Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Penile curvature (dorsal, ventral, or lateral)
Degree of curvature (estimated in degrees)
Erectile dysfunction (present or absent)
Pain during intercourse (present or absent)
Difficulty achieving or maintaining an erection (present or absent)
Psychological distress (embarrassment, anxiety) due to curvature
II. History of Present Illness:
Age at which curvature was noticed
Any worsening of curvature over time
Any history of trauma to the penis
Presence of other genitourinary anomalies (hypospadias, epispadias)
III. Past Medical History:
Previous surgeries (genital or pelvic)
Medical conditions affecting erectile function (diabetes, vascular disease)
IV. Social History:
Sexual history (frequency of intercourse, satisfaction)
Tobacco use (risk factor for erectile dysfunction)
V. Family History:
Family history of penile curvature
VI. Physical Exam:
General appearance (healthy, any signs of discomfort)
Genital exam:
Penile size (length and girth)
Degree and direction of curvature (in flaccid and erect state if possible)
Presence of palpable plaques or nodules (suggestive of Peyronie’s disease)
Meatal location (normal or ectopic)
Testicular size and symmetry
VII. Imaging Studies (if performed):
Ultrasound with color Doppler (assess blood flow and identify any plaques)
VIII. Assessment:
Type and severity of penile curvature
Functional impact (erectile dysfunction, pain during intercourse)
Possible underlying causes (congenital, Peyronie’s disease)
Psychosocial impact (anxiety, relationship problems)
IX. Plan:
Treatment plan depends on severity, functional impact, and patient preference:
Observation (if curvature mild and not causing functional problems)
Oral medications (phosphodiesterase-5 inhibitors) – for erectile dysfunction if present
Penile traction therapy (stretching devices) – for mild to moderate curvature
Penile injection therapy (alprostadil) – to improve erections before intercourse
Surgery (plicature procedures or grafting) – for severe curvature or failed conservative therapy
Referral (if indicated):
Urologist for further evaluation and treatment options.
Sexual therapist to address any psychological distress related to the curvature.
Education:
Discuss the different treatment options, their benefits and risks.
Provide information on maintaining sexual health and addressing erectile dysfunction.
Reassurance and addressing any anxieties related to the condition.
X. Notes:
Include any additional observations or concerns, such as patient’s understanding of the condition, treatment preferences, and emotional well-being.
XI. Resources:
Consider providing patient education materials on congenital penile curvature from reputable sources (e.g., American Urological Association (AUA), National Institutes of Health (NIH)).