Multimodal rehabilitation for hard flaccid syndrome in a retrospective case series

Hard flaccid syndrome (HFS) is an emerging condition of male sexual dysfunction characterized by a persistent semi-rigid penis in the flaccid state, altered penile sensation, erectile dysfunction, and pelvic or perineal pain. Single-modality treatments have shown limited success, and multimodal protocols have been reported only in single-patient case studies.

To describe clinical outcomes associated with completion of an integrative multimodal rehabilitation protocol in a retrospective case series of men with HFS.

Thirty-two men with HFS completed a comprehensive protocol combining class IV laser therapy, dry needling, radial pressure wave shockwave therapy, therapeutic ultrasound, biofeedback training, manual therapy, therapeutic exercise, behavioral coaching, and daily oral tadalafil. Patient-reported outcomes were collected at treatment initiation and completion.

Erection Hardness Scale (EHS), penile function satisfaction, PROMIS Interest in Sexual Activity, and PROMIS Global Health Physical and Mental Component scores.

Median EHS increased from 2 to 4 and median penile satisfaction increased from 2 to 5 (both P < 0.01). All 32 patients achieved EHS ≥3 by treatment end, compared to 8 of 32 (25%) at baseline. PROMIS Interest in Sexual Activity, Global Physical Health, and Global Mental Health scores all improved significantly (P < 0.01). Common comorbid features included low back pain (53%), hip or groin pain (38%), pelvic floor pain (31%), and urinary symptoms (28%).

In this retrospective case series, completion of a multimodal rehabilitation program was associated with improvements in erection hardness, penile satisfaction, sexual interest, and global health in men with HFS. These hypothesis-generating findings warrant prospective controlled studies evaluating efficacy, durability, and component-specific effects.