Is it Erectile Dysfunction or Hard Flaccid Syndrome?

By Dr. Zarina Vitebsky, DPT, MSPT, PRPC, TPS, LPF, DN on 9/20/2023


In a previous blog post, we discussed possible factors that contribute to erectile dysfunction. Erectile dysfunction, as the blog mentions, is known as difficulty initiating or sustaining an erection. Hard Flaccid Syndrome, on the other hand, is a constant state of a semi-rigid penis in the flaccid state and a loss of overall erectile rigidity. Hard flaccid syndrome is a type of erectile dysfunction, but not all erectile dysfunctions include hard flaccid syndrome. The condition of Hard Flaccid Syndrome (HFS) has been gaining more medical attention in the past few years, unlike in previous years in which a majority of conversations regarding Hard Flaccid Syndrome has primarily been shared through online forums and private chats.

Clinically, hard flaccid syndrome presents as penile sensitivity, coldness or numbness (especially at the tip of the penis). Penile or perineal pain during voiding or ejaculating is common, and often worse when standing. Prevalence is common in ages 20’s to 30’s but cases have been reported with males from their teens up to their 70s. Hard flaccid syndrome is an intimate condition that can often cause emotional distress, depression, decrease in libido, and social anxiety. These affective consequences often tend to create muscular tension - which can perpetuate the condition itself.

How does this happen?

The mechanism of injury and physiological mechanics behind hard flaccid syndrome is not well studied. A traumatic injury to the penis is often though to be the primary cause of the syndrome (whether that be a blunt force trauma, aggressive sexual experience, increased pressure from very lifting heavy). Physiologically, there would be neurovascular damage to the penis, meaning a nerve, artery, or vein would be negatively involved.

Structures involved for partial engorgement of the penis during erections:

  1. Arteries (Dorsal arteries of the penis, Bulbourethral artery, Pudendal artery)

  2. Nerves (Pudendal nerve branches (dorsal nerve of the penis)

The emotional distress from an initial injury may then heighten the central nervous symptoms to tighten the pelvic floor muscles. Pelvic floor tightening causes additional neurovascular compression to the aforementioned structures and can contribute to the chronicity of the initial injury.

One may consider the following pelvic floor muscles involved:

  1. Bulbospongiosus

  2. Ischiocavernosus

  3. External urethral sphincter

If the above muscles are tightened, they may obstruct venous blood flow (blood flowing out of the penis and back toward the heart) and prevent full relaxation of the penis.

It is imperative to address the psychological component of hard flaccid syndrome to then treat the source of the injury. Behavioral modifications such as 7-9 hours of sleep, healthy eating, regular exercises are essential for the body to undergo healing. Pelvic floor physical therapy can treat hard flaccid syndrome by educating the patient on breathing exercises, discussing therapeutic movement to reduce stress, and promoting well-being to pelvic floor muscle contraction. Based on examination and with patient consent, a pelvic floor physical therapist can also perform soft tissue manual therapy and lengthening of the pelvic floor muscles to promote relaxation of the pelvic floor muscles as well.

If you’re experiencing pelvic floor dysfunctions associated with the issues above, please reach out to us at Pelvic Health Center in Madison, NJ to set up an evaluation and treatment!

Feel free to call us at 908-443-9880 or email us at

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