Cases/Renal and Urology

Bent and Painful Erection — Free SCA Practice Case

Man with a bent and painful erection

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Neil Fairhurst

Age

48 years

Consultation Type

Video

Age

Situation

Video Consultation, booked to discuss a private matter.

Reason for Encounter

"This is embarrassing to talk about — my penis has developed a bend over the last few months and erections have become painful."

Medical Records

●PMH: None recorded.
●Medications: None.
●Allergies: NKDA.
●Recent notes: No significant recent consultations.

Patient Script

For the friend playing the patient role

Character Overview: You are Neil, a 48-year-old builder. Over the past six months your penis has developed a curve during erections, which has gradually got worse. Around the same time you noticed what feels like a firm lump or band of scar tissue on one side of the shaft, about halfway along. Erections are now painful, and intercourse has become uncomfortable for you and for your partner. It is affecting your erections, your confidence, and your relationship. You still get early-morning erections. You cannot recall any injury. You are embarrassed and have put off coming for months; you are frightened this could be cancer or that it will become permanent. You will open up if the doctor is matter-of-fact and unembarrassed, but you will shut down if they seem awkward.

Opening Sentence: "Hello Doctor. Sorry, this is… awkward to talk about. Over the last six months my penis has developed a bend when it's erect, and it's got worse. There's a hard lump along one side. Erections are painful now and sex is uncomfortable — for my partner too. I've put off coming about it. I'm worried it's something serious."

History if Asked (Data Gathering Phase)

●The curvature: "It started about six months ago and has gradually got worse. It bends noticeably when erect."
●The lump: "There's a firm lump or band on one side, about the middle of the shaft. It feels hard, not moving about. It's not ulcerated or bleeding."
●Pain: "Erections are painful now — a dull ache. It wasn't painful at the start."
●Sexual impact: "Sex is uncomfortable for both of us. My erections aren't as good, and honestly my confidence has gone. It's putting a strain on my relationship."
●Morning erections: "I still get them in the morning."
●Injury: "I can't remember any injury at all."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Neil does not know what this is and fears the worst. "I've no idea what it is. My mind's gone to cancer."
●Concerns: His dominant concerns are cancer, that the bend will become permanent, and the effect on his relationship. "I'm frightened it's cancer, or that I'll be left like this permanently. And it's damaging my relationship."
●Expectations: He wants to know what it is, whether it can be treated, and to be examined properly. "I want to know what it is and whether anything can be done."

If Asked — Peyronie's, Red-Flag, and Risk-Factor Screen

The patient answers these only when directly asked, and more openly if the candidate signposts sensitively.

●If asked about the lump's characteristics (firm, mobile, ulcerated, growing): "Firm and fixed-feeling, like a band of scar tissue. Not ulcerated, no bleeding, no discharge."
●If asked whether the curvature is still progressing or has stabilised: "It's still been changing — it's got worse over the six months." (Suggests the active/inflammatory phase rather than stable disease.)
●If asked about erectile function: "Erections aren't as firm as they were, and the pain doesn't help. But I do still get morning erections."
●If asked about skin changes, ulceration, or a growth on the glans/foreskin: "No sores, no ulcers, no growths." (Reassuring against penile cancer.)
●If asked about urinary symptoms or blood in the urine/semen: "No waterworks problems, no blood."
●If asked about weight loss, night sweats, or lumps in the groin: "No weight loss or sweats, no lumps in my groin."
●If asked about trauma (including during intercourse): "Nothing I can pin down."
●If asked about diabetes, or hand/foot lumps (Dupuytren's contracture or plantar fibromatosis): "No diabetes. Actually, my hand does get a bit tight — my ring finger's started to pull in." (Associated fibrosing condition.)
●If asked about family history of the same condition or Dupuytren's: "My father had the hand thing, the fingers pulling in."
●If asked about smoking, alcohol, and cardiovascular risk factors: "I smoke about 10 a day, drink at weekends. Never had my blood pressure or cholesterol checked."
●If asked about mood and the relationship: "It's getting me down, if I'm honest. My partner's been understanding but it's a strain."

Responses to Management (The Negotiation Phase)

●If the Doctor explains this is likely Peyronie's disease and not cancer: "Peyronie's disease? I've never heard of it. So it's not cancer?" (The tested point is naming the condition and addressing the cancer fear honestly, having screened for red flags.)
●If the Doctor arranges a face-to-face examination: "You need to examine me in person rather than on the screen? Yes — I'd rather be checked properly." (The tested point is arranging in-person examination, with a chaperone offered.)
●If the Doctor is honest about the limited treatment options — key: "So there isn't a tablet that fixes it? That's disappointing, but I'd rather know the truth." (The tested point is honest expectation-setting — there is no reliable medical cure, and the main options are specialist-led.)
●If the Doctor explains the natural history and referral: "So it may settle on its own, but because it's painful and affecting sex, I should see a specialist?" (The tested point is explaining the two phases and referring to urology.)
●If the Doctor offers psychosexual support: "Counselling — for both of us? I hadn't thought of that, but it might help."
●If the Doctor raises smoking and cardiovascular risk: "My smoking is relevant to this too? And you'd check my blood pressure and cholesterol?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Peyronie's Disease

●Peyronie's disease is the formation of a fibrous plaque in the tunica albuginea of the penis, causing curvature, a palpable plaque, pain on erection, and often erectile dysfunction. It is common and benign. The cause is not fully understood; it may follow microtrauma (including during intercourse) or occur without identifiable cause.

The Two Phases and Natural History

●There is an active (inflammatory) phase — progressive curvature with pain, typically over months — followed by a stable phase, in which the curvature plateaus. Pain commonly improves over time; curvature may persist, and a proportion of cases improve spontaneously. Knowing the phase matters because intervention is generally reserved for stable disease.

Exclude Penile Cancer

●Screen for ulceration, glans/foreskin lesions, discharge or bleeding, inguinal lymphadenopathy, and constitutional symptoms. Examination is essential — a face-to-face assessment with a chaperone offered (this cannot be done by video).

Associated Conditions

●Peyronie's is associated with other fibrosing conditions — notably Dupuytren's contracture and plantar fibromatosis — and with diabetes and erectile dysfunction. Erectile dysfunction is itself a marker of cardiovascular risk, so check BP, lipids, and HbA1c, and address smoking.

Honest Expectation-Setting on Treatment

●Be honest: there is no reliable medical cure, and oral agents (including vitamin E) are not recommended as effective. Specialist options include traction/vacuum devices, intralesional injection therapy, and corrective surgery, generally in stable disease, each with limitations and risks. Managing expectations honestly is a core skill in this consultation.

Referral

●Refer to urology where there is pain, progressive curvature, erectile dysfunction, difficulty with intercourse, or significant distress. Provide analgesia in the interim.

The Psychosexual and Relationship Dimension

●The impact on confidence, mood, and relationships is often the most burdensome aspect. Offer psychosexual counselling/relationship support (e.g. Relate) for the patient and partner, and safety-net appropriately.

Common Candidate Mistakes in This Case

●Managing it entirely on video: failing to arrange the intimate examination needed to exclude sinister pathology.
●Not addressing the cancer fear: leaving the patient's central fear unspoken, or reassuring without screening.
●Over-promising treatment: implying a tablet or easy cure exists, rather than setting honest expectations.
●Ignoring the psychosexual/relationship impact: treating it as purely anatomical and omitting partner support.
●Missing the associations: overlooking Dupuytren's contracture, diabetes, or cardiovascular risk and smoking.

Free MRCGP SCA practice case for GP registrars covering Bent and Painful Erection — Renal and Urology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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