Penile Cancer

Penile cancer is a rare disease where abnormal cells in the penis grow out of control, forming a tumor. While uncommon in developed countries like the United States, early detection and treatment can often cure this disease, making it crucial to recognize symptoms and seek medical help promptly.

Table of contents

• What is penile cancer?
• The structure of the penis
• Types of penile cancer
• How common is penile cancer?
• Signs and symptoms
• Risk factors
• How penile cancer is diagnosed
• Treatment options
• Outlook and survival
• Living with penile cancer
• Prevention

What is penile cancer?

Penile cancer develops when healthy cells in the penis change and grow out of control^[1]. A cancerous tumor (also called a malignant tumor) is a group of cancer cells that can grow into and destroy nearby tissue. It can also spread to other parts of the body^[5].

Penile cancer is a disease in which malignant cells form in the tissues of the penis^[2][4]. Most often, penile cancer starts in the flat, thin cells called squamous cells. These cells are in the skin of the penis and the head of the penis^[5]. This type of cancer is called squamous cell carcinoma of the penis.

The structure of the penis

• Penis
• Glans (head of penis)
• Foreskin
• Shaft
• Urethra
• Erectile tissue

The penis is a rod-shaped male reproductive organ that passes sperm and urine from the body^[7]. Its main parts include the rod-like area called the shaft that extends from the low belly to the tip of the penis, called the head or glans^[1]. If you are uncircumcised, a layer of skin called the foreskin covers the head. If you are circumcised, the head of the penis is exposed^[1].

The penis is made of different types of tissue, including skin, nerves, smooth muscle and blood vessels^[5]. It contains two types of erectile tissue, which is spongy tissue with blood vessels that fill with blood to make an erection. The corpora cavernosa are the two columns of erectile tissue that form most of the penis. The corpus spongiosum is the single column of erectile tissue that forms a small portion of the penis and surrounds the urethra, the tube through which urine and sperm pass from the body^[7].

The penis is part of both the urinary system and the reproductive system. It contains the urethra, which carries urine from the bladder to the outside of the body^[5]. The opening of the urethra in the glans of the penis is called the meatus^[5].

Types of penile cancer

There are several types of penile cancer, listed from most to least common^[1]:

• Squamous cell carcinoma: This cancer forms in the top part of the skin layer. It makes up 95% of all penile cancers^[1].
• Melanoma: This type of cancer begins in cells that control how dark or light the skin is, called melanocytes. Melanoma is a more aggressive form of cancer^[1].
• Basal cell carcinoma: The cancer begins in the bottom layer of the skin. This is a slow-growing form of penile cancer^[1].
• Adenocarcinoma: This cancer starts in glandular cells, which are cells that make sweat, mucus or other body fluids^[1].
• Urothelial carcinoma: This cancer forms in the tissue that lines the bladder, kidneys and other parts of the urinary system^[1].
• Sarcoma: This type of cancer develops in muscle or connective tissue. It is an extremely rare form of penile cancer^[1].

Cancer can form anywhere in the penis, but it most commonly starts on the head or foreskin, if you are uncircumcised^[1]. Squamous cell carcinoma can develop anywhere on the penis, but it develops most often on the foreskin in uncircumcised men or on the glans^[5].

How common is penile cancer?

Penile cancer is rare in the United States, making up less than 1% of cancers among males^[1]. The overall risk of penile cancer in the United States is 1 in 100,000 or less^[6]. The condition is more common in Africa, Asia and South America^[1].

Cancer of the penis is very rare in most developed nations, including the United States, where the incidence rate is less than 1 per 100,000 men per year^[13].

Signs and symptoms

Not all cancers cause changes you can see. But penile cancer usually causes the penis to look different^[1]. The skin on the penis may become discolored, and you may notice a lump.

