Multimodal Rehabilitation Improves Erectile Function and Quality of Life in Men with Hard Flaccid Syndrome

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. Our objective was to conduct a retrospective analysis of clinical outcomes from an integrative multimodal rehabilitation protocol in 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 oral tadalafil. Patient-reported outcomes were collected at treatment initiation and completion. The main outcome measures were Erection Hardness Scale (EHS), penile satisfaction, PROMIS Sexual Interest, and PROMIS Global Health Physical and Mental Component scores. In this case series, 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 with 8 of 32 (25%) at baseline. PROMIS Sexual Interest, Physical Component, and Mental Component 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, multimodal treatment produced substantial improvements in erectile function and sexual quality of life in men with HFS, supporting an integrative model in which musculoskeletal and end organ pathologies initiate the syndrome and are amplified by central and peripheral nervous system contributions.