In Your Pants with Dr. Susie G - Hard-Flaccid w/ Gerard Greene

Episode Date: January 3, 2019

Googling to find information on hard-flaccid is like searching for a needle in a haystack. There's not much on the topic other than a few blog posts and a forum or two. Hard-flaccid encompasses an umbrella of symptoms that can make any man cringe with fear and feel inadequate so that's why I've dedicated today's podcast to address this poorly recognized issue that men struggle with.   I've asked the UK's leading men's pelvic health physiotherapist, Gerard Greene, to help shed some knowledge on hard-flaccid and give you practical advice on what you can do when your penis just doesn't feel like yours anymore.  

You're listening to In Your Pants with Dr. Susie G, the physiotherapist for your private, helping you get in the know down below. Hey guys, it's Dr. Susie G, and thank you so much for joining me for another In Your Pants episode, a show where we talk about the issues in your undercarriage so that you can keep embarrassing search histories off your web browser. today's show talks about the ins and outs of what men might experience as hard flaccid in other words the joystick isn't operating optimally there's hardly any quality information out on the ethernet so i've asked my good friend and men's health specialist gerard green to come on

the show today gerard's going to help shed some light on this topic and give you some tips on what you can do when your penis doesn't feel like yours anymore. Gerard Green is a UK-based physiotherapist who combines teaching and research with working in his three specialist pelvic health physiotherapy clinics in Birmingham, UK. His clinics specialize in women's and men's health physiotherapy in addition to children and adolescent bowel and bladder physiotherapy and musculoskeletal and sports physiotherapy. He has a team of seven pelvic health physiotherapists, two of whom work with him in male pelvic pain and post-prostate surgery rehabilitation. He feels privileged to work with a wonderful group of pelvic health physiotherapists.

Gerard co-founded the Women's Health Physiotherapy Facebook group and is an administrator on the Men's Health Physiotherapy Facebook group. He was invited to present at the WCPT 2017 in Cape Town as part of the first focused symposium on men's health physiotherapy. He has taught men's health physiotherapy courses for the South African Society Physiotherapy in 2017 and Japanese Physical Therapy Association in 2018 with Joanne Milios. he has also worked with dr ruth jones in her uk leading pelvic health physiotherapy clinic gerard is a strong advocate of encouraging physiotherapists to get involved in women's and men's pelvic health he has also developed a strong reputation for organizing and delivering

pelvic health postgraduate courses and conferences and works with many leading international tutors he also works as a senior lecturer physiotherapy in coventry university uk gerard thank you so much for being on the show i'm so excited to be talking to you about such a an evolving topic for men and this is the topic of hard flaccid so you know let's start off by addressing you know What is hard flaccid? Where did the term come from? And what are some clinical findings? Thank you, Susie. And it's brilliant to be here. And a big hello from the UK. And so in the clinic that we have in Birmingham in the UK, we see a lot of male pelvic health. And one of the big groups of men that we see are men who present with the syndrome of hard flaccid.

and probably the main complaint that these men have is that they have noticed that their penis has really changed and a lot of them will say well it's almost like it's not my penis it's like it's changed completely and the main things that these men will will have noticed that they can't get a complete or full erection and sometimes they'll describe it that they can get maybe an 80 90 percent erection but maybe the end or the glands isn't isn't fully hard fully engorged but then when the penis should be flaccid or soft it's it seems to constantly be in kind of like almost a semi-rigid state so that they are probably some of the key things in that they can't get a what they would call a normal erection and i think every man knows when his erection is normal or not and

they can sense even subtle changes and then they don't really go into this flaccid state i think the other big thing that the men notice and get you know very concerned and anxious and stressed about is that they get they notice physical changes to the penile tissue and it really varies as to what they notice some will get what's called penile retraction so it looks like some of the length of the penis has been taken out almost like the penis has been drawn into the body so that penis now looks a little bit smaller the penis can also look like the veins are a little bit more engorged so it's almost like there's some circulatory change and also the penis can sometimes have kind of almost very subtle changes in in pigmentation

