Hard Flaccid Syndrome: Penetrating What We Know

Have you ever heard of Hard Flaccid Syndrome? Many clinicians and lay people have no idea what it is. If you try and search it on Dr. Google, all you find are message boards and blog posts. Not a single peer reviewed paper. Posts often cite that Hard Flaccid Syndrome involves things such as pelvic pain, pain on ejaculation, a retracted penis, a “rubbery” feeling to the penis, flaccid glans during an erection, symptoms reducing when laying down, and many others. 1,2 But, is it appropriate to call it a syndrome? One survivor speculates it as a symptom of Chronic Pelvic Pain Syndrome (CPPS) and not a condition itself. 3 Does it seemingly cause more catastrophization to comb this symptom out? Continuing with what the author of HF Unraveled cited, do we call one of the common cold symptoms “Runny Nose Syndrome”? Alas, this issue is still a somewhat common occurrence in males and often overlooked by healthcare providers. Pelvic health physiotherapists are the proverbial light at the end of the tunnel for many people. There is hope for individuals suffering!

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.4 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. 2,3,4 Stress causes activation of your sympathetic nervous system which in turn releases adrenaline throughout your body.5 This system is called the Fight or Flight response, and unfortunately your penis does not know if you are running away from a pack of rabid raccoons or wondering why you do not have the same erection you had before. Adrenaline acts by opening blood vessels more to things such as your muscles, heart, or brain and closing down smaller blood vessels, i.e. to your penis. This constant anxiety and stress can take a toll on your pelvic floor muscles too. While some of us hold stress in our jaws or stomachs, others hold their stress in their pelvic floor. They essentially forget how to relax their pelvic floor! Think of it like you have clenched your fist and you cannot extend your fingers back out to a resting position. It is stuck in a fist or you can only go part way. 

So, what can be done? As I mentioned before, a visit to your friendly neighborhood pelvic health physiotherapist may be in your interest. We can assess your pelvic floor muscles to determine how they are performing. What we find can help to direct your treatment. Here’s the catch: our assessment does not have to hurt. Neither does the treatment. Some people benefit from gentle self-massage to the area using a Z-Wand or other handy pelvic floor tool. 1 But, intensive internal manual therapy probably is not necessary, especially since Denneny et al concluded in their meta-analysis that evidence for trigger point manual therapy for chronic noncancer pain is weak and cannot be recommended. 6 We can also help you to employ relaxation techniques and constructive rest habits to help calm your sympathetic nervous system and increase your parasympathetic response. The parasympathetic nervous system releases nitric oxide (NO), the secret to the little blue pill, and causes smooth muscle to relax to allow more blood into your penis.5 Most importantly, we can help you get back on track with your exercise routine so you can increase blood flow to the entire body and help to increase endogenous endorphins! 

If you are a provider, get your clients to a pelvic floor therapist! If you are one of the many men suffering from CPPS and have this hard flaccid symptom, ask your primary care provider about what physical therapy can do for you and your penis. If you are in the Chicagoland area, come to Entropy Physiotherapy & Wellness and we will help get you back on track to healthy, normal erections! 


By Matt, Harville, SPT

Matt has been a student at Entropy Physiotherapy and Wellness since August, and will shortly be leaving us to complete his course work and help people with pelvises, with a focus on transgender care.


  1. I have managed to recover from chronic pelvic pain syndrome. Medium. https://medium.com/@anonymous2016/i-have-managed-to-recover-from-chronic-pelvic-pain-syndrome-da4502b3a77. Accessed November 14, 2018.

  2. Hughes K, Parnham A, Lucky M. Hard flaccid syndrome. Urology News. 2018; 23(1): 28-29. 

  3. HF unraveled: A guide to understanding, coping, & healing. https://hardflaccid.org. Accessed November 14, 2018. 

  4. Cure Hard Flaccid. Word Press. https://curehardflaccid.wordpress.com/. Accessed November 14, 2018. 

  5. Spitz A. The Penis Book: A Doctor’s Complete Guide to the Penis—From Size to Function and Everything in Between. Emmaus, PA: Rodale Books; 2018. 

  6. Denneny D, Frawley HC, Petersen K, et al. Trigger point manual therapy for the treatment of chronic noncancer pain in adults: A systematic review and meta-analysis [published online ahead of print Jul 17 2018]. Arch Phys Med Rehabil. doi: 10.1016/j.apmr.2018.06.019