Hard-flaccid syndrome (HFS) is a condition of male sexual dysfunction (MSD) that has become a relatively new focus in online forums and urologic conferences [1, 2]. It is a poorly understood syndrome characterized by chronic pain, a partially rigid penis while in a flaccid state, sensory changes mostly at the glans, and erectile dysfunction [1]. Interestingly, there are also reports of having the pain exacerbated during ejaculation and micturition. Additionally, this painful and psychologically worrisome condition results in significant anxiety and depression with significant impacts on quality of life [1, 3, 4].

HFS primarily affects men in their second and third decade of life, but its exact pathophysiology remains uncertain, with hypotheses most commonly suggesting an initial traumatic injury to the base of the penis typically during sexual intercourse [1]. Specifically, damage to the neurovascular bundles that supply innervation to the penis and pelvic floor. The pathophysiologic process is thought to be an emotional reaction following injury and noticing the sensory changes on the penis which then causes a feedback loop where this reaction triggers a hypersympathetic response leading to extensive pelvic floor muscle spasms which ultimately causes additional extrinsic damage to the penile neurovascular bundles [1, 4]. Work-up including cross-sectional imaging, penile ultrasound doppler, and labs tests tend to be completely normal [1, 5]. Regarding the treatment of HFS, there have been combinations utilized with pelvic physical therapy, lifestyle and behavioral modifications, antidepressants, and phosphodiesterase 5 (PDE5) inhibitors. However, there has not been strong evidence regarding their efficacy. Additionally, there are conflicting results for certain therapies, particularly medical therapy with PDE5 inhibitors [1, 3].

Given the paucity of studies and lack of established guidelines regarding HFS, an evidence-based understanding is lacking within the sexual medicine community, and this as understood as most of the published knowledge regarding HFS has been extracted from online forums and chat groups [1]. In order to better understand this condition and how to manage patients adequately, the current level of understanding of HFS first must be established. Because of this, we sought to query a group of contemporary clinicians on their baseline comprehension of HFS and how they diagnose and manage their patients.