so it's almost that it's never really fully erect fully flaccid and that there are some structural changes to that penile tissue and alongside those physical changes there also tends to be and rightly so like a lot of stress about the condition a lot of anxiety a lot of worry and those things lead to then a change in the penile a change in sexual performance some erectile dysfunction and what can also and some of these men will also present maybe with some urinary symptoms and those tend to vary depending what type of condition they have but what we commonly would see in the clinic is men complaining of urinary frequency so that they're having to go to pass

urine very frequently, but maybe not passing quantity. We also see some men who have some ejaculatory pain. And we also see men maybe who have some bowel involvement, maybe pain on passing a stool, maybe degrees of constipation. And also, but not always, that kind of very classic pelvic pain condition so although they're getting hard flaccid they're also getting maybe pain maybe some penile pain some changes in sensitivity the penis so it's it's maybe some of it's a bit little bit number some of it's maybe hypersensitive to touch or painful to touch and maybe some pain around that soft area underneath that which is called a perineum and maybe pain in the rectum or back passage so i think you i think the the type of

symptoms that someone gets with heart flaccid can be varied but i think the big things are this lack of complete erection lack of complete flaccidity and they notice that the penile tissue right and a lot of these symptoms sound like they overlap with pelvic pain as you're describing as well so we don't is it necessarily come hand in hand in your opinion or can you have these changes in penile function and tissue changes without necessarily having pain but then one would go on the internet and we all know there's a lot of stuff on the internet that are conflicting and most times very dangerous information for someone to read but that can set the perhaps the tone for something that might be common for someone or normal i mean i don't have

a penis but i can imagine that researching a lot of these things online can heighten one's sensitivity or awareness or state of threat or arousal not in a good way but of something that might be potentially wrong when in fact it might be quite normal to experience for a man yeah that's a really good question and in because we planned the podcast you know for some time um myself and one of my colleagues we kind of had a look at the patients that we see in clinic with hard flaccid and we see quite a few uh and i think from looking through their patient files i think there are there are kind of two there are two groups we do see a lot of maybe younger men and you know younger mean maybe late teens 20s early 30s we see a lot of those younger men and some of those younger men

don't have classic pelvic pain symptoms so we are seeing you know numbers of men who have those hard flaccid present type of presentation but they don't they're not getting that classic pelvic pain so pain is not a big complaint they're not getting that pain in the perineum pain on sitting pain on urination pain on on bowel movements ejaculatory pain they may be they will be getting some discomfort maybe some locally but pain is not their driving factor so i think you can develop hard flaccid outside of having you know persistent or chronic pelvic pain we do also though see some men who have got pelvic pain and hard flaccid but but i think from looking at the patients we've seen and you know we may see a younger demographic

but but a lot of those men maybe have hard flaccid is their primary complaint rather than pelvic pain you can see men with both but I think it's it is a condition or syndrome that exists independently right and in your opinion because there's not a lot of research there's no research I'll be I haven't I haven't found anything unless you unless you have in terms of actual scientific studies done on this but what do you think is for those that don't have the classic pain symptoms alongside with uh hard flaccid what what do you think are some of the potential causes for for these symptoms yeah so i think i would definitely agree with you that you know the men with hard flaccid are not best served by the research because there is very little

or none out there on hard flaccid you know i would be reluctant to say there's none because it may be that we we just haven't found it but i think you know both of us and some of our other esteemed colleagues have you know looked for research in this and there's not a lot there and i think if there isn't a lot of high quality peer-reviewed scientific research i think what we then um as physiotherapists or physical therapists with a scientific training and background i think But we then may look at some of the literature from some other similar type conditions and maybe tentatively extrapolate from that. In terms of what causes it, I think the men that we see, there are certain probably typical patterns that we see emerging. we do see some of the younger men may have had a degree of penile trauma

and that penile trauma may be related to maybe some aggressive manipulation of the penis and what we've seen in you know quite a few who've been trying to do some almost physical stretching of the penile tissue and foreskin i think it's commonly called jelking and they get almost um have a little bit of trauma to the penis and they get uh you know post-traumatic inflammatory response they maybe get some bruising to the penis some pain some lack of function which then seems to cascade the events that lead to heart flaccid we also see some men who have maybe been in a relationship and for some reason that you know as happens to to all of us for some reasons that relationship may have broken down there may have been a you know a big emotional