Penile cancer symptoms include^[1]:

• A painless lump or sore that may bleed
• Flat growths that look blueish-brown
• Foul-smelling fluid underneath the foreskin
• Rash
• Skin thickening or changing skin color
• Small, crusty bumps
• Swelling and irritation, especially in the head of the penis, a condition called balanitis

Signs of penile cancer can also include redness, irritation or a sore on the penis, or a lump on the penis^[4][7].

Less serious conditions like infections and allergic reactions also cause these symptoms^[1]. Still, it is better to have a healthcare provider take a look so early-stage cancer does not go untreated. The lesions are generally painless and do not typically cause erectile dysfunction or voiding difficulties in their early stages^[6].

Many benign lesions of the penis can present in the same way, so a biopsy is often needed to make the diagnosis^[3].

Risk factors

Cancer happens when healthy cells change and multiply out of control. Researchers do not know what causes that change to begin with^[1]. While researchers have not found causes, they have identified risk factors.

A risk factor is anything that increases the chance of getting a disease. Some risk factors for penile cancer, such as tobacco use, can be changed. However, risk factors also include things you cannot change, like getting older and your health history^[7]. Having one or more of these risk factors does not mean that you will get penile cancer. Many people with risk factors never develop penile cancer, while others with no known risk factors do^[7].

Penile cancer risk factors include^[1][7][6]:

• Age: Being 55 or over. About 80% of penile cancer diagnoses in the U.S. occur within this age range^[1].
• Being uncircumcised: Circumcision is an operation in which the doctor removes part or all of the foreskin from the penis. Many boys are circumcised shortly after birth. Men who were not circumcised at birth may have a higher risk of developing penile cancer^[7]. Circumcision may help prevent infection with the human papillomavirus^[4].
• HPV infection: Many of the same high-risk strains of human papillomavirus that cause cervical cancer have been found in penile cancer cases^[1]. Human papillomavirus causes about one-third of penile cancer cases^[2].
• Phimosis: Having phimosis, a condition in which the foreskin of the penis cannot be pulled back over the glans^[7].
• Poor personal hygiene^[7].
• Having many sexual partners^[7].
• Tobacco use: Using tobacco products^[7]. Smoking is a major risk factor in penile cancer^[6].

Risk factors for the development of penile cancer include phimosis, uncircumcised state, poor genital hygiene, human papillomavirus infection and smoking^[6].

How penile cancer is diagnosed

Tests that examine the penis are used to diagnose penile cancer^[4][7].

The following tests and procedures may be used^[4]:

• Physical exam and health history: An exam of the body to check general signs of health, including checking the penis for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. The tissue sample is removed during one of the following procedures:

Types of biopsy include^[4]:

• Incisional biopsy: The removal of part of a lump or a sample of tissue that does not look normal.
• Excisional biopsy: The removal of an entire lump or area of tissue that does not look normal.

A biopsy is often performed as an excisional biopsy, depending on the size of the lesion, where the doctor may try to remove the lesion with a surrounding layer of normal tissue. A circumcision is often performed at the same time^[3].

After penile cancer has been diagnosed, tests are done to find out if cancer cells have spread within the penis or to other parts of the body^[7]. Other tests to help stage the cancer include CT scan of the chest, abdomen and pelvis and bone scan to rule out any metastatic disease, which is cancer that has spread to other parts of the body^[3]. Penile cancer most often spreads to the nodal tissue in the groin and then pelvis before spreading elsewhere^[3].

Treatment options

Like many cancers, penile cancer is most treatable when diagnosed early. In many cases, it is curable^[1]. When found early, penile cancer can usually be cured^[2]. Treatment in the early stages can keep the cancer from growing. Penile cancer that has spread to other parts of the body is harder to treat^[1].

The treatment you need will depend on the size and type of penile cancer you have, where it is, if it has spread, and your age and general health^[15]. Certain factors affect prognosis (chance of recovery) and treatment options, including the stage of the cancer, the location and size of the tumor, and whether the cancer has just been diagnosed or has recurred (come back)^[4].

