Penile Cancer: Symptoms, Diagnosis & Treatment

Introduction

Cancer appears as a solid tumor (lump) that is malignant.¹ Penile cancer is a cancer of the penis (the external part of the male urinary and reproductive system). The cells present in the tissues of the penis give rise to different types of penile cancer.

Depending upon the type of cell affected in the penis, the type of penile cancer is determined. Following are the type of penile cancers: Squamous cell cancer, Melanoma, Basal cell cancer, Adenocarcinoma (Paget’s disease of the penis), and Sarcoma.²   Penile cancers can start in any part of the penis. 

Most commonly it has been found to begin on the head or foreskin of the penis.  This cancer goes untreated in many individuals since it is associated with psychological distress. Males suffering from this type of cancer often delay seeking medical opinion because they fear and suffer embarrassment.⁴ Males who are over 55 years are most often detected with penile cancer. However, people who are under the age of 40 can also develop this type of cancer.³

Signs and Symptoms of Penile Cancer

Irrespective of the type of penile cancer, mostly the foreskin and the tip of the penis (glans) get affected. Therefore, penile cancer symptoms are first visible on this part of the penis.⁵

Signs of penile cancer are listed as under:

• Skin changes: Skin thickening (phimosis), skin rash⁵, change in skin colour
• Swelling at the tip of the penis, particularly when the foreskin is restricted. It may be difficult to draw the foreskin back. 
• Groin-area lumps beneath the skin: Most frequently, lymph nodes in the groin are the first region affected by the malignancy, leading to the enlargement of lymph nodes. 

The following are the symptoms of penile cancer: 

• Skin thickening (phimosis), skin rash⁵, change in skin colour³
• Flat growth that appears bluish brown in colour³
• Bad-smelling fluid underneath your foreskin³
• A sore or a lump develops that does not heal within 28 days⁵
• Other symptoms include a feeling of tiredness, pain in the stomach, and weight loss⁵

When to See a Doctor

One should visit the doctor if the following conditions are observed. As a regular practice, one should look for the mentioned changes that occur in and around the penis: 

• If there is any bleeding from the penis 
• If the previous treatment for penile cancer was not effective
• If any other penile cancer symptoms prevail.⁵

Did you know squamous cell carcinoma (SCC) makes up 95% of penile cancer cases? This type of cancer develops in the epithelium that is the top layer of your skin. Different types of tissues may develop other forms of penile cancer: basal cell carcinoma (BCC), melanoma, and sarcoma. Out of these, the malignancy melanoma is more dangerous.

Dr. Siddharth Gupta, B.A.M.S M.D (Ayu)

Causes of Penile Cancer

Penile cancer is a rare form of cancer that starts in the tissues of the penis. The exact cause of penile cancer is not clear, but several factors have been identified that may increase the risk of developing this type of cancer:

• Human papillomavirus (HPV) is a common sexually transmitted infection that has been linked to penile cancer. One can get infected with HPV from unprotected vaginal, anal, or oral intercourse, sharing of sex toys, and skin-to-skin contact with the genital area.⁶  
• Lack of circumcision: Men who are not circumcised have a higher risk of developing penile cancer than those who are circumcised.
• Smoking: Smoking has been linked to an increased risk of many types of cancer, including penile cancer. 

In my experience, a healthy skin cell may become a cancer cell when you have penile cancer. Uncontrolled cancer cell growth results in the formation of a tumour that pushes the healthy cells aside. As time passes, cancer cells have the potential to invade further organs and tissues in your body. I strongly recommend routine complete body checkups for those who have a family history of cancer.

Dr. Rajeev Singh, BAMS

Risk Factors for Penile Cancer

Risk factors are not the factors causing penile cancer but these factors increase the chance of occurrence of developing penile cancer. Below are some of the risk factors:³

• Age: Individuals who are at the age of 55 or more are at higher risk of developing this cancer.³
• Lack of hygiene: Penis should be washed regularly, if not then fluids (smegma) accumulate and give out a bad odor.³
• Phimosis: Inability to pull the foreskin back due to foreskin rigidity.³ Phimosis history can elevate the chances of developing penile cancer from 25% to 60%.⁴
• Human papillomavirus (HPV): Unprotected intercourse can result in developing penile cancer and other sexually transmitted diseases.³
• Human Immunodeficiency Virus (HIV): Patients suffering from HIV infections are also prone to penile cancer.³
• Tobacco consumption: Tobacco suppresses immunity and thereby increases the chances of developing penile cancer.³ People who smoke cigarettes are 3 to 4.5 times more susceptible to penile cancer.⁴
• Psoralen and ultraviolet A photochemotherapy (PUVA treatment): People who have undergone this psoriasis treatment can have penile cancer since this treatment utilizes radiation.³
• Inflammatory disorder of the penis: Lichen sclerosis causes inflammation either on the head of the penis or on the foreskin. If someone has a Lichen sclerosis infection, then they may develop penile cancer. ³

Diagnosis of Penile Cancer

Upon visiting the doctor following diagnostic protocols are carried out to understand the developing penile cancer in an individual. The mean age of diagnosis of penile cancer is at the age of 60 years.⁴

