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Case Series

Koro, the Vanishing Penis: A Case Series

Ellepola Anuradha

Consultant Psychiatrist, Teaching Hospital, Anuradhapura, Srilanka
Received Date: July 22, 2021; Published Date: August 21, 2021;

*Corresponding author: Ellepola A, Consultant Psychiatrist, Teaching Hospital, Anuradhapura, Srilanka

How to cite this article: Ellepola Anuradha (2021) “Koro, the Vanishing Penis: A Case Series.” Sis Med Psy Neuro J 1(1): 27-31.

Abstract
Author of this study aims to present 03 cases of Koro which is associated with high levels of anxiety and firm believes. It was considered in the past, as a Chinese culture bound syndrome. However, the disorder shows existence in other cultures mainly in Asia and Africa. Some literature reviews the syndrome as a universal syndrome, rather than a condition found only in certain cultures. There’s literature describing rare cases of Koro in females and western culture. It is not uncommon to find comorbid conditions and psychopathology in these set of syndromes.  The cases in this article illustrate three different presentations of Koro in Sri Lanka where the affected males believed that their worth was associated with fertility and sexual potency. One patient had comorbid Schizophrenia, and other two were anxious personalities.

Keywords: Koro; Yang; Culture-Bound; Anxiety; Penis; Genitalia; Sexuality; Imu; Latah; Lanti; Dhat; Erection; Fertility; Coitus; Schizophrenia; Personality

Introduction
Culture-bound syndromes are the folk ailments unique to certain cultures in which alterations of behavior are prominent [1].  Majority of the conditions are actually not syndromes, instead, they are traditional, cultural and local ways of responding to an assortment of misfortunes [1]. Lanti In certain parts of the Philippines and Saladera in Peruvian Amazon are examples [1].  However, some culture-bound conditions are indeed syndromes [1]. A hyperstartling condition called Latah found in Malaysia and Indonesia, Imu in Japan, Jumping in Maine and uqamairineq among Eskimos are some of the examples [1].

Koro is considered as a culture bound disorder in which the affected male believes that his penis is shrinking, retracting or vanishing [2].  Affected individuals in certain cultures strongly believe that their genital shrinking leads to impotence, sterility and eventual death [2]. Traditionally, Chinese remedies include suo-yang which is used to treat locking up of Yang that could lead to dangerous disruption of life saving yin-yang equilibrium [2].  Yang refers to the active, virile directed male energies [3]. Suo-Yang is believed to be a tonic that builds stamina, sexual potency and energy [3]. Koro has originally been believed to be a Chinese culture-bound condition derived from this mentioned concept [2].  However, this phenomenon is also known among other cultures in Asia and Africa [2].  The disorder is especially prevalent in cultures in which reproductive ability is a major determinant of a young mans’ worth [2].

Some culture bound syndromes have associations with other psychiatric disorders. The findings of a study suggest a strong association between Dhat syndrome and depression [4]. Human sexuality related features are prominent in some of these disorders. Dhat is such a disorder found in India and Sri Lanka where the anxious patient has severe fears about seminal loss and associated problems [5,6]. It is worthwhile to analyze psychopathological basis of culture bound disorders. Patients with Dhat may harbor firmly held believes such as delusions or overvalued ideas regarding seminal loss [7].

Patients suffering from Koro too can have comorbid psychiatric conditions or/and associated psychopathology. It is characterized by acute and severe anxiety with strong fear of retraction of the penis into the body and subsequent impotence, sterility and death [8]. Some take remedial actions by tying the penis with strings to an object, or getting others help [9]. There are rare cases where affected females believe that her breasts and/or labia are shrinking [9].There is possible interactions between culture and psychopathology [8]. In some cases, the chronic firm belief can be attributed to a delusion, overvalued idea or an oedipal castration anxiety, while there’s a male dominant cultural significance. However, Koro is usually an anxiety state and not delusional [9]. The syndrome may occur in individual patients or as an epidemic [9]. Koro epidemics have been described in cultures in Thailand [rok joo] and India [jinjina bemar] [9].  Features of koro have been described in western cultures among patients with other psychiatric morbidities such as anxiety, depression and schizophrenia [10, 11, 12].

The three case reports describe different presentations and associations of Koro in Anuradhapura district, Sri Lanka. Two of the cases involved males who believed that masculinity is strongly associated with sexual and reproductive potency.

Case 1
A 30 year old recently married trishaw driver from Anuradhapura, Sri Lanka presented to psychiatry private practice with a week history of persistent, severe anxiety about his penis shrinking into the abdomen. He asked his wife several times to keep pulling his penis to prevent its’ retraction. He also experienced anticipatory anxiety prior to coitus with his wife. He suffered from insomnia, lethargy, lack of interest and fear of death as a consequence of retracting penis.

