Cases/Renal and Urology

Painful Bend in His Penis After An Injury During Sex — Free SCA Practice Case

Man with a painful bend in his penis after an injury during sex

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

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Hamid Rostami

Age

52 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"Bent and painful erections since an injury three months ago."

Medical Records

●PMH: Hypertension for 4 years. Appendicectomy aged 19.
●Medications: Amlodipine 5 mg once daily.
●Allergies: NKDA.
●Social: Quantity surveyor. Married. Ex smoker, stopped 15 years ago.

Recent Notes

●Annual hypertension review, 6 weeks ago: BP 132/80. eGFR 84. No previous urology contact.

Patient Script

For the friend playing the patient role

Character Overview: You are Hamid Rostami, a 52 year old quantity surveyor for a construction firm. You are married to Soraya, who is 50 and works as a practice nurse at a different surgery, and you have two grown up children who live away from home. You are a careful, private man who prefers to be precise, and you are very embarrassed to be talking about this. You booked a video appointment because you could not face a face to face visit, and you have put it off for three months. You speak in short, measured sentences at first and become more open if the doctor is calm and unhurried. You have not told anyone except Soraya. You do not use the name of the condition; you describe what happens.

Opening Sentence: "Doctor, this is a bit embarrassing. About three months ago I hurt myself during sex and since then my erections have been bent and painful. I'd like to know what can be done."

History if Asked (Data Gathering Phase)

●What happened: "About three months ago, Soraya and I were intimate and I slipped out and then thrust forcefully against her. I felt a sharp snap and a lot of pain. I lost the erection straight away."
●Immediately afterwards: "It was swollen and bruised for about a week. I could pass urine normally and there was no blood in it. It was very sore but I was too embarrassed to see anyone, so I waited to see if it settled."
●The bend: "When it is erect it bends to the left. I'd say about thirty degrees. It was not like this before. It seemed to get a little more bent over the first two months, and over the last month it seems about the same."
●Pain: "It hurts when I have an erection, a deep ache along the shaft, about four out of ten. When it is soft it does not hurt at all. The pain was worse at the beginning. It is a bit better than it was but it has not gone."
●A lump: "Yes, there is a firm patch on the top of the shaft, about the size of a lentil. It feels like a bit of gristle. It does not hurt when I press on it when soft."
●Length: "It feels slightly shorter when erect, maybe a centimetre or so. I have not measured it."
●Erections: "They are as firm as they ever were, including in the mornings. The bend and the pain are the only differences. I have no trouble getting or keeping an erection."
●Sex life: "We have avoided sex for about two months. We tried once about six weeks ago and it was painful, so we stopped. Soraya has been very understanding but I can tell she is worried that I have lost interest in her."
●Urinary and other symptoms: "No difficulty passing urine, no blood in the urine, no discharge, no sores or rash on the skin of the penis. Soraya is my only partner."
●Other changes: "No pain in the testicles and no other lumps anywhere. I feel well generally."
●Hands: "Actually, yes. I have a lump in the palm of my right hand and my little finger does not straighten as well as it used to. It has been there for years. My mother's brother had hands like that."
●Mood: "Low, if I am honest. I have been irritable and I lie awake thinking about it. I have no thoughts of harming myself. I still go to work and see friends."
●Treatments tried: "Nothing. I had a couple of paracetamol in the first week and that was all. I have not tried anything from the internet because I did not know what to trust."

Ideas, Concerns, Expectations

Gating note: Hamid does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

●Ideas: He thinks he tore or broke something inside during the injury, and that it has healed crooked, a bit like a bone. "I think something snapped and has set badly."
●Concerns: He is worried it is cancer. He is also worried it will keep getting worse and that he will never have a normal sex life again and that he is letting Soraya down. "My biggest fear is that it's something serious, like a cancer. And that it will carry on bending until I can't have sex at all."
●Expectations: He hopes for a cream or a tablet to straighten it, or for an operation. He would like to be referred to a specialist and wants someone to tell him honestly what is going on. "I'd like something to put it straight again. Or if it needs an operation, I want to know."