• Clinical evaluation by the doctor helps understand abnormal changes on the penis (changes like skin rash, colour change, soreness, or a lump). 
• Biopsy: In case the doctor suspects a tumour, he can suggest a biopsy. The results of the biopsy will confirm the presence or absence of penile cancer. 
• Imaging studies: Cancer has the characteristic of spreading to other parts of the body and affects healthy tissues. This reveals how much the cancer has grown and where it has spread. Hence, imaging studies are also a part of diagnosis. ³

Treatment of Penile Cancer

Treatment strategy for penile cancer depends on the size of the tumour, cancer stage, spread of the cancer, and its likelihood of relapsing after the treatment.³   Often, treatment options are combined to have maximum therapeutic effect, following is a list of treatments that might be employed for treating penile cancer: 

Treatment for a mild form:

• Medicinal creams 
• Removal of foreskin i.e., circumcision (restricted to certain religions)
• Laser treatment 

Treatment for a severe form:

• Mohs surgery 
• Excision
• Penectomy (some part of the penis is removed)
• Lymphadenectomy (groin area lymph nodes are removed)
• Radiation therapy³

Prevention of Penile Cancer

Following are the possible preventive measures:  ⁷

• Circumcision: In the past, circumcision—the removal of the foreskin from the penis—was advocated to reduce the risk of developing penile cancer. This was based on studies showing that circumcised males have significantly lower rates of penile cancer than uncircumcised men. However, in several investigations, after smegma and phimosis were taken into consideration, the circumcision’s protective effect was no longer evident. Nevertheless, some specialists assert that circumcision guards against penile cancer.
• Genital hygiene: Maintaining proper genital hygiene may be the most crucial element in preventing penile cancer in uncircumcised men. Men who aren’t circumcised must retract (drawback) their foreskin and clean their entire penis. By maintaining adequate genital cleanliness, non-circumcised men can help reduce their risk of developing penile cancer.
• HPV infection: Because HPV is so widespread, even one intercourse can increase your risk. The absence of visible warts cannot be used to diagnose HPV because a man can have the virus for years without showing any signs. A person can still be infected with HPV and transmit the virus to another person even if they do not have warts (or any other symptom).
• Use of tobacco products: Smoking raises the risk of developing penile cancer, thus abstaining from all tobacco products may reduce that risk. Using cigarettes less frequently or never at all is an effective method to lower your chance of developing numerous diseases, including penile cancer.⁸

Complications of Penile Cancer

Penile cancer complications are like any complication that arises due to surgical incidents such as:  

• Bleeding
• Infections
• Risks associated with the administration of general anesthesia. 
• Meatal stenosis is a very common complication post-penectomy. (Stenosis means an opening becoming narrower than normal)
• Complications occur repeatedly since the treated tumour might increase in size due to radiation therapy (RT). 
• Urethral strictures, 
• Fistula and pain in the penis 
• Penile necrosis problems that arise due to penile cancer.⁴

Research Facts About Penile Cancer

• Penile cancer is a malignancy that is rare in Western civilization. It accounts for less than 1% of cancers in men in the United States.
• Neonatal circumcision has been correlated with lower rates of penile cancer and has been established as an excellent prophylactic measure that can eliminate the occurrence of penile carcinoma. 

Frequently Asked Questions (FAQs)

References:

1. What is Cancer? | Cancer Basics | American Cancer Society [Internet]. Available from: https://www.cancer.org/treatment/understanding-your-diagnosis/what-is-cancer.html

2. What Is Penile Cancer? [Internet]. Available from: https://www.cancer.org/cancer/penile-cancer/about/what-is-penile-cancer.html

3. Symptoms and Causes Diagnosis and Tests Management and Treatment Prevention Outlook / Prognosis Living With Ad [Internet]. Available from: https://my.clevelandclinic.org/health/diseases/6181-penile-cancer

4. Engelsgjerd JS, Lagrange CA. Penile Cancer Continuing Education Activity [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499930/

5. Symptoms Penile cancer Main symptoms of penile cancer [Internet]. Available from: https://www.nhs.uk/conditions/penile-cancer/symptoms/

6. Causes of penile cancer – NHS [Internet]. Available from: https://www.nhs.uk/conditions/penile-cancer/causes/

7. Penile Cancer: Risk Factors and Prevention | Cancer.Net [Internet]. Available from: https://www.cancer.net/cancer-types/penile-cancer/risk-factors-and-prevention

8. Can Penile Cancer Be Prevented? [Internet]. Available from: https://www.cancer.org/cancer/types/penile-cancer/causes-risks-prevention/prevention.html

9. Sex and relationships | Penile cancer | Cancer Research UK [Internet]. Available from: https://www.cancerresearchuk.org/about-cancer/penile-cancer/living-with/sex-relationships

10. Penile Cancer: Symptoms, Stages & Treatment [Internet]. Available from: https://my.clevelandclinic.org/health/diseases/6181-penile-cancer

11. After surgery | Penile cancer | Cancer Research UK [Internet]. Available from: https://www.cancerresearchuk.org/about-cancer/penile-cancer/treatment/surgery/after-surgery

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