He married his 23 year old wife 2 months back, and experienced erectile failure and premature ejaculation in number of occasions. He was preoccupied with the distressing thoughts about sexual dysfunction, and showed features of extreme anxiety and adjustment reaction. He believed that a marriage and his maleness were useless unless he had good erection and fertility. His anxiety about being unable to have children in the future was very marked. His premorbid personality was anxious and avoidant.  He was treated with Fluoxetine for premature ejaculation at the age of 22 years. There was no history of substance abuse or co-morbid medical conditions.

His brief belief was not delusional, and more anxiety related. His presentation suggested anxious personality, concept of sexual identity and sexual dysfunction as predispositions and precipitants to current condition. A short course of benzodiazepines and counseling effectively treated his distressing illness.

Case 2
A forty year old single, unemployed patient with a history of Schizophrenia and on treatment for the condition presented with a firm belief that his penis was vanishing into the abdomen for one month. He attempted to prevent the disappearance of genitalia by tying his penis with pieces of cloth. He was anxious and agitated since the onset of the unshakable belief.  It was not possible to shake his belief with reassurance. His belief was systematized and associated with some logically connected believes. His other believes were related to non-existence of penis, infertility, erectile problems and death as a result of vanishing penis.

His psychosis had the onset at his age of 20 years. It was a genetically predisposed paranoid Schizophrenia. There were 4 relapses over the past 20 years as his medication adherence had been erratic. The patient was on depot intramuscular and oral antipsychotics. His previous psychotic symptoms included auditory hallucinations, persecutory delusions and thought interferences. He had involvement with police as he was caught for exhibitionism 5 years back. Current complaint was never found as a symptom in the history. The relapse was possibly precipitated by the use of cannabinoids.

His strong, unshakable belief was compatible with a delusion. There was nihilism since his belief was regarding disappearance and non-existence of the genitalia. This was in the context of psychotic relapse probably as a result of cannabis abuse.   Optimization of antipsychotics helped relieving his condition, though it took couple of months for the effect.

Case 3
A 38 year old divorced man presented to the psychiatry outpatient clinic with severe anxiety and depressive features for one month. He had a distressing belief that his penis was disappearing at night. He believed that his genitalia were retracting into his abdomen causing erectile impotence and nocturnal emission of semen. He tried several mechanical means to stop the penile retraction. He had a strong fear that he would soon die as a result of this problem. He developed anxiety, panic attacks and depression in this context.

He had a past history of alcohol dependence, social anxiety and erectile dysfunction. He had sought psychiatry help in the past with poor adherence to management plan. His wife left him 8 years back, and he managed to stop alcohol with medical help. His pre morbid personality revealed anxiety traits from childhood. He was a backward student who never involved in public performance. He had been bullied during childhood. He received no formal teaching about human sexuality as a student. There were several sexual myths including the belief that masturbation caused loss of energy.

Features of Koro of this patient were found to be related to anxiety traits, sexual myths and erectile dysfunction. The psychopathology was not substantial enough to label as a delusion or an overvalued idea. Treatment included a short course of benzodiazepines and counseling. Patient attended follow up clinics and recovered from the condition.

Discussion
Koro is known as a culture bound syndrome characterized by symptoms such as belief of retraction of penis into the abdomen and its’ potential lethality, intense anxiety and the use of different means to prevent it [13]. Feeling of sexual inadequacy, sexual myths and sexual practices may contribute to the disorder. Certain psychodynamic and anthropological precipitants such as financial problems have been identified. Course of Koro is usually brief and self-limiting. Few reported Koro-like cases had been chronic needing intense interventions.

Two of the three cases of this article had associated anxiety. Both of them had anxious personality traits. Sexual dysfunction was a marked feature. Believes about masculinity and sexuality seem to have contributed to the disease onset. Psychopathology was not consistent with delusions or overvalued ideas. Both men recovered, and had no residual symptoms, within a short period of time with counseling and Benzodiazepines.

The other case of Koro had an underlying psychosis. It could be justified as a Koro-like condition, where the patient developed a delusion in a context of disease relapse. He had a history of cannabis use, and a past history of exhibitionism. Patient took a longer time to recover from the distressing symptom.

All the tree males had classical features of Koro; belief of penile retraction, associated anxiety and fear, and attempts to prevent the disappearance of genitalia.  One patient was married, whereas the other two lived single. All the patients had current or past history related to disorders of human sexuality. They all sought medical help to relieve their symptoms.

Conclusion
Koro; a disease initially identified mainly in Chinese culture is prevalent in non-Chinese countries. Prevailing anxiety and sexuality related conditions play an important role in causation of the disease. Believes about masculinity are important predispositions. Anxiety and depression could be associated with Koro due to distress. The author emphasizes the importance of exploring for premorbid personality and other associated conditions in culture-bound disorders. It’s probably a brief, self-limiting condition with no residual symptoms when there’s no major underlying illness.