0022-5347/95/1532-0427$03.

00/0
THE JOURNAL
OF UROLOGY Val. 153,427-428. February 1995
ASSOCIATION,
UROLOGICAI.
Copyright 0 1995 by AMERICAN IN(. Printed in U.S.A.

THE KORO (GENITAL RETRACTION) SYNDROME AND ITS

ASSOCIATION WITH INFERTILITY: A CASE REPORT
SHLOMO COHEN, STEVEN Y. TENNENBAUM, ALEXANDER TEITELBAUM AND RIMONA DURST
From the Closed Ward of the Talbieh Mental Health Center, Jerusalem and The Ben-Gurion University of the Negev, Beersheeva Medical
School, Beersheeva, Israel, and the Department of Urology, Jack D. Weiler Hospital, Albert Einstein College of Medicine, Bronx, New York

ABSTRACT
The koro syndrome is a psychiatric disorder characterized by acute anxiety and a deep-seated
fear of shrinkage of the penis and its ultimate retraction into the abdomen, which will cause
death. Concurrence of t h e koro (genital retraction) syndrome with a pathological condition of the
urogenital system has rarely been described. We report a case of koro associated with infertility.
Within 3 weeks of treatment with haloperidol t h e classic symptoms of koro disappeared. To our
knowledge this case represents the sixth report of the koro syndrome associated with urogenital
pathology and t h e first report of its association with infertility.
KEY WORDS:genitalia, male; varicocele; infertility, male; delusions

The koro syndrome is a triad of deep-seated fear of penile 48% of sperm cells. Endocrine blood tests, including lutein-
shrinkage, its disappearance into the abdomen and appre- izing hormone, follicle-stimulating hormone, prolactin, thy-
hension regarding inevitable death.' The patient afflicted roid-stimulating hormone, triiodothyronine, thyroxine and
with koro experiences profuse anxiety and often performs the testosterone, were within normal range. Human immunode-
preventive maneuver of pulling the penis outward.' The dis- ficiency virus antibodies, Treponema pallidum hemaggluti-
order, which is considered culture-specific, is endemic in nation and test for venereal disease were negative. The pa-
Southeast Asia and China.3 While koro often occurs as an tient and his wife had negative serum anti-sperm antibody
epidemic in such areas: sporadic cases of the syndrome have titers. Electroencephalography and computerized tomogra-
been reported in the Western hemisphere, often in associa- phy were normal. The fertility potential of his wife was
tion with an underlying psychiatric or organic disorder that within normal limits.
usually involves the central nervous ~ y s t e m We. ~ report a At hospitalization the patient was a husky bald man with
case of the koro syndrome in a man with underlying infertil- no anomalous physical signs or endocrine stigmata on rou-
ity due to varicocele and the oligoteratoasthenospermiasyn- tine physical examination. Neurological and rectal examina-
drome. tions were normal. Psychiatric diagnosis was acute paranoid
psychosis with depressive features concurrent with the clas-
CASE REPORT sic koro syndrome. Initial treatment with 20 mg. haloperidol
daily was changed due to extrapyramidal side effects to a
A 44-year-old man of Jewish Ashkenazi descent presented combination
of antipsychotic and tricyclic antidepressant
to the psychiatric emergency room in an acute psychotic medications. The manifestations of koro resolved gradually
state. He expressed extreme anxiety that the penis was grad- within 3 weeks but psychotic expressions persisted 3 weeks
ually shrinking and disappearing into the abdomen, and that longer. When psychosis as well as koro symptoms resolved
death would inevitably result. While being examined he con-
the patient was discharged from the hospital. One-year fol-
stantly pulled the penis outward. In addition he complained lowup revealed no exacerbation of psychosis or koro manifes-
of voiding difficulties and constipation.
tations.
A decade previously the patient had emigrated to the
United States, where he married. Before the emergence of
DISCUSSION
any delusional ideations concerning penile shrinkage, he and
his wife experienced fertility problems. Furthermore, he com- The koro syndrome is regarded as a culture-specific disor-
plained of reduced sexual potency and performance at that der endemic in Southeast Asia and China.' Sporadic cases of
time with a tendency to frequent masturbation. Urological koro have occurred in the Western hemisphere, including 32
evaluation in the United States revealed bilateral varicoceles reported in 2 series6, Subsequently a few more single cases
and the oligoteratoasthenospermiasyndrome as the cause of have been described.'-'' Most sporadic koro cases are sec-
infertility. The patient was offered surgical intervention but ondary to a psychiatric disorder or organic pathology com-
he refused varicocelectomy. Subsequently the koro syndrome monly involving the central nervous system and less fre-
gradually developed with the typical dread of penile retrac- quently the urogenital system.6 Only 5 previous case reports
tion accompanied by paranoid ideations against the family of emphasize the concurrence of the retracted genital syndrome
his wife. The patient believed that they were poisoning him and urogenital pathology (see table)."-15 In addition to the
and taking away his sexual vitality. Sleep disturbances, feel- underlying organic pathology, we postulate that immigration
ings of depression and suicidal ideations occurred. The pa- and cultural conflicts can trigger the emergence of koro
tient returned to Israel for further evaluation. symptoms, especially when they are superimposed on reli-
Urological examination before the present hospitalization gious beliefs and prohibitions. l6 Jewish religious principles
confirmed a large grade 3 left varicocele and a small grade 1 and Chinese culture prohibit self-gratification and mastur-
right varicocele. Semen analysis using World Health Orga- bation. l7
nization criteria revealed poor quality with semen volume 1.5 To the best of our knowledge we report the first case of koro
ml. and sperm count 15 x 106/ml.Motility was less than 45% associated with underlying infertility due to the oligotera-
in the first hour and morphology was normal in less than toasthenospermia syndrome. In our case urological pathology
and infertility as well as patient fear of surgery may have
Accepted for publication April 22, 1994. been fundamental in the development of the koro syndrome.
427
428 KORO SYNDROME AND INFERTILITY

