Hard Flaccid: Causes, Treatments, and Symptoms

In Male Pelvic Pain by Elizabeth AkincilarLeave a Comment

By Elizabeth Akincilar, MPT, Cofounder, PHRC Merrimack

Although our knowledge is limited with regards to hard-flaccid syndrome, based upon the minimal medical literature dedicated to this syndrome and our own experience at PHRC, hard-flaccid syndrome most commonly occurs secondary to the following:


When the PFM, particularly the urogenital diaphragm, or superficial PFM, become too tight or hypertonic, they can contribute to hard-flaccid syndrome. These particular muscles are intimately involved in erectile function; therefore, if they aren’t functioning optimally, because they are too tight, they can contribute to erectile dysfunction and/or symptoms associated with hard-flaccid. Additionally, when these muscles are too tight they can also impede the vascular structures in the genitals, which can also negatively impact erectile function.


Jelqing – an exercise that stretches the penis in an attempt to elongate or enlarge it. When the penis is aggressively stretched, as with jelqing, the penile branch of the pudendal nerve, which travels along the penile shaft, is also stretched. Nerves can become painful and/or dysfunctional when they are overstretched. Therefore, if the penile branch of the pudendal nerve is overstretched during jelqing, it can contribute to the symptoms of hard-flaccid syndrome.


Similarly to jelqing, if the penis is aggressively stretched or manipulated during aggressive or prolonged masturbation, injury to the penile branch of the pudendal nerve can occur, contributing to the symptoms of hard-flaccid syndrome.


Lastly, compromised vascular structures, such as arteries and veins, can become compromised for a variety of reasons. As previously mentioned, tight pelvic floor muscles could play a role. Cardiovascular disease, high blood pressure, and/or diabetes are a few examples of health conditions that will negatively impact vascular structures. If you are suffering from hard-flaccid syndrome it is best to discuss all the health conditions that could be negatively impacting your vascular system with your physician to determine if these conditions are contributing to the symptoms of hard-flaccid.

hard flaccid treatments


If you are experiencing symptoms consistent with hard-flaccid syndrome, consider the following treatments.

Pelvic floor physical therapy can treat muscular impairments that may be negatively affecting the pudendal nerve as well as the surrounding vascular structures that can contribute to hard-flaccid syndrome.

Talk to your urologist about possible hormonal imbalances that could contribute to these symptoms.

Minimize comorbidities, especially concerning your cardiovascular system, such as high blood pressure, high cholesterol and diabetes. Improve your cardiovascular health by reducing alcohol consumption, quitting smoking, eating healthier and exercising regularly!

Although the jury is still out on shock wave therapy, some folks have reported improvements in their symptoms of hard-flaccid syndrome after undergoing shock wave therapy. Talk to your healthcare provider to see if you are a candidate!


hard flaccid symptoms


Common symptoms of hard-flaccid syndrome include the following:

  • Penile and/or perineal pain or discomfort
  • Inability to achieve a full erection or the feeling of a semi-erection when not aroused
  • Erectile dysfunction
  • Pain or discomfort during and/or after ejaculation
  • Reduced force of ejaculation
  • Feeling of coldness in the penis


Diagnostic Challenges


Although Hard-flaccid Syndrome is not a designated medical diagnosis, it is the name that the collection of symptoms has taken on over the years, primarily via online forums. Unfortunately there is very little information available within the medical literature; therefore, it is poorly understood and defined.


Additionally, many of the symptoms reported with Hard-flaccid syndrome are also reported with those suffering from CPPS/Male Pelvic Pain Syndrome and Chronic Nonbacterial Prostatitis. Although these are well defined diagnoses, they have challenges of their own when it comes to getting a correct diagnosis and undergoing an effective treatment plan. To complicate the matter further, many pelvic floor physical therapists are only trained to treat women. This is not the case at PHRC, in fact, some days we treat more men than women.


How We Can Help


Men experiencing Hard-flaccid Syndrome can benefit from an evaluation with a pelvic floor physical therapist specializing in pelvic pain. During the evaluation, the physical therapist reviews your history and symptoms with you, what you have been diagnosed with in the past, the treatments you have undergone and how effective or not effective these treatments have been. Importantly, we understand what you have been going through and that most men are frustrated by the time they get to see us. 


During the physical examination the physical therapist examines muscles, tissues, joints, nerves, and movement patterns. Once the physical therapist completes the examination they review their findings with you. The physical therapist creates an assessment which explains how you developed the symptoms and creates short and long-term goals for your treatment plan.Typically, the frequency of physical therapy is one to two times per week for roughly 12 weeks. You are given a home exercise plan to compliment your in-person sessions, and your physical therapist will help to coordinate your recovery with the other members of your treatment team. We are here to help you recover and live your best life!



Are you unable to come see us in person in the Bay Area, Southern California or New England?  We offer virtual physical therapy appointments too!


Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page

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What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

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