POSTOPERATIVE DIAGNOSES:
1. Rectal cancer with right ureteral involvement.
2. Right distal ureteral stricture.

PROCEDURES PERFORMED:
1. Cystoscopy.
2. Right retrograde pyelogram.
3. Right ureteral stent change.

SURGEON: John Doe, MD

ANESTHESIA: General inhalational.

FINDINGS: Right distal ureteral stricture.

SPECIMENS: Ureteral stent.

DRAINS: A 6-French x 26 cm right double-J ureteral stent.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

DISPOSITION: Stable.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic male with rectal cancer status post extensive pelvic and abdominal surgery. The cancer involved the right ureter, and we performed right ureteral repair six to eight weeks ago. The patient apparently has an indwelling ureteral stent and presents for stent removal versus change. Risks and benefits of the procedure were explained in detail to the patient, including bleeding, infection, damage to the urethra, bladder, ureters, kidneys, failure to diagnose and treat all disease, recurrence of disease, and possible need for further procedures. The patient expressed understanding and wished to proceed with cystoscopy, right retrograde pyelogram, and right ureteral stent change.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and after adequate anesthesia was placed in the dorsal lithotomy position on the OR table. His genital and perineal regions were prepped and draped in a sterile fashion. The 21-French cystoscope was manipulated through the patient’s urethra, which appeared normal into the bladder. There was moderate prostatic enlargement. The stent was seen effluxing from the right ureteral orifice, and no other bladder lesions were seen. The stent was grasped with a flexible grasper and removed to the level of the urethral meatus where a guidewire was placed through the stent and this passed easily up the right collecting system under fluoroscopic guidance coiled in the right renal pelvis. The stent was then removed.

We then cannulated the right ureteral orifice with a cone-tip catheter and injected dilute contrast, which revealed no filling defects. There was a 3 cm narrowed area at the level of the ureteral repair with some proximal dilation of the ureter and renal pelvis. This was consistent with a ureteral stricture; therefore, we decided to place a fresh stent. It is likely the patient’s ureter will be managed with indwelling ureteral stent and periodic changes. We then placed a fresh 6-French x 26 cm double-J ureteral stent via Seldinger technique in the right collecting system under fluoroscopic guidance without difficulty.

We removed the wire with a stent in good position. We drained the bladder and removed the scope. The patient tolerated the procedure well. There were no complications. He was awakened and transported to the postanesthesia care unit in stable condition.

POSTOPERATIVE DIAGNOSIS: Benign prostatic hypertrophy with obstruction and urinary retention.

PROCEDURES PERFORMED:
1.  Cystoscopy.
2.  Transurethral resection of prostate.

SURGEON: John Doe, MD

ANESTHESIA: General inhalational.

FINDINGS: Obstructing trilobar prostatic hypertrophy.

SPECIMENS: Prostate.

DRAINS: A 24-French 3-way Foley.

COMPLICATIONS: None.

DISPOSITION: Stable.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic male with BPH with obstruction and urinary retention. He has failed previous voiding attempts despite maximum medical therapy. His preoperative urodynamics showed evidence of obstruction and also detrusor dysfunction. He presents for cystoscopy and transurethral resection of prostate. Risks and benefits of the procedure were explained in detail to the patient, including bleeding, infection, damage to the urethra, bladder, prostate, and rectum, failure to diagnose and treat all disease, recurrence of disease, need for further procedures, urinary incontinence, persistent or recurrent urinary retention, impotence, and medical complications including but not limited to heart attack, stroke, and death. The patient expressed understanding and wished to proceed.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and after adequate anesthesia was placed in the dorsal lithotomy position on the OR table. His genital and perineal regions were prepped and draped in a sterile fashion. The 24-French resectoscope was manipulated easily through the patient’s urethra, which appeared normal, into the bladder. There was trilobar obstructing prostatic hypertrophy. The 24-French cutting loop was then placed on the resectoscope. The landmarks were identified, including the bladder neck, the ureteral orifices, the verumontanum, and the external sphincter.

We began the resection at the bladder neck at 6 o’clock and resected back to the verumontanum and proceeded counterclockwise from 6 o’clock to 3 o’clock and then from 3 o’clock to 12 o’clock resecting the left lobe of the prostate. All chips were evacuated from the bladder, and excellent hemostasis was achieved using the loop and rollerball electrode. We then resected the right lobe of the prostate in identical fashion. Again, all chips were evacuated, and excellent hemostasis was achieved. The bladder was not perforated. The ureteral orifices continued to efflux clear urine throughout the case. The sphincter was not injured.

