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BMJ Case Rep. 2010; 2010: bcr08.2008.0679.
Published online Mar 15, 2010. doi:  10.1136/bcr.08.2008.0679
PMCID: PMC3029136
Rare disease
Koro-like symptoms in two Greek men
Evangelos Ntouros,1 Athanasios Ntoumanis,1 Vasilios Panteleimon Bozikas,2 Stamatis Donias,3 Ioannis Giouzepas,1 and Georgios Garyfalos1
1Aristotle University of Thessaloniki, 2nd Psychiatric Department, Dodekanisou 2, Polichni, 56533, Greece
2Aristotle University of Thessaloniki, 1st Psychiatric Department, Papageorgiou Hospital, Thessaloniki, 56533, Greece
3Psychiatric Hospital of Thessaloniki, Mental Health Center of Central District of Thessaloniki, Karaoli kai Dimitriou 1, Thessaloniki, 54630, Greece
Correspondence to Evangelos Ntouros, duro_8/at/hotmail.com
Koro syndrome is a psychiatric disorder characterised, in its typical form, by acute and intense anxiety, with complaints in men of a shrinking penis or fear of its retraction into the abdomen and resultant death. Initially, this syndrome was described as a culture specific disorder. Sporadic cases referred to as the koro-like syndrome have been observed in western countries recently. They are more likely to appear in the context of a psychiatric or neurological disorder. The clinical course of culture bound koro syndrome is usually self limited, but in some cases it can be transient or take on a chronic or recurrent form, lasting from days to weeks, months or even years. We present two cases, one of a middle aged man whose koro-like symptoms have persisted for over 18 years in a relapse mode that is rarely observed, and one of a young schizophrenic, who also exhibits koro-like symptoms.
Background
We thought it would be of interest to report these cases of koro syndrome because of the rarity of the symptoms’ form, especially in the first case.
Koro syndrome is a psychiatric disorder characterised, in its typical form, by acute and intense anxiety, with complaints in men of a shrinking penis or fear of its retraction into the abdomen and resultant death. Initially the syndrome was described as a culture specific disorder in Southeast Asia and China.1 Sporadic cases referred to as the koro-like syndrome (in which the urogenital symptoms are not associated with fears of death) have been observed in western countries. Furthermore, they are more likely to appear in the context of a psychiatric or neurological disorder.
The clinical course of culture-bound koro syndrome is usually self-limited, but in some cases it can be transient or take on a chronic or recurrent form. Treatment of the non culture-bound syndrome comprises mainly of neuroleptics and antidepressants. We present two cases, one of a middle aged man whose koro-like symptoms have persisted for over 18 years in a relapse mode that is rarely observed, and one of a young schizophrenic, who also exhibits koro-like symptoms.
Case 1
A 40-year-old fisherman presented in the emergency room of our department with burning pain in the root of the penis which radiated to the front of the trunk. He was complaining of shrinking of his penis towards the abdomen with a persistent sensation of strain. He also described depressive symptoms for the last 3 months.
He attributed his symptoms to some kind of virus that had “lived” in his penis for the last 18 years after intercourse with a prostitute. For the next 18 years and until the time of examination, the patient reported periods of relapse with symptoms lasting for months at a time, restricting his ability to work. He was repeatedly examined by urologists and had had blood work done, that showed no signs of organic disease.
He had been hospitalised recently in a neurology and a urology department where no disease was found after scrutinous examinations including a computed tomography scan of the abdomen and pelvis, and cystoscopy.
The patient was diagnosed with major depressive disorder although the diagnosis of major depressive disorder with psychotic features was also considered. He was treated with citalopram 20 mg and quetiapine 200 mg and 2 months later he had improved considerably as far as his mood and the pain were concerned, but the penile discomfort persisted and his belief in the “genital virus” remained unshaken. Quetiapine was prescribed in order to relieve the patient from the underlying severe anxiety and sleep disturbances, and increasing the dose was under consideration in order to address the psychotic component.
Case 2
A 24-year-old man was brought to our department, exhibiting irritability and hallucinations. The patient had struck his father and the parents had alerted the emergency services.
