The penis
The penis is the male external sex organ.
It is also part of the urinary system. It is made up of different types of tissue such as skin, muscle, nerves and blood vessels. During sexual arousal, blood flows into the chambers of the penis and makes it hard and erect.
The penis also contains the urethra, a thin tube that carries urine from the bladder and semen from the testicles out of the body.
What is penile cancer?
Penile cancer is a rare type of cancer and occurs on the foreskin, the glans (head) of the penis, or on the skin of the penile shaft.
It occurs mostly in uncircumcised men (men who still have foreskin around the head of the penis).
Cancer is a disease of the cells. Normally, cells multiply and die in an orderly way, so that each new cell replaces one that has been lost. Sometimes, however, cells become abnormal and keep growing, forming a mass or lump called a tumour or a sore called an ulcer. Some of these are malignant (cancerous) and can grow and spread to other parts of the body.
But not all growths are cancerous. Sometimes growths can develop on the penis that are abnormal but are not malignant (these are called benign tumours). These lesions look like warts or irritated patches of the skin. These can be caused by the human papillomavirus (HPV). It is important to discuss any growths you might have on your penis with your doctor as they might increase your risk of penile cancer.
Types of penile cancer
There are several types of penile cancer, depending on the type of cell from which the cancer develops. Almost all penile cancers start in the surface layer of cells (called epithelium) of the penis.
- Squamous cell cancer (SCC) – the most common type of cancer of the penis. This cancer accounts for around 95% of cases and starts in the cells that cover the surface of the penis (squamous cell layer). Most of this type of cancer start on the foreskin (in men that have not been circumcised) or on the head of the penis (glans), but it can occur on the penile skin of the shaft as well.
- Carcinoma in situ (CIS), penile intraepithelial neoplasia (PeIN) – the earliest stage of squamous cell penile cancer where cancer cells are only found in the very top layer of the skin cells, and the cancer has not spread any deeper.
Other rarer types of penile cancer include:
basal cell carcinoma (BCC) – another type of skin cancer that can develop in deeper cells of the squamous cells in a layer of skin.
adenocarcinoma – a type of cancer that develops in the sweat glands in the skin of the penis.
melanoma of the penis – a type of cancer that develops in the pigmented skin cells that give the skin its colour.
penile sarcoma – a very rare type of cancer that develops in the deeper tissues of the penis such as the blood vessels, muscle, fat or connective tissue in the penis.
How common is penile cancer?
Penile cancer is rare with around 103 Australians diagnosed each year (this is about 0.8 cases per 100,000 people). It is more likely to be diagnosed in men over 50 years of age but can also occur in younger men.
What are the symptoms and the risk factors?
People with penile cancer may experience a range of different symptoms.
Having any of these symptoms does not mean a man has penile cancer but if you experience any of these symptoms you need to discuss them with your doctor.
Symptoms may include:
- a growth or sore on the head of the penis (the glans), the foreskin or on the shaft of the penis that doesn’t heal in a couple of weeks.
- bleeding from the penis or under the foreskin
- a smelly discharge under the foreskin
- a hard lump under the foreskin
- changes in the colour of the skin on the penis or foreskin
- thickening of the skin on the penis or foreskin that makes it difficult to pull back the foreskin
- pain in the shaft or tip of the penis
- swelling at the tip of the penis
- a rash on the penis or a persistent red patch of skin that does not go away
- lumps in the groin due to swollen lymph nodes.
What are the risk factors?
The cause of penile cancer is not known in most cases. However, there are several risk factors:
- Human papillomavirus (HPV) infection – This common group of viruses are spread through sexual contact. Some types of HPV increase the risk of certain cancers. Most people with HPV do not develop cancer but HPV infection is found in about half of all penile cancers. Some types of HPV can cause genital warts, which increase the risk of developing penile cancer.
- not being circumcised – Penile cancer is more common in men who are not circumcised. Circumcision is the surgical removal of the foreskin that covers the end of the penis. This procedure is commonly performed on newborn boys for medical, cultural and religious and reasons. Men who have a tight foreskin that is hard to pull back (phimosis) for washing sometimes notice a secretion under the foreskin that becomes a smelly substance (smegma). While smegma doesn’t necessarily cause penile cancer, it can irritate and inflame the penis, which can increase the risk of cancer.
- smoking – Chemicals found in cigarettes and other forms of tobacco can damage cells in the body, including cells in the penis, which can increase your risk of developing penile cancer.
- age – The risk of penile cancer increases with age and is more common in men over 50 years of age.
certain skin conditions – Men who have skin conditions such as psoriasis or lichen sclerosus may have a higher rate of penile cancer. - HIV/AIDS – Infection with the human immunodeficiency virus (HIV) causes acquired immune deficiency syndrome (AIDS) and men who contract HIV have a greater risk of developing penile cancer as their immune system is less able to fight off cancer.