The scope was removed after ensuring excellent hemostasis, and a 24-French 3-way Foley catheter was inserted and balloon inflated to 40 mL. The urine was clear. Continuous bladder irrigation with normal saline was begun. The patient tolerated the procedure well. There were no complications. He was awakened and transported to the postanesthesia care unit in stable condition.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Eroded artificial urinary sphincter.

POSTOPERATIVE DIAGNOSIS: Eroded artificial urinary sphincter.

OPERATION PERFORMED:
1.  Cystoscopy.
2.  Placement of suprapubic tube.
3.  Explantation of artificial urinary sphincter.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old gentleman with history of prostate cancer treated by radiation therapy and subsequent cryoablation therapy. He had rather significant stress urinary incontinence following his cryoablation procedure. He had male urinary sling and collagen injections by his primary urologist. He was ultimately referred for management. We placed an artificial urinary sphincter two years ago. This had kept him reasonably dry for a period of time. He has had increasing difficulty with elevated postvoid residuals. His PSA is detectable recently. A cystoscopy two months ago showed intact artificial urinary sphincter with radiation changes in the area of the prostatic urethra but no significant obstructive component. He was admitted to an outside hospital last week with acute urinary retention and elevated creatinine. He presented to our office five days ago with a Foley catheter in place, stating that he wanted his artificial sphincter removed. A cystoscopy was performed this morning, which showed erosion of the proximal cuff of the artificial sphincter as well as likely a small erosion of the distal cuff. We therefore brought him to the operating room today urgently for explantation of artificial urinary sphincter. He has had no fevers or signs of infection.

INTRAOPERATIVE FINDINGS:
1.  No evidence of extravasation upon removal of the distal cuff.
2.  Small amount of extravasation after removal of the proximal cuff.
3.  Most obstructive component during cystoscopy is the area at the bladder neck where there appears to be some obstruction from the remaining prostatic tissue.

FINDINGS AND PROCEDURE:  After obtaining consent, the patient was taken to the operating room and placed in supine position, whereupon general anesthesia was administered. He was then placed in the lithotomy position, prepped and draped in the normal sterile fashion. He received perioperative antibiotics.

A Jordan-Bookwalter retractor and a Wilson scrotal pack was utilized. A transverse scrotal incision was made. The pump was identified. We dissected around this and found the tubing. The tubing to the reservoir was identified in the right inguinal space. The reservoir was emptied and reservoir balloon delivered intact. Both cuffs wrapped around the urethra were excised. The distal cuff was removed initially and the urethra irrigated. There was no extravasation upon irrigation. Proximal cuff was also removed, and with irrigation, there was a small amount of extravasation at the right dorsolateral aspect of the urethra. The area was copiously irrigated with one liter of antibiotic solution.

A cystoscopy was performed with a 21-French cystoscope. The area of the erosions was still healthy and viable. The scope passed through this area. There was some mild resistance at the bladder neck. The scope was passed in here and bladder was distended. The patient was placed in Trendelenburg position. A small suprapubic incision was made with a 15 blade. The area was infiltrated with 0.25% Marcaine with epinephrine. A Bard suprapubic set was used to place the suprapubic tube. The 12-French suprapubic tube was draining well as visualized endoscopically. This was sutured in place with a 2-0 Prolene suture. A guidewire was placed through the cystoscope and coiled in the bladder. A 20-French Councill catheter was placed over the guidewire. Mildly pink urine was obtained from both catheters.

The operative site was infiltrated with approximately 20 mL of 0.25% Marcaine with epinephrine. The periurethral tissue was closed in two layers. A TLS drain was placed prior to closing the incision, and the skin incision was closed with 3-0 Monocryl suture. The sponge and needle counts were correct x2. There were no apparent intraoperative complications. The patient tolerated the procedure well and was taken from the operating room to the recovery room in stable condition.

PLAN:  Intraoperative events were discussed with the patient’s wife. He will be admitted to the hospital postoperatively. He will likely be hospitalized for a minimum of 24 to 48 hours.

She is followed by Dr. Jane Doe in urology who has her on Detrol LA 2 mg. She has other medications; Prilosec 20, vitamin C, Vicodin 5/500, and levothyroxine 25 mcg.

The patient denies any discrete burning with the urine. No fevers, no chills. No back pain. It is urinary frequency that is her prime concern and she knows that Dr. Jane Doe had thought she could improve these symptoms by going to the 4 mg dose of Detrol LA from prior conversation.

