Uro-Oncology - Penile Cancer

What is penile cancer?

The penis is the male sex organ involved in both the urinary and reproductive systems in the body. The penis consists of several parts — the head of the penis (glans), shaft, foreskin, and frenulum.

Penile cancer is a condition where cancerous cells grow and divide in an uncontrolled manner. It can develop anywhere on the penis but is most commonly found under the foreskin or the head of the penis. Although it is a rare type of cancer, incidences have increased in some countries due to shifts in sexual practices.

What are the symptoms of penile cancer?

Penile cancer may produce the following symptoms:

Growth or sore on the penis that does not heal within 4 weeks
Bleeding from the penis
Foul-smelling discharge
Rashes
Sudden inability to pull back the foreskin
Change in colour of the foreskin

These symptoms are not diagnostic of penile cancer. It is essential to note some of these symptoms may indicate other medical conditions, such as sexually transmitted diseases or non-cancerous growths. Do visit a doctor to discuss the symptoms you are experiencing for further evaluation.

What are the stages of penile cancer?

The stage of penile cancer describes the size of the cancer and whether it has spread to other parts of the body. It also takes into account the grade of the cancer, with high-grade being more aggressive than low-grade cancers. In general, penile cancer is categorised into several stages:

Stage 0 — Carcinoma-in-situ, this stage describes abnormal cells that are found only on the superficial surface of the penis and have not invaded deeper tissues. It can also denote non-invasive verrucous carcinoma, a subtype of cancer that is not associated with destructive invasion.
Stage 1 — the cancer cells have invaded the connective tissue just underneath the skin of the penis but have not invaded the blood or lymph vessels. The cancer is not high-grade.
Stage 2 — the cancer cells have spread to the tissue under the skin of the penis and into the blood or lymph vessels, and/or the cancer is high-grade. The cancer may have also invaded the corpus spongiosum (lower chamber of the shaft of the penis) and/or the corpus cavernosum (the part of the penis responsible for erection).
Stage 3 — the cancer cells have invaded one or more lymph nodes in the groin (also known as inguinal lymph nodes).
Stage 4 — the cancer cells from the penis have spread to nearby tissues such as the scrotum, prostate, pubic bone, or to the lymph nodes in the groin or pelvis. It also describes cancer cells that have spread to other parts of the body, such as the lung, liver, or bone (distant metastasis).

What causes penile cancer?

The exact causes of penile cancer are not fully understood, but there are several risk factors that are known to increase the risk of penile cancer.

1. Human Papillomavirus (HPV)

HPV is a common viral infection that spreads via skin-to-skin contact and usually during sexual activities. Majority of the HPV infections do not cause harm, and most people recover without treatment. However, in rare cases, some men with HPV infections, specifically HPV 16 and 18, may develop penile cancer. Around 60% of penile cancer cases are caused by HPV infections.

2. Age

Penile cancer is more common in men aged 60 years and older.

3. Uncircumcised Men

Circumcision is the process of removing a small part or all of the foreskin of the penis. Uncircumcised men may sometimes develop phimosis — a condition where the foreskin cannot be retracted. Men with phimosis have an increased risk of penile cancer. The reason for this correlation is unclear, but the build-up of secretions and dead skin cells under the tight foreskin may lead to inflammation of the penis. Circumcision performed as an infant or young child reduces the risk of future penile cancer. This preventative effect is not seen if circumcision is performed as an adult.

4. Smoking

Smoking is the most important modifiable lifestyle factor that increases the risk of penile cancer fivefold. Harmful substances in cigarettes can cause damage to cells and make it harder for cells to repair these damages. Over time, the build-up of these damaged and mutated cells in the penis may lead to the development of penile cancer.

5. UV Light

Ultraviolet light for the treatment of dermatological conditions such as psoriasis. Men with a skin disease called psoriasis may be treated with ultraviolet light and medications called Sporalene. This treatment has been associated with a higher risk of penile cancer, and men being treated now have their genitals covered during treatment.

6. Multiple Sexual Partners

Multiple sexual partners, early age or first sexual intercourse practices may increase the risk of sexually transmitted diseases such as HPV or human immunodeficiency virus (HIV), which are risk factors for the development of penile cancers.

How is penile cancer diagnosed?

How to prepare for your first consultation

During your first consultation with the doctor, you will be asked to describe your symptoms and also regarding your medical history. The doctor may perform a physical examination to take a closer look at your genital and groin area for possible signs of penile cancer. If penile cancer is suspected, you may be requested to undergo further testing, such as a biopsy and imaging tests to confirm the diagnosis.

Penile biopsy — A small sample of tissue can be taken from the affected area of the penis to check for cancer.
Imaging tests — Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Positron Emission Tomography (PET), and ultrasound scans are imaging tests that provide more details on the location and size of the cancer.

Is there a blood test to diagnose penile cancer?

There is no specific blood test that can help to diagnose penile cancer. However, blood tests may still be helpful in assessing a person’s general health to rule out any other medical conditions that may display similar symptoms. Tests may be ordered by your doctor to check for the presence of cancer and whether the cancer cells have spread from the penis to the rest of the body.