Treatment options for penile cancer include^[15][14][9]:

Surgery

Surgery is the most common treatment for penile cancer^[3][14]. Several different types of surgery are possible, depending on the stage of cancer:

• Circumcision: This procedure is used if the cancer is only on the foreskin^[15].
• Simple or local excision: The surgeon removes the tumor and some surrounding tissue^[15]. If a large amount of tissue must be removed, a skin graft taken from another part of the body can be placed over the surgical area.
• Mohs surgery: A surgeon uses the specialized Mohs technique, cutting out the tumor in thin layers and looking under a microscope after each layer is removed to check for cancer cells until none are seen. This process usually can save as much normal tissue as possible and creates better appearance and function after surgery^[14].
• Cryosurgery: This procedure involves freezing off the abnormal tissue^[15]. A small device is placed on the affected area to freeze the cancer^[3].
• Laser surgery: This procedure involves using a laser beam as a knife to remove a surface lesion or other abnormal tissue^[15].
• Partial or total penectomy: A surgeon either amputates the penis or removes part of it. If total removal is required to treat the cancer, surgeons also create a new opening for urine in the area between the scrotum and anus, called the perineum^[14]. For very advanced cancer, sometimes the scrotum and testicles also must be removed, which requires that the patient take testosterone supplements for the rest of their lives^[14].
• Lymph node surgery: Removal of some lymph nodes, which are part of the body’s system that helps fight off infections^[15].

Surgery for penile cancer can be life-changing, affecting a man’s self-image and sexual function^[14]. Reconstructive surgery may be possible if the penis needs to be removed. This uses skin and muscle from other parts of the body to create a working penis^[15].

Topical treatments

If caught early, penile cancer can sometimes be treated with creams applied to the skin of the penis or foreskin^[15]. Treatment may include:

• Fluorouracil (5FU): A chemotherapy cream which kills cancer cells directly in the skin^[15].
• Imiquimod: An immunotherapy cream which helps the body’s immune system to kill cancer cells^[15].

Radiation therapy

Radiation therapy uses energy from radiation beams, radio isotopes or charged particles to target tumors and to eradicate cancer cells^[14]. Sometimes a radiation source can be placed directly into or next to the penile tumor, called brachytherapy, which protects surrounding tissue from radiation^[14]. Radiation can be used to treat early-stage penile cancer or in addition to surgery when cancer has reached the lymph nodes^[14].

Radiation therapy may be given with chemotherapy, called chemoradiotherapy^[15].

Chemotherapy

Chemotherapy uses medicines to kill cancer cells^[15][14]. Chemotherapy uses drugs or combinations of drugs, given intravenously or as pills, to destroy cancer cells^[14]. Topical chemotherapy, an anti-cancer ointment, can be used for very early-stage penile cancers^[14].

Chemotherapy may be given with radiotherapy, before surgery to help make the cancer smaller, after surgery to kill any cancer cells that might be left behind, or if the cancer has spread to other parts of the body^[15].

Biologic therapy

Also known as immunotherapy, this approach uses a patient’s own immune system to fight the disease^[14]. One example of a biologic used for penile cancer is Imiquimod, a drug that comes in cream form that harnesses immune cells to destroy the cancerous lesion^[14].

Outlook and survival

The prognosis (chance of recovery) and treatment options depend on the stage of the cancer, the location and size of the tumor, and whether the cancer has just been diagnosed or has recurred^[4].

When diagnosed early (stage 0, stage I and stage II), penile cancer is highly curable. Curability decreases sharply for stage III and stage IV disease^[13]. Early detection is key^[1].

Patients with this condition tend to delay seeking medical attention due to embarrassment, guilt, fear, neglect and denial^[6]. Up to 50% of patients with penile cancers will have delayed seeking medical attention for the lesion for up to 1 year^[6]. This delay can significantly affect survival rates, morbidity and postsurgical outcomes^[6].

Living with penile cancer

Coping with penile cancer can be difficult^[16]. You are likely to have a range of emotions that change very quickly. You might feel upset, frightened and confused. One day you might feel positive and able to cope but the next day feel the exact opposite. This is natural^[16].

