Koro is a culture-bound delusional disorder in which individuals have an overpowering belief that their sex organs are retracting and will disappear, despite the lack of any true longstanding changes to the genitals. Koro is also known as shrinking penis, and was listed in the Diagnostic and Statistical Manual of Mental Disorders.
The syndrome occurs worldwide, and mass hysteria of genital-shrinkage anxiety has a history in Africa, Asia and Europe. In the United States and Europe, the syndrome is commonly known as genital retraction syndrome.
The condition can be diagnosed through psychological assessment, along with physical examination to rule out genuine disorders of the genitalia that could be causing true retraction.
The word was borrowed from Malay and means the head of a turtle (or tortoise), referring to how it looks when they retract their heads into their shells.
Signs and symptoms Most patients report acute anxiety attacks due to perceived genital retraction and/or genital shrinkage, despite a lack of any objectively visible biological changes in the genitalia that are longstanding. "Longstanding" refers to changes that are sustained over a significant period of time and do not appear reversible, unlike the effect of cold temperatures on some genital regions that cause retraction. These changes may trigger a koro attack when observed, although the effects of cold temperatures are objectively reversible.
According to literature, episodes usually last several hours, though the duration may be as long as two days. There are cases in which koro symptoms persist for years in a chronic state, indicating a potential co-morbidity with body dysmorphic disorder. In addition to retraction, other symptoms include a perception of alteration of penis shape and loss of penile muscle tone. In cases when patients have no perception of retraction, some patients may complain of genital paraesthesia or genital shortening. Among females, the cardinal symptom is nipple retraction in the breast, generally into the breast as a whole.
Psychological components of koro anxiety include fear of impending death, penile dissolution and loss of sexual power. Feelings of impending death along with retraction and perceived spermatorrhea has a strong cultural link with Chinese traditional beliefs. This is demonstrated by the fact that Asians generally believe koro symptoms are fatal, unlike most patients in the West. Other ideational themes are intra-abdominal organ shrinkage, sex-change to female or eunuch, non-specific physical danger, urinary obstruction, sterility, impending madness, spirit possession and a feeling of being bewitched.
Individuals with extreme anxiety and their family members may resort to physical methods to prevent the believed retraction of the penis. A man may perform manual or mechanical penile traction, or "anchoring" by a loop of string or some clamping device. Similarly, a woman may be seen grabbing her own breast, pulling her nipple, or even having iron pins inserted into the nipple. Physical injury may occur from these attempts. These forceful attempts often lead to injuries, sometimes death.
Causes Psychosexual conflicts, personality factors, and cultural beliefs are considered as being of etiological significance to koro. Sexual adjustment histories of non-Chinese individuals are often significant, such as premorbid sex inadequacy, sexual promiscuity, guilt over masturbation, and impotence.
Diagnosis
Several criteria are typically used to make a diagnosis of koro. The primary criterion is a patient's report of genital (typically penile or female nipple) retraction despite a lack of objective physical evidence demonstrating retraction. This is accompanied by severe anxiety related to the retraction, fear of death as a result of retraction, and use of mechanical means to prevent 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. Researchers have identified koro as a possible "cultural relative" of body dysmorphic disorder. DSM-IV explains the process of differential diagnosis between these two disorders.
History and physical examination A medical, psychosexual and psychiatric history should be documented. The physician should explore the patient's concerns about appearance and body image (ruling out body dysmorphic disorder). Additionally, the physician should inquire about overall beliefs, personal values, and assumptions that the patient is making about his or her genitals. Given that koro is often an “attack” with a great deal of associated anxiety, the physician should ascertain the patient's emotional state along with the timeline from onset to the presentation at the examination.
A physical examination should involve an assessment of overall health along with a detailed genital examination. In men, genital examination should be performed immediately after penile exposure, to avoid changes due to external temperature. The primary intent of the male exam is to exclude genuine penile anomalies such as hypospadias, epispadias and Peyronie's disease. The presence of a significant suprapubic fat pad should be noted as well.Elder JS. Congenital anomalies of the genitalia. In:Walsh PC, Retik AB, Walsh PC, Campbell MF, eds. Campell’s urology. Philadelphia, London, Toronto: W.B. Saunders Comp.; 1998: 2120–43. Careful measurements of flaccid length, stretched length and flaccid girth will also be useful. If male patients insist that their penis is shrinking and disappearing, measurements after intracavernosal alprostadil may be used in the office to determine the true erect length and to diagnose any penile abnormalities in the erect state. A physical examination should note any injuries inflicted by the patient in an effort to "prevent" retraction as further confirmation of koro.