- premalignant lesions/conditions – If left untreated, these can become cancerous.
- exposure to ultraviolet (UV) radiation – From either sunlight or UV lamps.
How is penile cancer diagnosed?
If your doctor thinks that you may have penile cancer, they will talk to you about your medical history, perform a physical examination and suggest that you have certain tests.
If the results of these tests suggest that you may have penile cancer, your doctor will refer you to a specialist called a urologist for further tests. These tests may include:
Blood tests
Blood tests may include a full blood count (to measure your white blood cells, red blood cells and platelets), tumour markers (to measure chemicals produced by cancer cells) and to check if you have an infection.
Biopsy
A biopsy is the removal of some tissue from the affected area or region for examination under a microscope. In penile cancer, the following biopsies may be used:
- a punch biopsy or elliptical excision of the affected region to remove tissue. This procedure is generally performed under a local anaesthetic.
- a fine needle aspiration biopsy where a local anaesthetic is used to numb the area then a thin needle is inserted into the tumour or lymph node under ultrasound or CT guidance.
- a sentinel lymph node biopsy (under local anaesthetic) to see if cancer cells have spread to lymph nodes near the penis
- removal of the lymph nodes from one or both sides of the groin to see if the cancer has spread. This operation is performed under a general anaesthetic and the nodes are removed through small cuts in the groin.
Ultrasound scan
Uses high-frequency soundwaves are used to create pictures of the inside of your body. For this scan, you will lie down, and a gel will be spread over the affected part of your body. A small device called a transducer is moved over the area by an ultrasound radiographer.
The transducer sends out soundwaves that echo when they encounter something dense, like an organ or tumour. The ultrasound images are then projected onto a computer screen. An ultrasound is painless and takes about 15–20 minutes.
CT (computerised tomography) or MRI (magnetic resonance imaging) scans
Special machines are used to scan and create pictures of the inside of your body. Before the scan you may have an injection of dye (called contrast) into one of your veins, which makes the pictures clearer. During the scan, you will need to lie still on an examination table.
For a CT scan the table moves in and out of the scanner which is large and round like a doughnut; the scan itself takes about 10 minutes.
For an MRI scan the table slides into a large metal tube that is open at both ends; the scan takes a little longer, about 30–90 minutes to perform. Both scans are painless. With an MRI, you may need an injection into the penis with a drug to make it erect. This makes it easier to find a cancer in the penis.
PET (positron emission tomography) – CT scan
A PET scan is combined with a CT scan, and you are injected in your arm with a glucose solution containing some radioactive material. Cancer cells show up brighter on the scan because they absorb more glucose than normal cells do.
Finding a specialist
Rare Cancers Australia have a directory of health professionals and cancer services across Australia.
Grading and staging of penile cancer
If cancer cells are found during any of your tests, your doctor will need to know the tumour grade and stage so your team of health professionals can develop the best treatment plan for you.
The grade of the cancer lets your doctor know how quickly the cancer might grow and spread while the stage of the cancer describes its size and whether it has spread.
Grading
Penile cancer is graded from 1 to 3 with 1 being the lowest grade and 3 being the highest grade. Low-grade means that the cancer cells are slow growing and less likely to spread. High-grade means that the cancer cells grow more quickly and are more likely to spread.
Staging
Staging describes where the cancer is and how far the cancer has spread. Knowing the stage helps doctors plan the best treatment for you. There are several staging systems for penile cancer, but the one most commonly used is the TNM staging system.
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T (tumour) |
describes the size and extent of the main tumour. Refers to if the cancer is in situ or penile intraepithelial neoplasia (Tis) and in only the top layer of skin; is like a wart (Ta) but only in the top layer of skin; has grown into tissue just below the top layer of skin but not any further (T1a); has grown into blood vessels, lymph vessels or nerves in the layers of the penis (T1b); has spread into the spongy tissue of the penis and/or the urethra (T2); has grown more deeply into the penis and/or urethra (T3); has spread further into the penis, urethra or scrotum (T4) |
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N (nodes) |
describes if cancer has spread to nearby lymph nodes. No spread (N0) or spread to one or more lymph nodes (N1, N2, N3) |
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M (metastasis) |
describes if cancer has spread to other parts of the body. No spread (M0) or spread to other organs or bones (M1) |
Treatment for penile cancer
You will be cared for by a multi-disciplinary team of health professionals during your treatment for penile cancer.