How is penile cancer treated?

Generally, the treatment for penile cancer is highly dependent on the stage, type, and grade of the cancer, as well as the general health of the patient. The aims of treatment are complete tumour removal with as much penile length preservation as possible without compromising cancer outcomes. The main treatment options for penile cancer may include surgery, laser therapy, radiotherapy and chemotherapy alone or in combination and largely determined by the stage of the cancer.

Surgical options include

Circumcision — For penile carcinoma in-situ localised only to the foreskin, a minor procedure can be done to remove the affected foreskin of the penis. Circumcision may be required when topical chemotherapy drugs are used for non-invasive penile cancers.
Glans resurfacing surgery — It is a surgical option for penile cancer localised to the top layers of the glans of the penis. This condition may also be called penile intraepithelial neoplasia or carcinoma in-situ. This procedure involves the removal of the top layers of tissue from the glans of the penis.
Partial and total glansectomy — This procedure is considered for localised penile cancer located at the glans of the penis. This refers to the tissue at the end of the penis, usually under the foreskin. The glans can be removed partly (partial glansectomy) or completely (total glansectomy), depending on how far it has spread.
Inguinal lymph node dissection — As the name suggests, this surgical procedure involves the removal of the lymph nodes from the groin area. This may be done to diagnose, treat and prevent the spread of cancer to the inguinal lymph nodes. Cancerous lymph nodes are removed and skin flaps may be necessary.
Partial and total penectomy — Surgery is usually the mainstay option for invasive penile cancer. Part of the penis may be removed (partial penectomy) or it may be removed completely (total penectomy). After a total penectomy, the urethra ( tube where urine flows) will be diverted to the perineum (area between the anus and scrotum) to allow passage of the urine in a seated position.

How do you urinate after a penectomy?

It depends on the length of the remaining penis. If the length is adequate, you can still urinate standing up. However, if a total penectomy is performed or the remaining shaft of the penis is too short, you may be required to sit down on the toilet. Passing urine will be done through an opening between your anus and scrotum.

Can you orgasm after penile cancer surgery?

This is entirely dependent on the type of surgery done. Treatment for early-stage cancer, such as circumcision and even a glansectomy or partial penectomy will still entail a fulfilling sex life and erections are still possible. However, sexual intercourse is not possible after a total penectomy or extensive partial penectomy, although your organsm and ejaculatory functions are usually preserved.

Bladder Augmentation

The main aims of bladder augmentation are to increase bladder capacity and reduce bladder muscle overactivity and pressure to protect the upper urinary tract. In this procedure, the bladder capacity is expanded by incorporating a segment of the intestines into the bladder. It is generally performed only after more conservative options have failed. Intermittent catheterisation may be necessary after this surgery.

Radiotherapy

Radiotherapy uses targeted high energy waves aimed at the penis to kill the cancer cells. Radiotherapy is an alternative treatment option to surgery for patients who do not want or are unable to have surgery. Radiotherapy can be used for early stage penile cancer less than 4cm in size. In general, when compared to surgery, the results after radiotherapy are slightly inferior. Radiotherapy can also be done after the surgery to kill off any remaining cancer cells.

External radiotherapy — External radiotherapy involves the delivery of radiation that is aimed at the cancer from a machine.
Internal radiotherapy — Internal radiotherapy or brachytherapy involves the delivery of radiation via radiotherapy tubes placed inside or on the penis. This form of therapy allows a high dose of radiation to be delivered to the cancer and very little to the surrounding tissues.

Chemotherapy

Chemotherapy uses cytotoxic drugs to kill cancer cells. It is given for stage 4 penile cancer. It may be performed with radiotherapy before the surgery to shrink the cancer. It may also be performed after surgery to kill off any remaining cancer cells. Chemotherapy is usually done intravenously through a drip into the arm or a large vein in the chest. One of the most common anti-cancer drugs used in penile cancer is cisplatin.

Is penile cancer curable?

The prognosis of penile cancer depends on several factors such as the stage, grade, location of the tumour, and whether the cancer cells have spread to the lymph nodes or other parts of the body.

In general, early detection and treatment will lead to better outcomes and a chance of full recovery. According to the statistics by the American Cancer Society, the 5-year survival rate for localised penile cancer is about 79%. However, if the cancer cells have spread to surrounding tissues, the 5-year survival rate drops to about 50%. Overall, penile cancer is highly curable in the early stages.

Summary

Penile cancer is a rare disease caused by a proliferation of cancer cells in the penis. Some common signs and symptoms to look out for that could indicate penile cancer include bleeding from the penis, sores, and abnormal discharge. Although the exact cause of this disease is still unclear, HPV is known to increase the risk of penile cancer.

If you experience the aforementioned symptoms, please visit a urologist for a proper diagnosis and treatment. Early detection is key to achieving the best outcomes for your condition.

Uro-Oncology - Penile Cancer