OBJECTIVE:  The patient’s vital signs revealed a blood pressure of 124/82, heart rate of 78, weight of 178, and temperature of 98.4. She appears comfortable, nonseptic, in no acute distress. Lung sounds are clear. Heart has regular rate and rhythm.

LABORATORY DATA:  Urinalysis shows trace blood, moderate protein, and small leukocytes. There are no nitrites.

ASSESSMENT:  Status post urinary tract infection with urinary frequency.

PLAN:  Recommend sending today’s urinalysis for culture. She can try Pyridium, which may help with her symptoms now. It is most important that she get back on her diuretic, which she has stopped, and a consideration to take this in the very early morning hours if she gets up to void would be appropriate so she can go back to sleep.

We will discuss this in two days’ time to see if the urine has completely cleared. At that time, if this is a negative urinalysis, C&S, then we would increase the Detrol LA to 4 mg per day. The patient will call back with other questions.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old gentleman who was initially seen by Dr. John Doe for hematuria and was found to have a transitional cell carcinoma of the bladder. We then saw him and performed a cystoscopy and transurethral resection of bladder tumor 2-1/2 years ago.

The patient was supposed to follow up in three months, but eventually, he was found to have metastatic disease to his lung. The patient, at that time, was followed for an abdominal aortic aneurysm. During one of the CAT scans for this reason, he was found to have distal metastasis from his transitional cell carcinoma proven by biopsy and resection.

After that, the patient was referred to Dr. Jane Doe in consideration of possible salvage chemotherapy. The patient states that he thought that since he was followed by Dr. Jane Doe and since he had serial PET scans to monitor the response to chemotherapy, he did not need to come back and see me and so he did.

The patient has received a total of 14 cycles of chemotherapy during the last two years. Recently, he had an episode of painless gross hematuria. He comes here for further evaluation.

Today, we sent a sample of urine for analysis and cytology and then he was prepared for an office cystoscopy.

DESCRIPTION OF PROCEDURE:  The patient was placed in a supine position on the operating table. Genitalia prepped and draped according to the usual sterile fashion.

A flexible cystoscope was introduced into the urethra and advanced through the prostatic urethra without difficulty. At the level of the bladder neck and on the right side of the trigone, there was evidence of papillary transitional cell carcinoma of the bladder. The left ureteral orifice was identified, but the right one could not be identified. The remaining portion of the bladder appeared free of disease.

The cystoscope was removed, and the patient was informed about the findings.

PLAN:  Schedule for cystoscopy, transurethral resection of bladder tumor.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with longstanding history of chronic back pain, status post lumbar fusion in the past, who comes in with left testicle pain of one day’s duration. He denies any swelling or trauma. He denies any dysuria, hematuria, and no penile drainage. He denies any headache, lightheadedness, dizziness, blurry vision, double vision, chest pain, shortness of breath, or difficulty breathing. He says that he is currently sexually active with one partner but has had previous partners in the past. He denies any constipation, no urinary frequency, no trouble starting his stream, no urinary hesitancy, no bowel or bladder retention or incontinence. He has not noticed any numbness or tingling in his fingers or toes, despite the fact that the nursing notes state that there was pain, numbness, and tingling in his left leg. He denies that to me and states that he just has some pain occasionally in his leg. He denies any falls.

PAST MEDICAL HISTORY:
1.  Lower lumbar fusions.
2.  Chronic back pain.
3.  Hepatitis C.

MEDICATIONS:  Morphine.

ALLERGIES:  None.

SOCIAL HISTORY:  The patient smokes a pack a day of tobacco. Does not drink alcohol or do drugs. He states that he also has hepatitis C as well, but he is unclear about the etiology or source for this.

