Multimodal rehabilitation for hard flaccid syndrome in a retrospective case series

Front Rehabil Sci. 2026 Sep 29;7:1970062. doi: 10.3389/fresc.2026.1970062. eCollection 2026.

ABSTRACT

INTRODUCTION: 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.

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

METHODS: 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.

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

RESULTS: 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%).

DISCUSSION: 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.

PMID:42871021 | PMC:PMC13658169 | DOI:10.3389/fresc.2026.1970062