At the age of 17 years the patient had started withdrawing from relationships with friends and even immediate family and had been initially diagnosed as “depressive”. However, within a year he exhibited irritability and ideas of reference (for example, “neighbours look through his window when he masturbates”). He finally asked his parents for help because of voices he could hear, voices that either mocked him as a homosexual or commanded him with single, whispered words such as “strike”, “close”, the meaning of which he could not entirely grasp. He had been diagnosed with paranoid schizophrenia and, before his admittance, had been treated as an outpatient with risperidone. Our intake confirmed the diagnosis and raised a question of comorbidity with an obsessive compulsive disorder, but the latter diagnosis could not be established, as criteria were not met and the main disorder could account for the symptoms.
Apart from the aforementioned symptoms, the patient reported for the first time a sensation that his penis retracts into the abdomen and a fear that it will subsequently be lost. This would be accompanied by anxiety and sadness pertaining only to the loss itself. He would then proceed to search manually for his penis and masturbate. No pleasure was gained by masturbation, but the anxiety would be lifted.
The patient’s history uncovered an incident of sexual assault by an older male cousin at the age of 17. The incident had filled our patient with guilt and had left him with an ambiguous stance on gender and sex. He presently reported feeling that he had breasts.
He was treated with 30 mg of olanzapine orally daily and was placed under supportive psychotherapy, which—tailored to the situation—is the norm at our clinic. The psychotherapy was geared towards relieving feelings of guilt, “normalising” the delirious ideas, and mobilisation for better social adaptation. Two months into the treatment, the auditory hallucinations were very sparse and had lost their commanding tone. The koro-like symptoms abated long before that, within the first 3 weeks of treatment.
Although Koro syndrome is a rare condition, an increasing number of cases are being reported among Caucasians living in the West. The pathogenesis of the condition is poorly understood. Sporadic cases have been associated with organic mental illness2,3 and psychiatric conditions like schizophrenia.4 Recently, Chowdhury5 suggested a useful classification.
The presenting symptoms of our two patients, characterised by anxiety and a belief that their genitalia were shrinking, are similar to those found in koro patients. The first is a typical Caucasian patient, meaning a poorly educated middle aged man with a well defined neuropsychiatric disorder, part of which is the syndrome of koro. The underlying dynamics resulting in chronicity of symptoms of koro are not clear.
It is worth mentioning that a common finding in koro affected individuals is conflicting feelings about sexuality and sexual identity.6 Those were strikingly apparent, especially with our second patient.
The treatment of koro syndrome and koro-like symptoms depends on its aetiology. For sporadic koro, the underlying neuropsychiatric disorder should be treated. Standard antipsychotic and antidepressant treatment has been successfully used in most cases. In our first case the use of such treatment was able to alleviate symptoms but not eliminate them. In the second case, our patient exhibited the koro-like symptoms only once for a period of approximately 3 weeks. Antipsychotic treatment eliminated the sensation of retraction of the penis and the anxiety that accompanied it, but did not totally eliminate other schizophrenic symptoms, such as the auditory and some somatic hallucinations. Hence, we lean toward a diagnosis of “secondary koro with a primary psychiatric disorder (schizophrenia)” in the classification system proposed by Chowdhury.5
Learning points
  • While rare in western societies, koro-like syndrome (as well as other similar rare conditions) can be observed in everyday practice.
  • In many sporadic cases of koro-like syndromes there is an underlying condition other than psychiatric (eg, central nervous system tumours, drug induced, HIV/AIDS).5
  • Urogenital complaints must be thoroughly examined in some cases because their cause could be psychiatric.
  • Koro-like syndrome or Koro-like symptoms secondary to psychosis may be especially hard to differentiate, especially if treatment includes antipsychotic medication.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
1. Mattelaer JJ, Jilek W. Koro – the psychological disappearance of the penis. J Sexual Medicine 2007; 4: 1509–15. [PubMed]
2. Ungvari GS, Mullen RS.: Koro: the delusion of penile retraction. Urology 1994; 43: 883–5. [PubMed]
3. Fishbain D.: Koro: classification and case reports. Am J Psychiatry 1991; 148: 1765–7. [PubMed]
4. Edwards JG. The koro pattern of depersonalization in an American schizophrenic patient. Am J Psychiatry 1970; 126: 1171–3. [PubMed]
5. Chowdhury AN. The definition and classification of koro. Cult Med Psychiatry 1996; 20: 41–65. [PubMed]
6. Bernstein RL, Gaw AC.: Koro: Proposed classification for DSM-IV. Am J Psychiatry 1990; 147: 1670–4. [PubMed]
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