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 have been made by numerous authors to place koro into different classes. For example, koro may fit into 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).
Various authors have attempted to distinguish between complete and incomplete forms of koro, along with cultural and non-cultural forms. Cultural forms are said to involve a cultural belief or myth which plays a role in the genesis and spread of the disease in the community. These are regarded as complete forms of koro, matching all the symptoms required for diagnosis without significant co-morbidity. Differentiation into primary koro, a culture-bound expression, and secondary koro. Secondary koro is proposed to have co-morbidity with a CNS disorder, another psychiatric disorder, or possible drug use.
Traditional Chinese medicine recognises koro as a sexual disease and classifies it into two categories, namely "cold conglomeration in liver" and "depletion of kidney's yang".
Differential diagnosis Men who present with this complaint may have koro, but they may also be misinformed about normal genital size. Additionally, they may have penile dysmorphophobia. Penile dysmorphophobia is related to body dysmorphic disorder (BDD), defined by the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (Text Revision) (DSM-IV-TR) as a condition marked by excessive preoccupation with an imaginary or minor defect in a facial feature or localized part of the body. BDD is different from koro. In koro, a patient is overcome with the belief that his penis is actively shrinking, and it may be in imminent danger of disappearing. Clinical literature indicates that these two psychological conditions should be separated during differential diagnosis.
In addition to differentiating koro from body dysmorphic disorder, physicians also recommend that differential diagnosis separates koro from physical urological abnormalities. For example, one physical disorder that causes loss of penile size is Peyronie's disease, where the tunica albuginea develops scar tissue that prevents the full expansion of an erection and causes flaccid penis retraction. Additionally, a buried penis is a normally developed penis, partially covered by the suprapubic fat which can be surgically removed.
Treatment In historical culture-bound cases, reassurance and talks on sexual anatomy are given. Patients are treated with psychotherapy distributed according to symptoms and to etiologically significant points in the past. Prognosis appears to be better in cases with a previously functional personality, a short history and low frequency of attacks, and a relatively uncomplicated sexual life.
For sporadic Western cases, careful diagnostic workup including searching for underlying sexual conflict is common. The choice of psychotherapeutic treatment is based on the psychiatric pathology found.
Indigenous treatment In China, traditional treatment based on the causes suggested by cultural beliefs are administered to the patient. Praying to gods and asking Taoist priests to perform exorcism is common. If a fox spirit is believed to be involved, people may hit gongs or beat the person to drive it out. The person will receive a yang- or yin-augmenting Chinese medicine to try to balance the internal conditions, usually including herbs, pilose antler (stag of deer) or deer tail, and tiger penis, deer penis, or fur seal penis. Other medicinal foods for therapy are pepper soup, ginger soup and liquor.
Epidemiology Among the Chinese, koro is confined to South China and the lower Yangtze Valley. A 1992 study of self-report questionnaires suggests that in the epidemic area of China, individuals with koro are mostly Han, male, young, single, poorly educated and fearful of supernatural forces and koro.
The phenomenon is also found among overseas Chinese in Southeast Asia, especially Malaysia and Indonesia, and less frequently among the Malay and Indonesian inhabitants of the countries. Though there are speculations that the occurrence of koro among people in Malaysia and Indonesia was the result of Chinese migrants, this cultural diffusion view is challenged since koro epidemics have been reported in Thailand and India, involving masses of non-Chinese people.
Sporadic cases of koro among people with non-Southeast-Asian ethnicity have been reported across the globe, for example, Nepali, Sudanese, Jordanian, Tanzanian, Nigerian, French, British, American and Canadian. In most of the non-Chinese cases in the Western Hemisphere, fear of genital shrinkage is reported but not all the other typical koro symptoms, such as fear of death, as in endemic countries. The incomplete forms of koro are regarded as the non-cultural forms, while the complete form with acute anxiety is the classical culture-bound type.
China