trauma to that relationship ending and that seems to have um for some reason started this process of maybe subtle changes in penal function sexual function so almost it's that linked to that maybe relationship or the kind of psychological emotional trauma that person's going through we also have seen some people who've maybe had some penile injury during maybe you know prolonged episodes of sexual activity maybe some trauma there maybe some prolonged episodes of masturbation although i can't say what the uh average length for masturbation is but you know you come across we've had some patients who've maybe masturbated for hours at a time and then they get an almost like a normal um kind of traumatic response to that we also then see

some men and the heart flaccid in almost like an evolvement of their pelvic pain in that they've maybe started off with pain in that perineum penile pain maybe some urinary symptoms maybe a little bit of ejaculatory pain which we know is common and then the anxiety goes with that they've had multiple investigations that hasn't really found anything mechanically you're structurally wrong and then as that condition gets more persistent or chronic those men start to develop some kind of structural penile changes as to what maybe the physiological mechanism is we we know that normal tissue function needs a normal nerve supply it needs good vascularization it needs a kind of good motor control muscle control and it may be that

the either due to the if they're getting pain as well or due to the maybe changes in sensation around the penis or the anxiety that's associated with that for some reason they're not getting normal sensation into that pelvic area whether that's the internal pelvic floor muscles whether that's normal penile stimulation and that tends to affect some of those autonomic or sympathetic nerves that leads to them firing too much which then affects the both the vasculature to the penis and affects the nerve supply to the penis so it's almost a bit like we have we we see this in the in the upper limb in complex regional pain syndrome where someone has had a maybe an injury to the wrist or hand most people that settles down but some people they get these what are called tissue

changes where the tissue or hand or in this case the penis gets very hypersensitive the skin of the hand changes we see that in the penis the hand change color we see that in the penis as well and so it's almost like the nerve supply vasculature is in has been affected by those nerves but maybe that's causing some of this penile atrophy or penile changes and we also see this in females maybe maybe for different reasons maybe it's a bit more hormonal based in females but also due to pain we you know we see a lot of women with vaginal atrophy and i think although they're separate conditions i think some of the mechanisms are similar and then as it as the condition gets worse and people maybe are reluctant to

engage in any activity with the penis or touch it that tends to become worse and hopefully maybe in time we can be optimistic here maybe that's where some of the research will go right right and it does sound like even along with all those changes that you mentioned the tissue changes the vascularization um the the structural changes that occur may also on that neurological level you mentioned the autonomic nervous system but also a cortical restructuring in the brain and also in the spinal cord very much so like pain like pain does although you know for some that don't have pain but these same processes are are underlying these mechanisms perhaps and again this is very theoretical based and biologically plausible but no research yet to

back up these theories which is sad yeah and i think i i think you know patients i'm sure patients will say to you Susie and patients will say to me you know uh why is there no research on the men you know why why is no one interested in this uh you know why have I and you mentioned looking on the internet and I think what the internet is good for for these men is that it may direct them to some of the male pelvic pain forums particularly on on facebook or at least then what the men can get out of that is one that they're not they're not the only person to have this so they start to get a little bit of peer support it may also direct them to some resources a bit like you know the brilliant book that that you've just brought out

that we recommend uh some of the books on pelvic pain and it may be that through engaging in the forum if they find the forums you know and sometimes they have to go through a lot of pain to find forums they may also maybe end up with someone who can actually help them but it's but the internet is difficult to navigate and you know sometimes finding a very good resource like one of the male pelvic pain forums it takes a lot of time and you know a lot of the stuff there that they end up in is on penile enlargement and it's a quite dubious relevance right and quality right right absolutely so what can men do to help themselves of course you know physical therapy or physiotherapy is on the forefront of of these um the syndrome of course i believe anyway uh so what