Koro syndrome associated with urogenital pathology

Fear of Accompanying
Reference yir? Origin Shrinking Fear of Death Maneuvers Urogenital Pathology Psychiatric
Orean Patholoev
Ovebode et all' 56 Great Britain Yes No Yes Micropenis - deuression
Maior .
Dkvan and Hang1* 75 Singapore Yes Yes Yes Inguinal hernia Depression,
paranoid
schizophrenia
Holden13 38 Zululand Yes Yes Not Urinary tract infection Anxiety,
available hepatitis,
alcoholism,
vitamin
deficiency
Kranzler and 36 Jamaica Yes Yes Yes Swollen testicles Paranoid
Shah14 schizophrenia,
anxiety
De Leo et all5 39 Italy Yes No, attempted suicide Not Phimosis Atypical
available psychosis,
paranoid traits
Present case 44 Israel Yes Yes Yes Oligoteratoasthenospermia, Psychotic
varicocele depression
(paranoia)

These factors, superimposed on the religious background of
the patient and concomitant with the stress resulting from
cultural conflicts due to emigration, led to the outburst of
psychosis and the genital retraction syndrome. We suggest
that sporadic koro cases be carefully evaluated for organic
pathology involving the urogenital system. Prompt psychiat-
ric and surgical treatment may prevent the development of
the koro syndrome.
REFERENCES
1. Yap, P. M.: Mental disorders peculiar to certain cultures: survey
of comparative psychiatry. J . Ment. Sci., 97:313, 1951.
2. Edwards, J . W.:Indigenous koro, a genital retraction syndrome
of insular Southeast Asia: a critical review. Cult. Med. Psych.,
8: 1, 1984.
3. Tseng, W.S.,Mo, K. M., Hsu, J., Li, L. S., Ou, L. W., Chen, G. Q.
and Jiang, D. W.: A sociocultural study of koro epidemics in
Guandong, China. h e r . J . Psych., 145: 1538,1988.
4. Dutta, D.:Koro epidemic in Assam. Letter to the Editor. Brit. J.
Psych., 143 309,1983.
5. Durst, R. and Rosca-Rebaudengo, P.: Koro secondary to a tumour
of the corpus callosum. Brit. J. Psych., 153 251, 1988.
6. Durst, R. and Fbsca-Rebaudengo, P.: The disorder named koro.
Behav. Neurol., 4 1, 1991.
7. Berrios, G. E. and Morley, S. J.: Koro-like symptom in a non-
Chinese subject. Brit. J. Psych., 145 331, 1984.
8. Kennedy, B. and Flick, G. R.: Classification of koro. Letter to the
Editor. Amer. J. Psych., 148: 9, 1991.
9. Anderson, D. N.: Koro: the genital retraction syndrome after
stroke. Brit. J. Psych., 157: 142,1990.
10. Chen, E.:Drug-induced koro in a non-Chinese man. Letter to the
Editor. Brit. J. Psych., 158 721, 1991.
11. Oyebode, F., Jamieson, R., Mullaney, J. and Davison, K.:
K o r e a psychophysiological dysfunction? Brit. J . Psych., 148
212,1986.
12. Devan, G.S.and Hong, 0. S.: Koro and schizophrenia in Singa-
pore. Brit. J . Psych., 150 106,1987.
13. Holden, T. J.: Koro syndrome associated with alcohol-induced
systemic disease in a Zulu. Brit. J . Psych., 151: 695,1987.
14. Kranzler, H.R. and Shah, P. J.: Atypical koro. Letter t o the
Editor. Brit. J. Psych., 152 579,1988.
15. De Leo, D., Mauro, P. and Pellegrini, C.: An organic triggering
factor in koro syndrome? A case report. Eur. J . Psych., 3 77,
1989.
16. Durst, R., Teitelbaum, A,, Cohen, S. and Rosca-Rebaudengo, P.:
Koro syndrome-clinical and cultural aspects. Harefuah., 124
673,1993.
17. Malinick, C., Flaherty, J. A. and Jobe, T.: Koro: how culturally
specific? Int. J . SOC.Psych., 31: 67, 1985.