Penile cancer

This is one of the rarest cancers in men. It almost always starts in the skin — a patch, a small lump or a sore on the glans or on the inner surface of the foreskin. That is why it shows up early, and it is also why it is so often missed: a similar patch appears in a dozen harmless conditions, and showing it to a doctor feels awkward. What follows is what to look for, what it gets confused with, how the two are told apart, and what can be preserved with today's treatment.

What appears on the penis

The changes are almost always visible or can be felt, and they almost always sit on the glans or on the inside of the foreskin, where the skin is thin and permanently moist.

• A sore, a raw area or a crack that has not healed in more than four weeks.
• A lump, a nodule or a growth that looks like a wart or a cauliflower.
• A flat red velvety patch with a sharp edge, which can sit there painlessly for years.
• An area of white thickened skin, or a change in colour: pale, brownish, bluish-red.
• Blood on your underwear or from under the foreskin with no clear cause.
• Discharge with a foul smell that does not go away after washing.
• A foreskin that has stopped pulling back when it used to pull back easily.

There is usually no pain at first, and that is what misleads people most. You expect cancer to hurt, and it does not; so the thing to go by here is not soreness but time. Any change on the skin of the penis that has lasted a month and shows no sign of settling needs to be looked at.

Later on there may be firm, painless lumps in one or both groins, unexplained tiredness and weight loss. Those are already late signs, and there is no reason to wait for them.

What it gets confused with — and what is far more common

Almost everything that alarms a man when he looks turns out not to be a tumour. It cannot always be told apart by eye, so this list is not there to reassure you on your own, but so that you know what will be discussed in the consulting room.

• Balanitis and balanoposthitis — inflammation of the glans and foreskin. Redness, itching, a curd-like coating, often from thrush or from high blood sugar. Settles within days or weeks on treatment.
• Lichen sclerosus — hard white areas, narrowing of the foreskin and of the opening of the urethra. It needs treatment and follow-up, because the risk of cancer on top of it is higher than usual.
• Genital warts — soft, fleshy growths, also caused by human papillomavirus but by different types of it.
• The syphilitic sore — a firm, painless ulcer with smooth edges. It can look exactly like a tumour and is treated in a completely different way, which is why a syphilis test is taken.
• Genital herpes — clustered blisters that leave painful raw areas, with stinging and repeated episodes.
• Psoriasis, lichen planus and eczema — skin conditions that often flare in exactly this area.
• Pearly penile papules — a normal variant that is regularly mistaken for something serious.

There is also a stage in between: pre-cancerous change in the skin of the penis. It looks like that same red velvety or whitish patch, it is not yet malignant, but without treatment some of it turns into cancer over time. It is found on biopsy and treated with creams or laser, and it is the best of all possible outcomes.

What raises the risk

In roughly half of cases, traces of human papillomavirus are found — the same virus that causes cervical cancer in women. It passes on through any skin contact in the genital area and through any kind of sex. Very large numbers of people carry it and only a handful develop a tumour: the virus on its own does not make the disease.

The rest comes down to circumstances in which the skin of the glans has been irritated for years:

• a foreskin that will not pull back, with smegma collecting underneath and chronic inflammation persisting;
• repeated bouts of balanitis, particularly untreated ones;
• lichen sclerosus;
• smoking — it multiplies the risk and acts independently of the virus;
• weakened immunity: HIV, or medicines that suppress the immune system after a transplant;
• PUVA treatment in the past — psoriasis treated with light-sensitising drugs plus ultraviolet light — if the genitals were not shielded;
• age: most cases occur in the second half of life, although the disease does occur earlier.

What can be done in advance

Nothing gives a complete guarantee, but the measures below genuinely lower the odds and head off far more common troubles along the way.

• Vaccination against human papillomavirus. It protects against the types of the virus behind most of these tumours, and against genital warts as well. The effect is greatest before sexual activity begins, but many countries also offer it to adults; the age limits differ from country to country, so ask your doctor.
• Condoms. They cut down transmission of the virus without removing it altogether: the virus also lives on skin outside the area a condom covers.
• Stopping smoking. The one item on the list that is entirely in your hands.
• Sensible hygiene. Daily washing with warm water, pulling the foreskin back and drying afterwards. Harsh antiseptics and perfumed soaps cause inflammation in their own right.
• Not putting up with a tight foreskin or with lichen. If the foreskin will not retract, or hard white areas appear on it, that can be treated — with ointments, and if they fail, with circumcision, which also removes part of the cancer risk.

How the diagnosis is made

Examination raises the suspicion; it does not make the diagnosis. The diagnosis rests entirely on a piece of tissue.