have you been doing in the clinic what does an assessment look like right so i think what the men that we see and i'm sure it's similar in in whether it's the states or australia generally these men have already seen several medical specialists so they've probably seen one or two urologists and they've probably seen a sexual medicine physician and then some of them may have seen a colorectal surgeon and some of them depending what country they're in may have seen a pain specialist so by the time they come to us we are confident that they have been extensively screened for any serious pathology so and if they haven't been which is unusual we would determine what screening

they need but usually the men have had all that you know they're tired of that because they've been told nothing is wrong but you know it's a good thing you know they don't maybe have any serious pathology but there's still symptoms are still unchanged so what do we do with them uh i think what we do is we spend quite a good bit of time trying to work out what's going on both in terms of their symptoms so what's happening with that penile function what's happening in terms of that facidity that erectile function what's happening in terms of urinary symptoms bowel what's happening in terms of low back pain hip pain so we try and get a clear idea of what's going on symptom wise you mentioned the kind of brain connection we we spend a lot

of time trying to work out how this man is you know how are they in terms of their emotional health relationships mood stress anxiety we try and find out what what effect this condition is have it has had on them so you know have they had to give up work you know what effect is it having on on maybe their relationship with their partner if they have a partner maybe what relationship it's having up with the with the time they spend with friends maybe family so trying to see what the impact is and also what's changed so if if they looked themselves well you know you've had this for 18 months so if i'd seen you for something else maybe maybe you know one of my colleagues sees you for a knee problem so if we'd seen you in the clinic

two years ago what man would we be seeing and what and what's changed now and we also try and and tease out what do they feel is going on and maybe you know what have they tried to do to have that's what have they read so that really gives an insight into also their concerns about about what's going on in terms of the physical assessment i think some of the people are surprised in that in that we we do you know we look at people's back movements we look at people's how that pelvis is moving we look at their hips so things you'd expect if you had low back pain we also uh do a lot of kind of hands-on kind of feeling of some of the muscles around the abdomen the uh pelvis and hip really to see are they also uh maybe producing symptoms especially

the men who are getting pain the probably the big thing we use a lot is is ultrasound imaging so this is you know it's very non-invasive it's a bit like a lady who's uh expecting and goes on 12 weeks here in the uk to have their first scan so we put the ultrasound probe lower tummy and that's really so we can try and work out what's happening with some of those pelvic floor muscles so we we try and see with the pelvic floor muscles uh can they contract them can they relax them because it's it's sometimes you see with these men those muscles tend to be in spasm so they're working very hard and we can kind of determine that to a degree by looking at it with ultrasound and also if those muscles are in spasm they're not going to work properly and we can kind of

see well can they contract those fast pelvic floor muscles which are really important for sexual function and can they contract some of those slow muscles pelvic floor muscles which are also important for um erectile function because if it's a bit like if i say to some the men you know if you come in and your calf was in spasm and we got you to run you wouldn't be able to run and that would be that that muscle would probably be very weak but it's probably weak because it's doing too much it's in spasm it's over right so we look at the pelvic floor muscles and then the other thing we do with the majority of the men is we do what's called an internal examination so that's a rectal examination most of the men would probably have had that done before

probably to check their prostate the and the reason we're doing that internal examination is to say well are those muscles those pelvic floor muscles are they in quite a healthy state are they overactive so they're working too hard are they generating pain for the men who are getting pain and also it helps us confirm are they working properly because if they're not working properly so if they have this secondary weakness because of the over activity they're not working properly we can feel that when they contracted around our kind of gloved finger that tends to contribute or be one of the causative factors of hard fat so those muscles are just not working properly they've become very dysfunctional but you can also affect the

kind of nerves this normal sensation to that penis the blood supply in and out of that penis so we do probably a bit of what you'd expect to see on a spine a low back pain assessment do some ultrasound imaging we do some internal examination and we try and really try and we explain each step of the way we explain to the men what we're doing and why we're doing it because men want good quality information they want to know what's going on right of course when you when you know more about your body you are more relaxed than with with treatment and also i think it puts the fear out of what's happening in their body and in their world which will help with their symptoms in general i think definitely i completely agree and the men want that yeah absolutely and

