What is the diagnosis and treatment for a 47-year-old male experiencing flashes (palpitations) for two weeks and erectile dysfunction (ED) for months, with a painless bump on the left side of the penis shaft?

Differential Diagnosis and Management Approach

This patient requires urgent evaluation for two distinct problems: the painless penile bump likely represents Peyronie's disease requiring non-urgent workup, while "flashes" (if referring to palpitations) needs cardiovascular assessment given the strong link between erectile dysfunction and cardiovascular disease.

Immediate Assessment for Cardiovascular Risk

• Evaluate the "flashes" (palpitations) urgently, as erectile dysfunction is a risk marker for underlying cardiovascular disease that warrants immediate evaluation and treatment 1.
• Obtain vital signs including pulse and resting blood pressure 1.
• Order ECG and consider cardiology referral if palpitations are confirmed, as ED often precedes cardiovascular events 1.

Evaluation of the Penile Bump and Erectile Dysfunction

History and Physical Examination

Perform a comprehensive genital examination with the penis held stretched and palpated from the pubic bone to the coronal sulcus to assess for Peyronie's disease plaque 1.

Key historical elements to elicit:

• Onset and duration of erectile dysfunction (months in this case) 1
• Presence of penile curvature or deformity during erection 1, 2
• Whether the bump causes pain (painless suggests stable Peyronie's disease) 1
• Presence of nocturnal or morning erections (suggests psychogenic component if present) 1
• Ability to achieve and maintain erections sufficient for intercourse 1

Diagnostic Testing

Order morning serum total testosterone levels in all men with ED to determine if testosterone deficiency (<300 ng/dL) is present 1.

• Consider glucose/hemoglobin A1c and serum lipids as these may alter ED management 1.
• Perform in-office intracavernosal injection test with duplex Doppler ultrasound prior to any invasive intervention to assess penile deformity, plaque size/density, and vascular integrity 1.
• The ultrasound will differentiate calcified from non-calcified plaques and evaluate for veno-occlusive dysfunction, which occurs in 87% of Peyronie's patients with erectile dysfunction 3.

Diagnosis: Most Likely Peyronie's Disease with Associated Erectile Dysfunction

The painless bump on the penile shaft present for months, combined with erectile dysfunction, is highly consistent with Peyronie's disease 1, 2.

Distinguishing Active vs. Stable Disease

This patient has stable Peyronie's disease based on:

• Absence of pain (pain defines active disease) 1
• Chronic presentation over months 1
• Painless plaque 1

Treatment Algorithm for Peyronie's Disease with Erectile Dysfunction

First-Line: Oral PDE5 Inhibitor Therapy

Initiate sildenafil citrate or other PDE5 inhibitor as first-line therapy for erectile dysfunction associated with Peyronie's disease 4.

• In a study of 73 men with Peyronie's disease and ED, 70.8% reported satisfaction with sildenafil, with no worsening of deformity or increased penile pain 4.
• This is the least invasive and most convenient treatment option 4.
• Counsel the patient that ED treatment does not address the underlying plaque but can restore erectile function sufficient for intercourse 4.

Alternative Treatment Options if PDE5 Inhibitors Fail

If sildenafil is ineffective or not tolerated:

• Intracavernosal injection therapy with vasoactive agents 3
• Vacuum constriction device 3
• These should be tried before considering surgical intervention 3

When to Consider Surgical Intervention

Reserve surgery only for men who have failed conservative therapy and whose curvature, indentation, or erectile dysfunction precludes intercourse 2.

Surgical options include:

• Plication procedures 2
• Graft-based techniques 2
• Penile prosthesis implantation (for severe ED unresponsive to medical therapy) 3, 2

Critical Pitfalls to Avoid

• Do not assume the palpable plaque definitively confirms clinically relevant Peyronie's disease without additional diagnostic procedures 1.
• Do not delay cardiovascular evaluation, as ED is a sentinel marker for cardiovascular disease and the palpitations require urgent assessment 1.
• Do not proceed to surgery without first attempting medical management of erectile dysfunction 2.
• The presence of veno-occlusive dysfunction (likely in this patient given the plaque) may limit response to oral medications, but they should still be tried first 3.

Counseling and Follow-up

• Discuss all available treatment options and their known benefits and risks to ensure realistic expectations 1.
• Consider referral to a mental health professional to promote treatment adherence, reduce performance anxiety, and integrate treatments into the sexual relationship 1.
• Schedule follow-up after initiating PDE5 inhibitor therapy to assess response and adjust treatment as needed 1.