(149) Prevalence of Lumbosacral Annular Tears in Individuals with Hard Flaccid Syndrome
Authors: Goldstein I , Komisaruk BR , Goldstein SW , Yee A 
Published: February 2024

Abstract

Introduction
Hard flaccid syndrome (HFS), characterized by the penis in an unwanted persistent semi-rigid flaccid state, is an acquired, painful, and bothersome sexual dysfunction that is poorly understood. We have previously postulated that HFS is, in part, a consequence of pathological activation of a somato-visceral and/or a viscero-visceral reflex that we term the “pelvic/pudendal-hypogastric” reflex. In patients with HFS, physical examination reveals a hypercontracted flaccid penis that feels hard on palpation. Biological complaints include penile morphometric changes such as wrinkles or indents; cold-feeling glans with decreased penile sensation; urinary symptoms such as decreased force of stream; constipation; high tone pelvic floor; perineal and penile pain during ejaculation; and erectile dysfunction. Since there is limited understanding of HFS and its pathophysiologic triggers, men with these complaints often seek help from online support groups.

Objective
To assess the prevalence of lumbosacral annular tears in individuals participating in an HFS online support group and compare this to the prevalence reported in asymptomatic individuals in the peer-reviewed literature.

Methods
A sexual medicine clinic patient with HFS likely from a lumbosacral annular tear causing sacral radiculopathy who leads an HFS online support group shared his information regarding the suspected pathophysiology. Consequently, other members of the group contacted the sexual medicine clinic to share lumbar MRI images for the spine surgeon to read. All lumbar MRIs had been performed within the last year. They were uploaded to an image sharing service for the spine surgeon to read the sagittal and axial views to assess for the presence of lumbosacral annular tears. For comparison, the literature was reviewed regarding the prevalence of lumbosacral spine disease in asymptomatic individuals.

Results
A total of 21 individuals, mean age 28 (range 19-42) years, with symptoms consistent with HFS contacted our sexual medicine clinic. Symptoms were verified during the courtesy triage call after which a lumbar MRI was submitted by each individual for evaluation. 16/21 (76%) had surgically treatable annular tears, the most common location being L5-S1 and L4-L5. In addition to HFS symptoms, 38% had concomitant complaints of low back pain and lower extremity sciatica. In a systematic review of 33 peer-reviewed articles reporting imaging findings for &gt;3000 asymptomatic individuals, the prevalence of lumbosacral annular tear varied from 19% to 29% in individuals aged 20 to 80 years [Brinjikji et al, 2015].

Conclusions
There is a higher prevalence of lumbosacral annular tears among HFS individuals in this support group who had a lumbar MRI compared to the rate in asymptomatic individuals from peer-reviewed literature. This further supports our hypothesis that HFS is the result of a hyperactive “pelvic/pudendal-hypogastric” reflex. In those men with lumbosacral annular tears, HFS may be triggered by the cauda equina pathology causing sacral radiculopathy that reflexively induces excess sympathetic activity in the efferent hypogastric nerve causing the unwanted HFS symptoms.

Disclosure
No.