Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chief complaint of penile discomfort, localized erythema, and edema of the glans and prepuce. Duration of symptoms: [Number] days. Associated symptoms include pruritus, dysuria, and localized purulent or serous discharge. Denies history of recent trauma, unprotected sexual intercourse, or known contact dermatitis. No systemic symptoms such as fever or chills.
Clinical Examination Findings
Genitourinary examination reveals significant erythema and edema of the glans penis and prepuce. Presence of [exudate/ulcerations/fissures/phimosis]. Prepuce is [retractable/non-retractable]. No palpable inguinal lymphadenopathy. No evidence of meatal stenosis or urethral discharge.
Treatment Protocol
Initiate conservative management: daily gentle cleansing with warm water and mild soap, followed by thorough drying. Prescribe topical [antifungal/antibiotic/corticosteroid] cream applied twice daily for [Number] days. Advise sitz baths as needed. If phimosis is present, consider temporary topical steroid application to facilitate retraction. Follow-up in [Number] weeks to assess resolution.