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. 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.
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