If Asked: Medical History and Medications

Gating note: Hamid answers each of these plainly when the doctor asks about it.

●Other health problems: "Blood pressure, for four years, and my appendix out at nineteen. No diabetes, as far as I know. My last blood tests were normal."
●Medicines: "Amlodipine 5 mg once a day. No other tablets, no supplements, no testosterone or gym products."
●Stomach, kidneys, asthma, bleeding: "No ulcers or stomach trouble, no bleeding problems, no kidney trouble, no asthma."
●Allergies: "None."
●Penile surgery or previous injury, genital infections: "None."
●Family history: "My mother's brother had the hand problem. No one has had anything like this that I know of."

Social History and Lifestyle Impact

●Work: Quantity surveyor, desk based with site visits. Work is fine and not affected.
●Home: Lives with Soraya. Their children, Reza and Leila, are grown and live away from home. Soraya knows about the problem and has encouraged him to come.
●Smoking and alcohol: Smoked 10 a day until 15 years ago. About 12 units of alcohol a week, mostly wine at weekends.
●Medication for erections: Has never needed any and has never used any.
●Availability to be seen: Could attend the surgery tomorrow after work, or any lunchtime this week.
●Support: Soraya would be happy to be involved if he wants. He is not sure he wants her to come to an appointment, but would be glad to be offered it.

If Asked: Associated Symptoms

Gating note: Hamid answers these only when asked. Every one is negative unless stated.

●If asked about blood in the urine, difficulty passing urine, or a weak stream: "No, nothing."
●If asked about fever, weight loss, night sweats or feeling unwell: "No, I feel well in myself."
●If asked about a lump in the groin or testicle, or swelling in the scrotum: "No."
●If asked about diabetes symptoms such as thirst, passing a lot of urine or tiredness: "No."
●If asked about low sex drive: "No. My desire is the same. It's only the pain and the bend that stop me."
●If asked about ejaculation or orgasm: "Normal, but I have avoided it so it is a while since I tried."

Responses to Management (The Negotiation Phase)

●
If the doctor says he needs to be examined in person:
- ●Reaction: Reluctant but accepts. "I was dreading that, but I do see why." If asked to examine himself or describe the lump on screen, he declines politely: "I'd rather the doctor did it properly. Can I come tomorrow evening?" He asks whether a chaperone will be present.
●
If the doctor explains that the problem is caused by scarring (a hard patch or plaque) in the lining of the penis and that it is common and not cancer:
- ●Reaction: Visibly relieved. "A fibrous patch? So it isn't cancer? That is the main thing." He asks: "Will it go away by itself, and will it get straighter?" If told honestly that the pain usually settles with time and the curve often stays, he is disappointed: "So it may stay bent?" He appreciates being told that it does not harm the penis and that intercourse is possible for many men.
●
If the doctor suggests pain relief such as a short course of an anti inflammatory:
- ●Reaction: Practical. "Is that safe with my blood pressure tablets? I don't want to push it up." If the doctor explains how to take it, for how long and what to watch for: "Right, with food, the lowest dose, and I'll stop it if I get heartburn or notice my ankles swelling."
●
If the doctor discusses treatment options, injections, devices or surgery:
- ●Reaction: Wants to understand the options. "What treatments work? Is there a cream or a tablet that straightens it?" If told that no cream or tablet reliably straightens it and that surgery is considered only once things have settled, he asks: "So how long would I wait?" He accepts the idea of a specialist opinion. "I would rather be seen sooner, so I know the plan, even if there's nothing to do yet."
●
If the doctor discusses sex, Soraya or his mood:
- ●Reaction: Opens up. "It's the guilt, really. I think Soraya feels rejected." If advised that sex can be tried gently once the pain allows, or to be open with Soraya and bring her to a later appointment: "I'll talk to her tonight. That is a good idea." He accepts the offer of support for low mood and says he does not need urgent help.
●
If the doctor gives the plan and safety netting:
- ●Reaction: Wants specifics. "What should make me come back sooner?" He repeats back clearly when told to seek urgent help for a painful erection lasting several hours, new swelling or bruising of the penis, difficulty passing urine, blood in the urine, a sore that does not heal, or new erectile difficulty.