and this i have a follow-up question with um in in terms of function and it most most men will ask this question and i know this came up on a lot of questions to ask but is caggling good for me yeah so if you have something like the symptoms of hard flacid would caggling be something that's good for a gentleman to do just based on everything you said so i can't speak for all men but I have met you know quite a few patients and quite a few friends and generally a lot of men well most men know nothing about the pelvic floor and kegling so kegling are these exercises that you do to strengthen the pelvic floor and most men may have maybe maybe have a partner or a relative who's been expecting and they may have heard that after the birth or maybe

around that peri-postmenopausal period someone's been doing these kegel pelvic floor strengthening and when men sense that they have a problem down in that pelvic area they may have gone on google and they will have found maybe strengthen your pelvic floor so a lot of men will go 150 percent into working that hard but that generally tends to make things worse and that and and some and you do see some men where that's maybe been one of the either causative factors or it's really contributed to a big flare-up and the reason it tends to make things worse is that with a lot of these men the the muscles are already not functioning very well and it may be that they're working too hard already so by so

they're almost overworking uh these these muscles so it tends to cause more problems and that's not the men's men just want to do something to help so what we try and do is almost either either those men that are doing that we get them to stop and sometimes men would be doing lots of abdominal work because they want they feel that more abdominal strength core strength core stability whatever people call it will help that tends to make things worse as well however when the pelvic floor is a in a much healthier state but not as tight not as spasm with some of the men then we will get them to do very specialist type of pelvic floor activity and i don't i never really say to the men we're going to get you to strengthen your pelvic floor now we i say to them you know things

are a lot better now we're going to get these muscles working in a better way and that's looking more efficient way and that's looking at getting some of the fast muscles working better some of the slow muscles working better but but generally uh and and the ultrasound is very good for that so you put a probe on someone's lower tummy above their pubic area you get a big picture the bladder i think everyone's intrigued to see their bladder for the first time um and you can say to them you know if if we want you're now at a stage things are much much better this is well down the line i want you to do some recruit get these muscles working better and they can see how these muscles are working on the ultrasound but generally that's more later stages initially

we want to get them to do stuff to calm down those abdominals calm down those pelvic floor muscles get them more relaxing rather than firing them up so what would be some things that um some of these gentlemen can do to help themselves if they're listening to this podcast and they're like well what where do i start what should i do right i think a good starting point is to try and maybe learn more about the condition now that is not easy I think some good resources, and there is not much on Heart Placid, aren't there? So sometimes a good starting point is looking at some of the very well-written patient information books on pelvic pain. And not all men get pelvic pain, but it starts to give them a little bit of good quality information on the pelvic floor, erectile function, bowel, bladder.

And some really good stuff in that is a lot of men will have looked at Teachers to Sit Still by Tim Parks. A lot of men will have looked at putting in the pelvis. and what we've and what we've started recommending to our patients is urobo uh which is the ultimate the ultimate cock block but i almost can't say that especially on being recorded we don't we don't say that you just did gerard it came out so natural we don't say cock in the uk uh so that so although those you know although those aren't completely focused on heart flaccid it's starting to give some information we've we've got some of our patients to write some blogs for us and i'm sure at some point susie will put in the web

address at harbour and physio.co.uk but on on our blog we've got we've got some of our men to write for us so it explains what their symptoms are it explains um what they went through and what what the process of physical therapy was so i think the the education is really is a good starting point because people can do that remotely they because you know if you can find a physical therapist who specializes in men's health that's brilliant but as Susie and I know it's a it's a question of geography you may be fortunate to have someone within a couple of hours of you you may not in terms of the other things that that are very good to do and we'll probably come on to the physical therapy in a moment but other things that are very good to do is to try and almost

to address some of this normal anxiety, stress, this kind of catastrophization which comes with hard flaccid. And that really depends what works for the individual men. Some men like doing mindfulness. Some men, particularly if they're very gadget focused, will like headspace the other good things is to add some an exercise component and it doesn't you've got to get you've got to get the men doing something they enjoy so that may be even we get some of them just starting to walk as an exercise walk you know high heart rates they're getting like a physiological exercise response so we get them walking uh some of them want to do yoga maybe tai chi swimming something that's that's