• Biopsy — the decisive test. Under local anaesthetic a fragment of the altered area is taken and a pathologist examines it under the microscope. No treatment starts without this step, because far too many things look alike.
• Examination with the foreskin fully retracted. If it will not pull back, whatever lies underneath cannot be seen, and circumcision is sometimes done purely in order to look.
• Blood tests — the general ones, plus syphilis and HIV testing, because both cause similar ulcers and change what happens next.
• Ultrasound or MRI of the penis — to work out how deep the tumour goes and whether the erectile bodies are involved. The extent of surgery depends on this.
• Assessment of the groin lymph nodes. Feeling them is unreliable: a node can be enlarged simply from inflammation and, conversely, be involved while still normal in size. So ultrasound with a needle sample is used, and where the risk is high, a sentinel node biopsy — sampling the first node the lymph drains into.
• CT or PET — where spread beyond the groin is suspected.

Biopsy results usually take one to two weeks. Ask when the answer is expected and whom to contact if it is delayed.

How it is treated

One thing is worth knowing in advance: modern treatment tries to keep the organ. Removing the penis is not the first option but the last, used when there is no way to save the tissue.

• Creams with an anti-cancer or immune action — for pre-cancerous change and the most superficial tumours. They are applied in courses; the skin becomes inflamed and peels, and that is expected.
• Laser and cryotherapy — burning or freezing away a small, shallow area.
• Circumcision — if the whole lesion sits on the foreskin, this may be enough on its own.
• Removing the tumour with a margin of healthy tissue, or stripping the surface of the glans and covering it with a skin graft; with deeper involvement the whole glans is removed and a new one is shaped from the tissues of the shaft.
• Partial or total removal of the penis — for large, deep tumours. After a total removal, urine is passed through an opening formed in the perineum; reconstruction may be possible later.
• Surgery on the groin lymph nodes — where they are involved or the risk is high: the state of the nodes matters more to the outlook than anything else.
• Radiotherapy, including brachytherapy — instead of surgery for small tumours, after surgery where there is a risk of return, or to ease symptoms.
• Chemotherapy — before surgery to shrink the tumour, after it where nodes are involved, and when the disease has spread to other organs.

A tumour found before it grows deep is cured in most cases. In advanced disease the aim changes: hold the growth back, take away pain, protect quality of life. That is the work of the palliative care team, and it is worth involving them as soon as that conversation begins, not in the final weeks.

Passing urine, sex and appearance after treatment

Almost nobody asks these questions out loud, but everybody thinks about them, and there are answers.

• After organ-preserving surgery most men still pass urine standing; the stream may change direction, and people adapt to that.
• Sensation is reduced once the surface of the glans has been removed, but erection and orgasm are usually kept; sex is resumed once the surgeon says so.
• After total removal, urine has to be passed sitting down, and orgasm remains possible — it does not depend on the penis as a whole.
• Appearance changes, and being distressed by that is not weakness. Talking to a psychologist helps more than people expect.
• After surgery on the groin nodes the leg and scrotum often swell. Compression garments and specialist massage help, but they need to be started early, not once the swelling is long established.

Once treatment is over, regular check-ups are arranged: a return of the disease is nearly always picked up at those and nearly always treatable. It is worth keeping them even when nothing is troubling you.

When help is needed straight away

The tumour itself grows slowly, but a few situations will not wait. Call an ambulance — in Spain, Italy, Portugal, Poland and Ukraine the single number is 112 — if:

• bleeding from the tumour or from a surgical wound does not stop with firm pressure through a clean dressing;
• you cannot pass urine although the bladder is full and the lower abdomen feels bursting;
• a high temperature with shivering sets in, the skin of the groin or penis turns hot, red and acutely painful, and confusion or severe weakness appears — that is how spreading infection looks.

The same day, though without an ambulance, see a doctor if pain suddenly worsens, swelling keeps growing after surgery, pus comes from the wound or the stitches give way.

Online consultation

A doctor has to see the skin lesion with their own eyes, and a biopsy is done by hand — nothing replaces that. But there is plenty around the examination for which it is easier to speak to a doctor from home, without putting it off out of embarrassment: describing what you have found and working out how urgent it is; going through the biopsy report and the stage; preparing the questions for the surgeon before an operation; deciding what to do about a swollen leg or a discharging wound during recovery; weighing up whether vaccination against human papillomavirus makes sense for you or for your children. And one reason of its own: the sore that will not heal, the one you have been meaning to show someone for six months.

This material is for information only and does not replace medical advice.