Makindo Medical Notes

Penile cancer is a rare malignancy (≈1 per 100,000 men in Western countries) that usually arises on the glans or foreskin. It is strongly linked with HPV infection, poor genital hygiene, smoking, and chronic inflammation (e.g. phimosis). Early detection is crucial, as prognosis depends heavily on stage at presentation.

About

• ⚠️ Rare cancer, but potentially aggressive if diagnosed late.
• Most common in men aged >50 years; incidence higher in developing countries where circumcision is less common.
• Often presents late due to stigma, embarrassment, or lack of awareness.

Pathology

• Squamous cell carcinoma (SCC): >95% of cases; usually arises on the glans or prepuce.
• Basal cell carcinoma: Very rare; slow-growing, less aggressive.
• Melanoma: Extremely rare but highly aggressive.
• Adenocarcinoma: Rare; usually from sweat glands of the penile skin.
• Verrucous carcinoma: A low-grade, warty variant of SCC with local invasion but minimal metastatic risk.

Risk Factors

• 🦠 HPV infection – especially types 16 and 18.
• 🧼 Poor genital hygiene – accumulation of smegma in uncircumcised men increases chronic irritation.
• 🚬 Smoking – contributes carcinogens directly to genital mucosa.
• 🔄 Phimosis – foreskin that cannot retract leads to chronic inflammation.
• 📅 Age: Incidence rises with age; most cases occur after 50.
• Immunosuppression (HIV, transplant patients).

Clinical Presentation

• 🌱 Lesion on penis – may be a growth, ulcer, or wart-like mass (usually on glans/foreskin).
• 💉 Bleeding/ulceration – common with more advanced lesions.
• 😷 Foul discharge under foreskin, sometimes malodorous.
• 🎨 Skin colour/texture change – thickening, erythema, or pigmentation change.
• ⚡ Pain – usually a late symptom.
• 🧩 Lymph nodes: Inguinal node enlargement may indicate metastasis.

Investigations

• Bloods: FBC, U&E, LFTs, calcium.
• Biopsy: Essential for diagnosis (incisional or excisional depending on size).
• Imaging for staging:
  • USS/MRI penis and groin to assess depth of invasion and nodal status.
  • CT thorax/abdomen/pelvis for metastasis if advanced.

Management

• Early/localised disease:
  • Topical therapy (imiquimod, 5-FU) or laser ablation for very superficial lesions.
  • Wide local excision with circumcision if foreskin involved.
• Invasive disease:
  • Partial or total penectomy depending on tumour extent.
  • Inguinal lymphadenectomy if nodes are clinically involved or high-risk primary tumour.
• Radiotherapy: Option for organ preservation in some early/intermediate cases or palliation.
• Chemotherapy: For advanced/metastatic disease (cisplatin-based regimens).

Staging (TNM simplified)

• T1: Subepithelial connective tissue only.
• T2: Invades corpus spongiosum/cavernosum.
• T3: Urethral or prostate involvement.
• T4: Invades adjacent structures (scrotum, pubis, etc).

Prognosis depends on stage and nodal status – 5-year survival >80% in node-negative disease but <30% with bulky nodal metastases.

References

• NICE CKS – Penile cancer
• EAU Guidelines on Penile Cancer (2023)