Several criteria are typically used to make a diagnosis of<unk>  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<unk> like symptoms or given a diagnosis of partial<unk> syndrome. It has been argued that the criteria are sufficient but not necessary to make a diagnosis of<unk>  Researchers have identified<unk> 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<unk> 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<unk>  Classification In DSM-IV-TR,<unk> is listed as one of the entries in the Glossary of Culture-Bound Syndromes of Appendix I. The manual gives<unk> 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<unk> into different classes. For example,<unk> 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<unk>  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<unk>  matching all the symptoms required for diagnosis without significant co-morbidity. Differentiation into primary<unk>  a culture-bound expression, and secondary<unk>  Secondary<unk> is proposed to have co-morbidity with a CNS disorder, another psychiatric disorder, or possible drug use. Traditional Chinese medicine recognises<unk> 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<unk>  but they may also be misinformed about normal genital size. Additionally, they may be suffering from 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<unk>  In<unk>  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<unk> from body dysmorphic disorder, physicians also recommend that differential diagnosis separates<unk> 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.
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