Cancer and its treatment may cause physical changes in your body. These changes can be very difficult to cope with and may affect the way you feel about yourself^[16]. Changes can affect your self esteem, the way you relate to others, especially close family and friends, and your sex life if you are in a sexual relationship^[16].

Self-esteem and body image

How a person feels about themselves is called self-esteem. Body image is how a person sees their own body^[20]. Penile cancer and its treatments can affect a man’s self-esteem and body image. Often this is because cancer or cancer treatments may result in body changes, such as scars, changes to the shape or size of the penis, loss of all or part of the penis, loss of the ability to urinate standing up, or a urethrostomy, which is an opening created for urination^[20].

These body changes can cause concern, anxiety and feelings of embarrassment. Men with penile cancer may feel uncomfortable around others because of changes to their body^[20]. Some men feel that they are no longer attractive after their penile surgery. This may cause problems with sex and intimacy^[16].

Talking about feelings may help some men cope with their changed body. If you are in a relationship, talk to your partner about your feelings and concerns. Support from other men who have had penile cancer and professional counsellors can help^[20].

Sexuality and relationships

Many men have strong, supportive relationships and a satisfying sex life after penile cancer^[20]. If sexual problems occur because of penile cancer treatment, there are ways to manage them. How much penile cancer affects your sex life and sexuality depends on the stage of your cancer and what treatments you have^[20].

If you are diagnosed with early stage penile cancer, your treatment may not have a big effect on your sex life. If you have a circumcision, Mohs surgery, wide local excision, laser surgery, cryosurgery, radiation therapy or topical drug therapy, it will not usually affect your ability to have an erection and penetration during sex^[20].

If part of your penis is removed, it is still possible to have an erection and there is often enough of the penis left for penetration during sex. But you may have difficulty having an erection, called erectile dysfunction, after treatment. When this happens, sensitivity and function usually return over time. Using drugs such as sildenafil (Viagra) may help^[20].

If all of your penis is removed, you will not be able to have an erection or penetration during sex in the same way^[20]. However, you can still experience pleasure and intimacy with your partner in other ways.

Support and counseling

Talking to your friends and relatives about your cancer can help and support you. But some people are scared of the emotions this could bring up and will not want to talk^[16]. Help your family and friends by letting them know you would like to talk about what is happening and how you feel^[16].

You might find it easier to talk to someone outside your own friends and family. Specialist nurses can help if you are finding it difficult to cope or if you have any problems^[16]. Counselling can help you to cope with the difficulties you will face. It can help to reduce your stress and improve your quality of life^[16].

Prevention

While penile cancer cannot always be prevented, there are steps you can take to lower your risk:

• HPV vaccination: Vaccination against HPV emerges as a powerful preventive measure, significantly reducing the risk of penile cancer associated with the virus. Early vaccination is recommended and can provide a safeguard against the development of all HPV-related cancers^[2].
• Circumcision: Some studies suggest that male newborn circumcision is associated with a decreased risk of penile cancer. Circumcision removes the foreskin of the penis, exposing the head. Many risk factors related to penile cancer are likely related to having a foreskin^[1][13].
• Good hygiene: Maintaining good genital hygiene can help reduce risk. Addressing phimosis through medical treatment and maintaining good genital hygiene can help reduce this risk^[3].
• Quit smoking: Smoking is a major risk factor in penile cancer. Quitting reduces cancer risk, eliminates exposure to carcinogens, improves blood circulation, enhances immune function and overall health, and lowers inflammation^[22].
• Healthy lifestyle: Maintaining a healthy weight, eating a balanced diet rich in fruits and vegetables, staying hydrated and exercising regularly can all support overall health and may help reduce cancer risk^[22].
• Regular check-ups: Routine medical check-ups help detect early signs of potential health problems. Early detection of infections or abnormal growths can prevent the need for more extensive treatment^[22].