REVIEW OF SYSTEMS:  Otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 116/84, pulse 86, respiratory rate 18, temperature 98.2, and O2 sat is 95% on room air.
GENERAL: The patient is a well-appearing Hispanic gentleman in no acute distress.
HEENT: The pupils are equal, round, and reactive to light. The extraocular muscles are intact. TMs are clear bilaterally. No erythema or effusion. Nares are patent bilaterally. The oral mucosa is pink and moist. No oral lesions. No posterior pharynx erythema or exudate. Uvula is midline. No swelling or asymmetry.
NECK: Supple without lymphadenopathy or JVD.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended with good bowel sounds. No organomegaly. No masses palpated.
BACK: The patient had a scar over his midline in his lower lumbar area. He was nontender to palpation in the midline of the C-spine, T-spine or L-spine. He had some paraspinal musculature tenderness. He had a negative log roll to his hips bilaterally.
EXTREMITIES: The patient moves all four extremities in all directions. No cyanosis, no clubbing, no edema.
GENITOURINARY: Revealed normal circumcised male genitalia. There were no rashes or lesions noted to his phallus. He had no penile drainage noted. A swab was taken. His testicles were of equal size, shape, and consistency and normal lie. His testicle was minimally tender to palpation, and his epididymis was tender to palpation on the left. He did not have hernias to palpation bilaterally.
SKIN: Warm and dry without any rashes or lesions.
NEUROLOGIC: The patient is awake, alert, and oriented x3. Cranial nerves II through XII are checked and intact. Motor is 5/5 in the bilateral upper and lower extremities. Sensation is grossly intact to light touch. Reflexes; biceps, triceps, patellar, and Achilles tendons are 2+.
PSYCHIATRIC: The patient had normal affect, normal insight, and normal judgment.

EMERGENCY DEPARTMENT COURSE:  The patient is brought back to the room. He was seen and evaluated. He was given 2 mg of Dilaudid IM for his pain. Given the large amounts of narcotics he takes on a regular basis, urinalysis was obtained as well that showed small bilirubin, trace blood, and 30 protein.

MEDICAL DECISION MAKING:  We feel this patient is likely suffering from two processes, one being chronic back pain from his chronic back pain source of his lower lumbar fusion; however, we do not think that is causing the testicular pain and hip pain, and this is likely due to epididymitis. Given his age and risk factors, he certainly may be susceptible to prostate related versus sexually transmitted disease, and we will elect to treat him for both, and we explained this to both him and his significant other, who was present in the room. The patient was comfortable with this.

He was given a shot of Rocephin 250 mg IM and given a gram of azithromycin here and was given a prescription for ciprofloxacin and doxycycline. He was urged to follow up with his primary care physician and his spine physician for a repeat MRI, given the progression of his pain. He is to keep his scrotum elevated. He is to use ice packs as needed. The patient is to return for worsening scrotal pain, trouble urinating or defecating, trouble walking, numbness, tingling or weakness.

We do not think this is an acute cord compression, given his physical exam, and we do not think this is a testicular torsion based on his risk stratification and physical exam.

DIAGNOSES:
1.  Epididymitis.
2.  Back pain.

DISCHARGE CONDITION AND DISPOSITION:  Stable, to home.

PREOPERATIVE DIAGNOSIS: Carcinoma of the prostate.

POSTOPERATIVE DIAGNOSIS: Carcinoma of the prostate.

OPERATION PERFORMED: Laparoscopic robotic radical prostatectomy.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, NP

ANESTHESIA: General.

DESCRIPTION OF OPERATION: Under general anesthesia, in the supine, steep Trendelenburg position, the patient was properly and sterilely prepped and draped. Pneumoperitoneum was carried out above the umbilicus with Veress needle to 20 mm pressure. A 12 mm port was placed and this was done with direct vision. Excellent entry into the abdomen was noted. Left lower, left mid, and right mid 8 mm robotic ports were placed, right lower quadrant 12 mm port was placed, and a 5 mm right upper quadrant working port was placed.

Attention was turned towards bringing the robot, and it was docked in the usual fashion in steep Trendelenburg. Bladder was dropped in the usual fashion. Prostate was mobilized from apex to base. Dorsal vein complex was ligated with 2-0 PDS and 2-0 Vicryl suture and 2-0 PDS suspending suture. Bladder neck was transected anterior and posterior, and Denonvilliers’ space was entered. Vas were ligated. Seminal vesicles were dissected free. Unilateral nerve sparing was carried out. The rectum was spared. Urethra was transected, and the prostate and seminal vesicles were removed en bloc, placed in an EndoCatch bag for later retrieval. Anastomosis was carried out with 2-0 PDS V-Loc suture, starting at 6 o’clock and running to 12 o’clock. An 18-French Foley catheter was placed and the return was clear. Irrigation showed no leaks. A #19 Blake drain was placed through the right robotic port, placed in the space of Retzius, and sutured to the skin with 2-0 nylon suture.

Sponge and needle count and instrument count were correct x2. Estimated blood loss was 50 mL. No blood was transfused. There were no complications. The robot was undocked. The specimen was brought out the camera port. The fascia was closed with interrupted running 2-0 Vicryl suture. Skin was closed with 4-0 Monocryl and Dermabond. The patient was very stable throughout and left the operating room for recovery in satisfactory and stable condition.