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 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Hamid is a 52 year old man who felt a snap during sex three months ago and now has painful erections that bend to the left, a firm patch on the shaft, a hand lump suggesting Dupuytren's contracture, low mood and a fear of cancer. Erections are otherwise firm. The station tests whether the candidate recognises Peyronie's disease, separates the active phase from the stable phase, gives honest expectations without promising a cure, and times referral sensibly.
●The model plan has seven parts. Take a focused history of the injury, the bend, pain, lump, length, erectile function and sex life, with screening for urinary and other symptoms. Arrange an in person genital and hand examination within days because a plaque cannot be assessed on video. Explain the likely diagnosis and that it is not cancer. Offer a safe, time limited plan for the pain. Avoid prescribing treatments that will not straighten the penis. Make a plan for specialist input. Give specific safety netting and review.
●Acceptable alternatives: referring to urology now because the disease is active and he wants to know the options, or examining first, confirming the plaque and referring once pain has settled and the bend is stable. Both are guideline consistent. Prescribing a short NSAID course at the first visit after checking safety, or at the examination visit, are both acceptable. Offering no drug for pain, if he prefers, is also acceptable. Arranging a diabetes blood test now or at the review is acceptable.

Recognising Peyronie's Disease

●Peyronie's disease is a fibrous plaque in the tunica albuginea, the sheath around the erectile tissue, which causes curvature, pain on erection, a palpable nodule and sometimes shortening. Typical age of onset is 50 to 60 years, and it is probably underdiagnosed (EAU Sexual and Reproductive Health Guidelines, 2026).
●Some men recall a bending or snapping event during sex, and others have no clear injury. Hamid's account of a sharp snap with loss of the erection fits a minor injury to the sheath followed by an abnormal scarring response.
●Associated features include Dupuytren's contracture of the palm or Ledderhose disease of the foot, and a higher prevalence in men with erectile dysfunction and diabetes. The EAU guideline advises examining the hands and feet as well as the penis. The candidate who asks about the hand finds a clue that makes the diagnosis likely.
●Erectile dysfunction is common in Peyronie's disease (reported in 30 to 70.6%), so the candidate should ask about erection quality. Hamid has none.

Active Versus Stable Disease

●The EAU guideline advises a focused history to separate active from stable disease because this influences medical treatment and the timing of surgery. Men likely to have active disease have a shorter symptom duration, pain on erection, or a recent change in deformity.
●Resolution of pain and stability of the curvature for at least three months are the accepted criteria of stabilisation.
●Hamid still has pain on erection and the bend worsened over the first two months, so he is in the active phase even though three months have passed. He has about one month of apparent stability, which is not yet three months.
●Explaining this is the key to honest expectations: the pain is expected to settle as disease matures, the bend may then stay as it is, improve a little or worsen, and any decision about straightening depends on it being stable.

Urgency and Excluding Other Causes

●A penile fracture is a urological emergency in the first hours, with a snap, immediate detumescence, swelling and bruising. Hamid had these features at the time but is now three months on, has passed urine normally, has no discharge or ongoing swelling and has firm erections. Emergency care is not needed now. The candidate should show they have considered the possibility and explain why it is not an emergency. A missed fracture can leave a scar and a bend, so examination and urology review cover both.
●Sending him to an urgent suspected cancer pathway is not supported by the history: there is no skin lesion, ulcer, discharge, groin node or weight loss. A palpable plaque in the shaft is not a cancer feature.
●Safety net for new features that would change the urgency: a painful erection lasting several hours, new swelling or bruising, difficulty passing urine, blood in the urine, a sore that does not heal, or new erectile difficulty.

