{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T06:05:01Z","timestamp":1790661901579,"version":"4.1.0"},"reference-count":84,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:00:00Z","timestamp":1790640000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Rehabil. Sci."],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>To describe clinical outcomes associated with completion of an integrative multimodal rehabilitation protocol in a retrospective case series of men with HFS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcomes<\/jats:title>\n                    <jats:p>Erection Hardness Scale (EHS), penile function satisfaction, PROMIS Interest in Sexual Activity, and PROMIS Global Health Physical and Mental Component scores.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Median EHS increased from 2 to 4 and median penile satisfaction increased from 2 to 5 (both\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&amp;lt;\u20090.01). All 32 patients achieved EHS \u22653 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 (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&amp;lt;\u20090.01). Common comorbid features included low back pain (53%), hip or groin pain (38%), pelvic floor pain (31%), and urinary symptoms (28%).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fresc.2026.1970062","type":"journal-article","created":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T05:47:21Z","timestamp":1790660841000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Multimodal rehabilitation for hard flaccid syndrome in a retrospective case series"],"prefix":"10.3389","volume":"7","author":[{"given":"Christopher L.","family":"Mendias","sequence":"first","affiliation":[{"name":"Performance Medicine Institute","place":["Phoenix, AZ, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tariq M.","family":"Awan","sequence":"additional","affiliation":[{"name":"Performance Medicine Institute","place":["Phoenix, AZ, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,29]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"503","DOI":"10.1038\/s41443-019-0151-x","article-title":"A qualitative analysis of internet forum discussions on hard flaccid syndrome","volume":"32","author":"Gul","year":"2020","journal-title":"Int J Impot Res"},{"key":"B2","doi-asserted-by":"publisher","first-page":"458","DOI":"10.1038\/s41443-024-00853-2","article-title":"Hard flaccid syndrome symptoms, comorbidities, and self-reported efficacy and satisfaction of treatments: a cross-sectional survey","volume":"37","author":"Niedenfuehr","year":"2025","journal-title":"Int J Impot Res"},{"key":"B3","doi-asserted-by":"publisher","first-page":"446","DOI":"10.1038\/s41443-024-00917-3","article-title":"Hard-flaccid syndrome: a survey of sexual medicine practitioners\u2019 knowledge and experience","volume":"37","author":"Gryzinski","year":"2025","journal-title":"Int J Impot Res"},{"key":"B4","doi-asserted-by":"publisher","first-page":"176","DOI":"10.1038\/s41443-019-0133-z","article-title":"Hard flaccid syndrome: initial report of four cases","volume":"32","author":"Gul","year":"2020","journal-title":"Int J Impot Res"},{"key":"B5","doi-asserted-by":"publisher","first-page":"qeaf082","DOI":"10.1093\/sxmrev\/qeaf082","article-title":"Persistent genital arousal disorder\/genito-pelvic dysesthesia in all genders: recommendations from the fifth international consultation on sexual medicine (ICSM 2024)","volume":"14","author":"Goldstein","year":"2026","journal-title":"Sex Med Rev"},{"key":"B6","doi-asserted-by":"publisher","first-page":"S103","DOI":"10.1016\/j.jsxm.2022.01.218","article-title":"203 Successful treatment of hard flaccid syndrome: a case report","volume":"19","author":"Nico","year":"2022","journal-title":"J Sex Med"},{"key":"B7","doi-asserted-by":"publisher","first-page":"2793","DOI":"10.3390\/healthcare11202793","article-title":"Hard flaccid syndrome: a biopsychosocial management approach with emphasis on pain management","volume":"11","author":"Billis","year":"2023","journal-title":"Exercise Therapy and Education. 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