PREOPERATIVE DIAGNOSIS: Acute left testicular pain.

POSTOPERATIVE DIAGNOSES:
1.  Acute left testicular pain.
2.  Acute left testicular torsion.

PROCEDURE PERFORMED:  Scrotal exploration, left orchiectomy, and right orchiopexy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

SPECIMEN:  Included the left testis.

DRESSINGS:  Included bacitracin, Telfa, fluffs, and jockstrap.

DRAINS:  None.

DESCRIPTION OF PROCEDURE:  The patient was brought on urgent basis in the main operating room. He was placed in the supine position. After adequate instillation of general anesthesia, the scrotal pubic hair was clipped. He was prepped and draped in the usual sterile fashion.

A midline scrotal incision measuring approximately 4 mm was established with a knife. The dartos was incised with electrocautery. The tunica vaginalis was open. The left testis and cord were delivered from the left hemiscrotum. The left testis was dark blue in color. The left spermatic cord was twisted 720 degrees. After detorsion, left testis was wrapped in a warm towel.

Attention was turned to the right hemiscrotum. The dartos muscle was incised with electrocautery. The tunica vaginalis was opened sharply. The right testis was returned to the right hemiscrotum, and the tunica albuginea was fixed to the dartos muscle of the scrotum medially, laterally, and inferiorly with a 3-0 nylon suture.

Attention was turned to the left testis. The decision was made to proceed with left orchiectomy. The left vas deferens was separated from the lymphatic and blood vessel, and each of the bundles was cross-clamped and transected. The left testis was sent to the pathology department in anatomically labeled container. The left vas deferens, the remaining cord structures were secured with 2-0 silk suture.

The wound was vigorously irrigated. Hemostasis was obtained. The dartos was closed with running 2-0 Vicryl suture. The scrotal skin was closed with 4-0 chromic suture. Bacitracin and a piece of Telfa were placed over the scrotal wound, and in addition fluffs were placed inside a jockstrap. The patient tolerated the procedure well. He was awoken in the operating room and accompanied to the recovery room in stable condition. The estimated blood loss was negligible. The procedure was performed with approximately 650 ml of IV fluids. The procedure was performed without transfusion. The procedure was performed without complications.

PLAN:  The plan for this patient includes routine postoperative care. Norco one tablet every four to six hours as needed for postoperative pain is recommended. The patient is encouraged to contact the office with questions and/or problems. He was asked to return to the office in one to two weeks for postoperative evaluation. The disposition for this patient depends on his clinical course.

PREOPERATIVE DIAGNOSIS: Left ureterovaginal fistula.

POSTOPERATIVE DIAGNOSIS: Left ureterovaginal fistula.

OPERATION PERFORMED: Laparoscopic left ureteral reimplant with robotic assistance.

OPERATIVE FINDINGS: There was evidence of a left ureterovaginal fistula and a reimplant was performed over a 7-French stent without difficulty.

SURGEON: John Doe, MD

ANESTHETIC: General.

BLOOD LOSS: About 150.

COMPLICATIONS: None.

SPECIMENS: None.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the lithotomy position. The entire abdomen and genitalia were prepped and draped in the usual sterile manner. Surgical time-out was performed. A Veress needle was inserted through the umbilicus. Pneumoperitoneum was established without difficulty.

After adequate insufflation, a 12 mm port was placed at the umbilicus. Laparoscope was inserted with no evidence of injuries or abnormalities. Two 8 mm robotic ports were placed on the left side, one on the right and 12 mm assistant port in the right lower quadrant, all under laparoscopic control. The patient was then positioned in a steep Trendelenburg position. Da Vinci surgical robot was brought into the field and docked in the usual fashion.

The posterior peritoneum on the left lateral side was incised. The ureter was identified below the level of the iliac vessels, fair amount of fibrosis around the ureter. Using cautery and sharp dissection, the ureter was mobilized. An umbilical tape was passed around it to provide traction. We did get some bleeding in the pelvic sidewall, which was controlled with cautery and then some hemostatic agent.

The ureter was then mobilized down to its insertion with the bladder and then it was completely freed up and then transected, taking the ureter off of the bladder as well as off of the vagina itself. The edges of the bladder were identified and then closed with a running V-Loc 3-0 Monocryl suture. We then placed a sponge stick in the vagina and identified the small hole in the vaginal mucosa, and this was closed separately with another 3-0 Monocryl suture with good result, taking care to keep the suture lines well separated from the bladder and the vagina.

