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.
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.
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.