Abstract

Koro is a unique psychiatric disorder in which acute anxiety accompanies the perception of genital retraction sometimes unflatteringly called penis panic. Originally thought to be a Chinese and Indonesian culture-bound syndrome, it has recently been noted to occur in “Indian” patients as well. This case report describes a case of Koro syndrome associated with penile and scrotal pain.

Case- Study

Amit (name changed), a male, aged 32 was for a cinema show when he felt the need to micturate. He went out to the toilet, and as he was easing himself, he suddenly felt a loss of feeling in the genital region, and straightaway the thought occurred to him that he was going to get penile retraction. Sure enough, he noticed that the penis was getting shorter. He felt coldness in the limbs, was weak all over, and his legs gave way under him. So he sat on the floor, all this time holding onto his penis. About half an hour later, the attacks abated.
He further had a similar attack within a week which made him panic and he rushed to a general physician who prescribed some pills. Those pills had some psychological effect and he felt better for around a month but one night while having an intercourse with his wife he found that he was unable to perform as his penis was flaccid and probably retracted inside his abdomen. He also felt some penile and scrotal pain. He immediately rushed into the toilet and grasped his penis for quite some time. This made him very anxious and tensed that he refused to share the experience with his wife for the fear of losing her because of his sexual failure. He could not sleep all night and next morning he came to my clinic.
On further interrogating, he told that at 24 years of age, he had relationship with prostitute and was infected with gonorrhea since then he has abstained himself and was felt very guilty about his act. He also told that he heard about some fatalities during intercourse previous to the attack.
Treatment
The goal of the treatment is to help the patient in healthy functioning of his daily routine. A combination of medication and cognitive-behavioral therapy (CBT) was chosen.
The following rubrics were selected for repertorisation:
MIND-DELUSIONS-genitals-shrunken, are
MIND-DELUSIONS-worthless; he is
MIND-ANXIETY-conscience; anxiety of
MIND-THOUGHTS-persistent
The following is the repertorisation sheet using Synthesis 9.0 repertory from Radar software:

Because of his secretive nature, sycotic miasm and history of suppressed gonorrhoea, Thuja 1M, 1dose was prescibed. Along with that he was vigorously reassured and given some talk on sexual anatomy.
No further attack occurred even after 1 year of follow up.
About Koro Syndrome
Koro Syndrome
Koro is a culture-specific syndrome from Southeast Asia in which the patient has an overpowering belief that his penis (or other genitalia) is shrinking and will shortly disappear. Also known as shrinking penis, the syndrome is listed in the Diagnostic and Statistical Manual of Mental Disorders.
Classification
In DSM-IV-TR, koro is listed as one of the entries in the Glossary of Culture-Bound Syndromes of Appendix I. The manual gives koro’s definition as “a term, probably of Malaysian origin, that refers to an episode of sudden and intense anxiety that the penis (or, in females, the vulva and nipples) will recede into the body and possibly cause death.” Attempts by numerous authors to sub-group culture-bound syndromes place koro into different classes according to the system of classification, such as the group of “specific culture-imposed nosophobia” (classification with cardinal sign), “the genital retraction taxon” (classification with common factors between syndromes), and the group with “culture-related beliefs as causes for the occurrence” (classification according to how the syndromes might be affected by cultural factors).
Signs and symptoms
Most of the victims complain about episodes of acute attack of genital retraction or genital shrinkage, sometimes both. Each episode usually last several hours, though the duration can be as long as two days. Victims of koro worry compulsively over what they view as sexual excess. They also lack confidence in their own sexual capacity and thus their sense of virility. This sexual anxiety leads to the body-image distortion syndrome that accompanies depersonalization. But in koro, unlike other states of depersonalisation where the person realises that they are simply “spaced out” because of stress, this person (with koro) has limited insight of his condition, yet he does not suffer wide-spread emotional disturbances. Ethnographic psychologists consider koro to be closely related to the panic attacks precipitated by sexual anxiety.
A typical episode will occur when a man goes to urinate in the cold or while emotionally upset (often due to guilt over masturbation or frequenting prostitutes, while concerned about his sexual performance, or after a fight with his wife) and observes that his penis is becoming smaller, a condition known medically as hyperinvolution. Remembering the dangers of a shrinking penis, the man grabs his genitals before they can retract into his body, and calls for help. If no one is around to help he holds onto his penis, the individual may use mechanical devices to keep the penis from retracting, including cords, chopsticks, clamps, or small weights. While there are no substantiated reports of the condition itself resulting in any physical damage to the individual, many sufferers have unfortunately inflicted harm upon themselves in frantic attempts to stretch the penis to prevent further shrinkage. It is not unusual for those with koro to resort to using mechanical devices such as clamps or weights.
Causes
Psychosexual conflicts, personality factors, and cultural beliefs are considered as being of etiological significance to koro.
Diagnosis
Several criteria are typically used to make a diagnosis of koro: penile (or breast) retraction, anxiety related to the retraction, fear of death as a result of retraction, and use of mechanical means to prevent full retraction. Cases that do not meet all the requirements are generally classified as koro-like symptoms or given a diagnosis of partial koro syndrome. It has been argued that the criteria are sufficient but not necessary to make a diagnosis of koro.