We then trimmed the ureter and spatulated to nice healthy tissue, and we then continued to free up the ureter proximally until it would come down to the bladder without any tension. The bladder was then again filled with saline. The overlying peritoneum and the muscle on the anterolateral aspect were incised until the mucosa could be identified. The mucosa was then incised and then we used a double-armed 3-0 Monocryl V-Loc suture starting at the heel of the ureter, around the back wall and the mucosa-to-mucosa anastomosis, and then put the end of the stent into the bladder, which had been previously placed and then ran the front wall with the other arm of the 3-0 Monocryl suture with excellent result. We then closed the muscle and peritoneum over the top of the anastomosis in antireflux mechanism with excellent result. Filled the bladder, ensured we had no leak.

We then came back down underneath to the vagina. We mobilized some omentum, brought all the way down to the pelvis without any tension, then tacked it over the top of the vaginal incision with another 2-0 Monocryl suture with good result. A Jackson-Pratt drain was placed in the left pelvis, brought out through one of the port sites. The remaining ports were then removed after all the gas had been evacuated. The skin was closed with Monocryl followed by Dermabond. Dressings were applied. Anesthetic was reversed. The patient was transferred to the recovery room in stable condition.

REQUESTING PHYSICIAN: John Doe, MD

CHIEF COMPLAINT AND REASON FOR CONSULTATION: Erectile dysfunction, penile curvature, and low testosterone.

IDENTIFICATION: This is a (XX)-year-old Hispanic married gentleman.

HISTORY OF PRESENT ILLNESS: The patient initially states he is here seeking information regarding trauma during intercourse that he had some years ago. He reports that approximately three years ago while on vacation, he sustained a penile fracture while having intercourse. He noticed a complete detumescence of the erection without bruising and pain.

Since that time, he has been complaining of a slight penile curvature, ventral, with penile instability. His curvature is approximately 30 to 40 degrees without pain. He is still able to penetrate. He has no history of Dupuytren’s contracture, and he has not been treated for this in the past.

Currently, his erectile grade is 7/10 with a profound lack of sustaining capability. He states that within seconds of achieving maximum penile rigidity, his erection decreases to approximately 30% erection. He is not experiencing loss of penile length in the erect or the flaccid state. He does state his libido is at 20%. He has no issues with ejaculation or orgasm.

PAST MEDICAL HISTORY: Anxiety disorder.

REVIEW OF SYSTEMS: Remarkable for shortness of breath and joint pain. Review of systems is negative otherwise.

FAMILY HISTORY: Unremarkable.

MEDICATIONS: Prozac.

SOCIAL HISTORY: The patient denies use of recreational drugs and tobacco. He has one alcoholic drink per week. He is employed. He does not have any children.

PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse is 70. Blood pressure is 126/68. He weighs 214 pounds.
GENERAL: The patient is alert and oriented x3 with a normal mood and affect.
SKIN/NECK/CHEST: Examinations are grossly normal. There is no gynecomastia.
ABDOMEN: Abdominal examination reveals a soft, nontender, nondistended abdomen, without masses or hernias.
GENITOURINARY: Examination reveals a normal-appearing scrotum with bilaterally descended testicles. The right testicle is 18 mL and firm. The left testicle is 15 mL and firm. The epididymides are normal. There is no varicocele present. Penile examination reveals a circumcised phallus with good penile stretch and no Peyronie’s plaques present.
MUSCULOSKELETAL AND VASCULAR: Examinations are grossly normal.

IMPRESSION: Erectile dysfunction, penile curvature, status post penile trauma, and possible hypogonadism.

PLAN: We had a structured conversation with the patient regarding his issues. For his erectile dysfunction, we have given him a prescription for Viagra. He will take this medication in an effort to increase his erectile rigidity. For penile curvature/penile trauma, we will have him return to the office for curvature assessment and diagnostic ultrasound of the phallus. During this test, we will be able to assess the morphology as well as his erectile capacity. We will be able to discuss the results of this test immediately after completion. At the same time, we can discuss treatment options that are available to him.

With regard to his hypogonadism, we have reviewed his outside labs, which revealed a bioavailable testosterone of 101. We would like to confirm this result before prescribing a prolonged course of supplemental testosterone. Of note, the patient states that he and his wife were unable to have children so exogenous testosterone may not be the right answer for him, if he is hypogonadal. A better option may be a centrally-acting agent such as Clomid to increase his natural testosterone manufacturing capability.