madman
Super Moderator
* This gap in knowledge leads to a vicious cycle: patients are misunderstood or dismissed, often cycling through multiple specialists without answers, while clinicians lack the awareness or confidence to identify these conditions. Moreover, these disorders rarely present with objective, measurable signs. Many originate from complex interactions between neurovascular, endocrine, immunological, and psychological systems. Their pathophysiology is still unclear, and the literature—mostly consisting of case reports and small case series—reflects that ambiguity.
It was during a routine day in the clinic that I encountered a patient who would unknowingly set me on an academic and clinical journey that has yet to slow down. He was a young man presenting with persistent penile discomfort, altered sensation, and a strange mix of erectile rigidity and flaccidity that did not fit any known diagnostic category. His distress was real, but his symptoms fell through the cracks of classical definitions. That patient – and several similar ones soon after – led me and a group of international colleagues to first define and publish what we later named the Hard Flaccid Syndrome (HFS) [1, 2].
This experience became a revelation: how many more sexual health conditions remain unnamed, misunderstood, or worse—dismissed? From that point forward, I developed a keen interest in rare male sexual disorders. What I found was a vast and largely uncharted territory of clinical syndromes—Post-SSRI Sexual Dysfunction, Post-Orgasmic Illness Syndrome (POIS), Post-Finasteride Syndrome (PFS), Sleep-Related Painful Erections (SRPE) and others—each posing diagnostic and therapeutic challenges for the practicing urologist and andrologist. While these disorders are rare, they are not nonexistent. And for the men who suffer from them, they are often devastating.
This gap in knowledge leads to a vicious cycle: patients are misunderstood or dismissed, often cycling through multiple specialists without answers, while clinicians lack the awareness or confidence to identify these conditions. Moreover, these disorders rarely present with objective, measurable signs. Many originate from complex interactions between neurovascular, endocrine, immunological, and psychological systems. Their pathophysiology is still unclear, and the literature—mostly consisting of case reports and small case series—reflects that ambiguity.
This issue includes original investigations and analyses that span from the neurovascular hypotheses in HFS to biochemical and immune mechanisms in PFS and POIS. It includes discussions on underreported entities like SRPE and addresses controversial or emerging concepts such as delayed ejaculation and drug-induced sexual dysfunctions. We also provide real-world insights into management strategies, challenges in patient communication, and the psychosocial toll of diagnostic uncertainty.
We dedicate this special issue to the patients who taught us to ask better questions, and to the clinicians who continue to look for answers even when the textbook offers none.
It was during a routine day in the clinic that I encountered a patient who would unknowingly set me on an academic and clinical journey that has yet to slow down. He was a young man presenting with persistent penile discomfort, altered sensation, and a strange mix of erectile rigidity and flaccidity that did not fit any known diagnostic category. His distress was real, but his symptoms fell through the cracks of classical definitions. That patient – and several similar ones soon after – led me and a group of international colleagues to first define and publish what we later named the Hard Flaccid Syndrome (HFS) [1, 2].
This experience became a revelation: how many more sexual health conditions remain unnamed, misunderstood, or worse—dismissed? From that point forward, I developed a keen interest in rare male sexual disorders. What I found was a vast and largely uncharted territory of clinical syndromes—Post-SSRI Sexual Dysfunction, Post-Orgasmic Illness Syndrome (POIS), Post-Finasteride Syndrome (PFS), Sleep-Related Painful Erections (SRPE) and others—each posing diagnostic and therapeutic challenges for the practicing urologist and andrologist. While these disorders are rare, they are not nonexistent. And for the men who suffer from them, they are often devastating.
Why do these conditions remain overlooked?
The short answer is: because they don’t fit. They defy simple classification, lack standardized diagnostic criteria, and are rarely discussed in mainstream training or guidelines. Most urologists are well-trained in managing erectile dysfunction, premature ejaculation, or Peyronie’s disease, but few are prepared for the patient who walks in with unexplained genital dysaesthesia after stopping finasteride or a man who experiences flu-like symptoms after every orgasm.This gap in knowledge leads to a vicious cycle: patients are misunderstood or dismissed, often cycling through multiple specialists without answers, while clinicians lack the awareness or confidence to identify these conditions. Moreover, these disorders rarely present with objective, measurable signs. Many originate from complex interactions between neurovascular, endocrine, immunological, and psychological systems. Their pathophysiology is still unclear, and the literature—mostly consisting of case reports and small case series—reflects that ambiguity.
The need for structure in chaos and what this special issue offers
In 2024, we published a clinical guide on rare male sexual disorders in Nature Reviews Urology, aiming to consolidate the fragmented knowledge in the field [3]. This Special Issue of IJIR builds on that foundation, providing a focused, comprehensive, and peer-reviewed collection of original research, reviews, and expert commentaries on the topic. Our goal was not only to highlight the pathophysiology and management of these disorders but also to give them a place – a home – within the urological literature. By doing so, we hope to validate the experiences of patients and empower clinicians with tools for recognition and early intervention.This issue includes original investigations and analyses that span from the neurovascular hypotheses in HFS to biochemical and immune mechanisms in PFS and POIS. It includes discussions on underreported entities like SRPE and addresses controversial or emerging concepts such as delayed ejaculation and drug-induced sexual dysfunctions. We also provide real-world insights into management strategies, challenges in patient communication, and the psychosocial toll of diagnostic uncertainty.
Looking ahead
The time has come to formally integrate rare sexual disorders into the broader framework of sexual medicine. Doing so requires awareness, research funding, cross-disciplinary collaboration, and—perhaps most crucially—an openness from clinicians to acknowledge what they do not yet fully understand.We dedicate this special issue to the patients who taught us to ask better questions, and to the clinicians who continue to look for answers even when the textbook offers none.