Examination and Investigation

●The EAU guideline advises a physical examination covering palpable plaques, stretched or erect length, the degree of curvature and related conditions such as Dupuytren's contracture. A remote examination is not appropriate, and the patient declines to examine himself.
●Objective assessment of the curve during erection is advised by the guideline using self photography, a vacuum assisted test or an injection test. These are specialist tools, and this station does not rely on images, so the candidate need not arrange them. Imaging with computed tomography or magnetic resonance imaging is not recommended routinely.
●Ultrasound is not accurate for plaque size, and no investigation is needed in primary care to make the diagnosis. A blood test for diabetes (HbA1c or fasting glucose) is reasonable because of the association with diabetes, and his blood pressure and kidney function were recently checked.

Pain Relief and What Not to Prescribe

●The EAU guideline says NSAIDs may be considered for penile pain in active phase disease, with regular reassessment of pain severity and effectiveness. Hamid has hypertension treated with amlodipine, an eGFR of 84 and no stomach problems.
●The BNF advises that systemic NSAIDs are used at the lowest effective dose for the shortest possible time, and lists uncontrolled hypertension and renal impairment among cautions. A short course of ibuprofen with food after checking blood pressure control is reasonable. Stomach protection is a sensible addition if risk factors are present. Declining an NSAID and using paracetamol, or no analgesic, is also acceptable.
●The guideline notes that the evidence for oral and topical agents, and for injections of steroids or verapamil, is weak or contradictory. Primary care should not prescribe antibiotics, steroids or other agents to straighten the penis, and should not promise that a cream or tablet will cure the bend.
●Phosphodiesterase type 5 inhibitors are suggested by the guideline for concomitant erectile dysfunction. Hamid has none, so there is no indication in primary care.

Treatment Options and Timing of Referral

●The EAU guideline describes conservative options in the active phase: NSAIDs for pain, extracorporeal shockwave therapy for pain only (it does not improve the curve), penile traction and vacuum devices (limited data), and intralesional agents (hyaluronic acid with limited data; collagenase has been withdrawn from the European market). These are specialist decisions and availability on the NHS varies.
●Surgery is for stable disease, where the deformity is significant and compromises intercourse, with stability for three to six months or more than 9 to 12 months after onset. The guideline recommends operating only when the disease is stable and intercourse is compromised by the deformity.
●Referral timing is therefore a judgement. Referring now suits a man who is distressed, wants to know the options and may benefit from early specialist advice. Waiting for the examination and a review at four to six weeks, then referring when stable or if the bend is affecting intercourse, is equally acceptable. What is not acceptable is discharging him with nothing, or labelling him an emergency.

Honest Expectations, Mood and the Relationship

●Explain in plain words that the problem is scarring and not cancer, that the pain usually settles, that the bend may not straighten without treatment from a specialist, that many men can still have intercourse, and that straightening surgery is considered only when it has stopped changing.
●Hamid is low, sleeps poorly and has avoided intimacy for two months, so his wife feels rejected. Asking about mood and risk, naming the guilt, offering to involve his wife if he wishes, and mentioning psychosexual or talking therapy are part of a complete plan.
●Avoid unexplained terms and false reassurance before examining him.

Common Mistakes in This Station

●Diagnosing and treating over video with no examination, or asking him to examine himself on screen.
●Labelling the problem an infection, or sending him to an emergency or urgent cancer pathway.
●Missing the hand lump by not asking about Dupuytren's contracture or family history.
●Prescribing an NSAID without considering his blood pressure treatment or kidney function, or with no time limit.
●Prescribing antibiotics or steroids, or promising a cream or tablet will straighten the penis.
●Giving false reassurance that it will straighten by itself, or saying nothing can be done.
●Not explaining the difference between active and stable disease, and giving no plan or timescale for referral.
●Ignoring low mood and the strain on the relationship, and giving vague safety netting.

Mapped to the RCGP curriculum topic: Renal and Urology.

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