS). Can Urol Assoc J 2014;8(11-12):403-8. is of upmost importance in management. 11. Montenegro ML, Gomide LB, Mateus-Vasconcelos EL, et al. Abdominal myofascial pain syndrome must be Patients are taught to address any underlying considered in the differential diagnosis of chronic pelvic emotional issues whilst promoting the growth pain. Eur J Obstet Gynecol Reprod Biol 2009;147(1):21-4. and development of stress management 12. Tripp DA, Curtis Nickel J, Katz L. A feasibility trial of a techniques. Keeping a symptom diary may cognitive-behavioural symptom management program for chronic pelvic pain for men with refractory chronic help with this. Promotion of good sleep, prostatitis/chronic pelvic pain syndrome. Can Urol hygiene, healthy eating and exercise, all Assoc J 2011;5(5):328-32. factors which are known to help reduce stress 13. Fry RP, Crisp AH, Beard RW. Sociopsychological factors and improve wellbeing, is important. Regular in chronic pelvic pain: a review. J Psychosom Res exercise is also beneficial as it strengthens 1997;42(1):1-15. Arie Parnham MBChB, FRCS(Urol) core muscles, taking pressure off the pelvic 14. Franco JVA, Turk T, Jung JH. Non-pharmacological Consultant Urologist, The Christie NHS Foundation interventions for treating chronic prostatitis/chronic Trust, Manchester, UK floor muscle. pelvic pain syndrome: a Cochrane systematic review. E: [email protected] Relaxation techniques like breathing BJU Int 2018;doi:10.1111/bju.14492 [Epub ahead of exercises and encouragement of mindfulness print].

urology news | NOVEMBER/DECEMBER 2018 | VOL 23 NO 1 | www.urologynews.uk.com