going to stress them physiologically the other stuff that's good to do is things that try and get some more movement in that back and hips so that's some of the kind of very gentle lumbar spine stretching and then probably getting into more of the specifics of what we as men's health physiotherapists do get to do a lot of kind of breath work and that's really to try and relax some of those abdominals and really get some movement in the pelvic floor so what we would try and do with the men is using the ultrasound is demonstrate them that if they're doing some relaxed abdominal breathing that's getting some movement of that pelvic floor that's getting some excursion of that pelvic floor and that is then good because we we kind of know if we had a calf

muscle and spasm if we had a hamstring it would probably be good to move that muscle to its full range to move that knee joint move that ankle joint so i kind of say to them doing the abdominal breathing helps that muscle move a little bit and then we get them doing more specific kind of pelvic floor kind of getting a little bit of a sustained stretch which are called reverse kegels so that's so those are things people can do at home uh in terms of the specifics of pelvic floor um physical therapy or men's health physiotherapy you know if we feel that spine is very stiff we will do some work on that to mobilize it complement that with some exercise same with the hips in terms of the specifics we do a lot of external kind of muscle work

that's you know maybe there's an area of increased sensitivity in the muscle so we press into maybe some of the muscles and it's producing some of this penile pain or maybe testicular pain so for the men who also have pain and we do some internal rectal work and it's really gently trying to gently stretch some of those pelvic floor muscles try and settle down the activity in them so it's very gentle it's very non-threatening you know we're not trying to be very aggressive with those muscles it's just getting some normal sensation into them with a view with a view to then uh normalizing that environment which is good for their penile function vasculature nerve supply and then if we can get those muscles settled down we can then start to get them working

a bit more normally which helps with that penile function and we we do some of that in clinic and then we use these um the ez magic which is a an internal device it's like almost like a small glass wand so the ez magic uh we give though we use those in clinic on the patients and we get the patient to do it at home so the patients then feel that they're actually taking control of this condition so they're doing some of the internal work at home and once they've done that once or twice they see it as just like doing another exercise so I think there's a combination loads of education getting the men to do loads of stuff for themselves getting them more active dealing with some of that stress anxiety which is not easy and then us doing some specific

pelvic floor work with them some hands-on work with them and getting them to continue that at home that's great awesome this is really great and i was just looking at all those wonderful questions that we received from the social media posts that we that you blasted out of what are some questions that you have for the podcast and one that i know i'm probably running on a tangent here but it guys and i've gotten this too where some men will say did that did this happen because i watch porn yeah and i think i think we are you know quite uh clear with them that you know the reason they have hard flaccid is not related to them watching porn a bit like the men who have pelvic pain have not developed pelvic pain because they are watching porn and i think

where that possibly comes in is there is a lot of anxiety around heart flaccid syndrome there's a lot of worry concern and also a lot of guilt as well because

they have developed this condition you know they've just been unlucky to develop this condition but it's having a massive effect maybe on a relationship they're in so that then carries a lot of guilt but the the what we where the porn probably does come in is that you know we we talk a lot about uh getting patients gently back into exercise and you know if someone's going back to running

after a while we get them to taper the running up and i think sexual activity whether that's masturbation whether that's uh intercourse with a partner whether that's any other type of sexual activity we do say to them that you know it's good to do that it's good to do it it's good to build it up gradually it's been like if you haven't ran in 6 18 months you're not going to do a half marathon the first day you go out right i think the men are relieved when they finally meet someone whether that's you whether that's myself or one of the people i work with in clinic or one of the other you know that we've got some brilliant men's health physios worldwide i think they are relieved that people are asking them and happy to discuss these questions you know these men are

happy that someone's saying to them can you get an erection is it a normal erection can you do you get can you ejaculate normally has your ejaculation changed um are you getting any premature ejaculation are you getting delayed ejaculation um do what happens after and i think suddenly the men think you know you might be the first person to have asked them those detailed questions and you know we ask them well what happens do you masturbate uh has your masturbation changed and i think they're so suddenly they realize actually maybe this person one knows about this condition and maybe because they're asking very relevant questions they may actually be able to help me after so long so i think it's important right it's important we as you know uh men's

health physiotherapists get comfortable with asking those questions because the men want to hear those questions absolutely we're not asking enough that's for sure true that's for sure and and normal just to clarify would that be normal based on what they perceive as normal yeah and i think what i think what we look at is is what's changed so right you know they've maybe had heart flaccid for six months so what was normal to them in terms of either any type of sexual activity what was normal to them maybe a year ago and obviously that that normal that fluctuates anyways whether depending on other things that are going on in men's eyes we try and work out what was happening before this happened what are things

like now so what's changed and i think like what we do with all of our patients we ask them two big questions how will they know if it's getting better and also you know what do they want to you know what point do they want to reach you know what's their kind of end goal individual care it might be the first time that anyone's ever asked them that yes right right because there's such a lack um in the medical community to address and doctors aren't asking these questions physicians aren't asking these questions definitely so they might be happening but they're not being asked and don't ask don't tell yeah and i think the i think what you do notice is that once you start to discuss these questions and once the men start to talk about it

and really they understand more about it some of that anxiety some of that stress seems to change a little bit you know i'm not it doesn't go completely obviously but you it starts to change in a good way right absolutely the guard is down the threat the threat that big lion in the room becomes a little cub eventually and i think they're also relieved to hear that you know that you know i suppose i can talk from from my experience that we especially myself and lisa my colleague that we see lots of men with heart flaccid so whereas they think no one gets it says them well you know on an average week we might see 30 um male pelvic pain patients probably a third of those are maybe heart flaccid uh they kind of that's that's kind of good news to them

because yeah well yeah they're not alone yeah great Gerard this is awesome this is really great because i think it is one of the first actual formal podcasts ever done on the hard flacid symptoms and syndrome that men experience and i know it they want to hear this stuff so thank you so much for sharing your wisdom your knowledge and giving our listeners and men things to do to help themselves what about invaluable resources is and thank you very much can i just say a big thank you to the men from the various groups on facebook who submitted some questions to us and we've kind of embedded those questions in in the plan that suzy and i have uh done for the podcast and also a big thanks to all the brilliant uh men's health physio or physical

therapists from the various groups on Facebook Twitter etc who also took time to send us some questions that their patients commonly ask them and a massive thanks to Susie who it's this has been a real highlight for me to do the podcast with you. Well thank you so much and yes thank you to all who have been a part of this to make this happen we greatly appreciate all the feedback and your experiences. So this is so wonderful. Gerard, how can our listeners get in touch with you? Okay, so as a clinic, we do lots on Twitter. And on Twitter, we are at Gerard Green PHY. So I'm sure Susie can put that somewhere in there. Absolutely. And we also have loads of resources on our clinic website so that's www.harbourbornphysio.co.uk and in particular there

we have got some brilliant blogs that we haven't written our patients have written on uh heart flaccid and people people like to read those uh and they're probably the two probably website and and twitter but seriously great i will i will definitely link up all of the resources that you've mentioned throughout the podcast links uh your website and those blog posts wonderful i've read all of them and they are fantastic again just support supporting each other in you know our human experience so that's just great and and thank you to the men who have taken the courage to write those yeah as someone said in one of the facebook groups recently that you know the men or the patients have so much expertise in this condition so we need to involve

them in in kind of writing material for other patients so that more men can be helped and that's what we all want to do we all want to help these men because we know these men are with hard flaccid life is

not fantastic yeah that's right that's right oh Gerard again thank you big thanks and thanks to everyone everyone listening to the show thank you so much for listening and as always in loving wellness for your pelvis.

This is Dr. Susie G. Until next time, my friends. Thanks for listening to today's episode. Be sure to head on over to drsusieg.com where you can get more information, show notes, and related articles on today's topic. Also, if you like what you're hearing, head on over to iTunes,

subscribe to the podcast, and leave us a rating and review. We'd love to hear feedback. Thanks again. Thank you.