The team may include a urologist, a surgeon, a radiation oncologist (to prescribe and coordinate a course of radiation therapy), a medical oncologist (to prescribe and coordinate a course of systemic therapy which includes chemotherapy), a radiologist, specialist nurses and allied health professionals such as a dietitian, social worker, psychologist, physiotherapist and occupational therapist.
Discussion with your doctor will help you decide on the best treatment for your cancer depending on the type of penile cancer you have, if the cancer has spread, your age and general health. The main treatments for penile cancer include surgery, radiation therapy and chemotherapy. These can be given alone or in combination.
Many people may have concerns about how the treatment could affect their sexuality and fertility. It is important to discuss these issues with your doctor before treatment begins.
Surgery
Surgery is the main treatment for penile cancer. A surgeon will remove the tumour as well as some surrounding healthy tissue, called a margin. The extent and type of surgery depends on the location and the grade and stage of the tumour. Your surgeon will discuss the type of operation you may need. In most cases, any physical changes to your penis after an operation can be corrected with reconstructive surgery.
Surgical procedures
Circumcision – Used when cancer is only on the foreskin. The foreskin of the penis is surgically removed.
Simple excision – The affected area of the penis and a small margin are removed surgically. If the tumour is small, the skin can be stitched back together.
Wide local excision – The tumour is removed along with a larger amount of normal tissue. If there is not enough skin left to cover the area, skin may be taken from another part of the body (a skin graft) to cover it.
Glans resurfacing – Used when the cancer is in situ and in only the top layer of skin. The surface tissue from the glans or head of the penis is removed. A skin graft may be needed to replace tissue removed.
Partial or total glansectomy – Removal of part or all of the head of the penis (the glans). The amount of tissue removed will depend on the extent of the cancer.
Partial or total penectomy – Removal of part or all of the penis and reconstruction of the urethra. In a total penectomy, the urethra is passed through to the perineum.
Lymph node surgery – You may need nearby lymph nodes in the groin to be removed to check for the spread of cancer. This may be done during penile surgery or at a separate time. There are four types of lymph node surgical procedures all of which need to be performed by a urologist:
- Dynamic sentinel lymph node biopsy to see if cancer cells have spread to lymph nodes near the penis. If positive, further surgery (dissection) is needed to remove more lymph nodes.
- Modified inguinal node dissection where some, but not all the lymph nodes in the groin, are removed. If positive, a full dissection will be performed.
- Radical inguinal node dissection. If lymph nodes in the groin are involved, all the nodes in this area will be removed.
- Pelvic lymph node dissection. If nodes are involved or a high risk of being involved, the pelvic lymph nodes will also be removed.
Other treatments for penile cancer
Some early-stage, low-grade penile cancers, especially carcinoma in situ (where the cancer is only in the top layers of skin), can be treated with techniques other than surgery. These include laser treatment, cryotherapy, radiation therapy and topical therapy. These treatments are called penile sparing techniques and cause the least damage to the penis. Discuss your options with your doctor.
Laser treatment
If the cancer is very small and only on the surface of the penis, laser therapy may be used to kill cancer cells. Laser therapy uses powerful beams of light to destroy the cancer cells and can be used for tumours with lower staging instead of surgery.
Photodynamic therapy (PDT)
Photodynamic therapy uses special drugs, called photosensitising agents, along with light to kill cancer cells. The drugs only work after they have been activated or turned on by the light. In penile cancer the drugs are put on the skin and after a period of time, light is applied to the area. The procedure is usually painless and less invasive than surgery.
Cryosurgery
Cryosurgery uses liquid nitrogen to freeze and kill the cancer cells. The procedure may sting and cause slight discomfort. The treated skin will blister and peel over following days and may leave a scar. Sometimes several treatments are needed.
Radiation therapy
Radiation therapy (also known as radiotherapy) uses high energy x-rays to destroy cancer cells. The radiation comes from a machine outside the body. It may be used for penile cancer:
- to treat smaller penile cancers instead of surgery
- after surgery, to destroy any remaining cancer cells and stop the cancer coming back
- if the cancer cannot be removed with surgery
- at the same time as chemotherapy to help shrink the tumour before surgery to make it easier to remove with less damage to the penis
- if the cancer has spread to other parts of the body (e.g. palliative radiation for the management of pain).
There are two ways to have radiation therapy for penile cancer:
External beam radiation therapy
This is the most common way to have radiation therapy for penile cancer and uses carefully focused beams of radiation aimed at the tumour from a machine. A course of radiation therapy needs to be carefully planned. During your first consultation session you will meet with a radiation oncologist. At this session you will lie on an examination table and have a CT scan in the same position you will be placed in for treatment. The information from this session will be used by your specialist to work out the treatment area and how to deliver the right dose of radiation. Radiation therapists will then deliver the course of radiation therapy as set out in the treatment plan.
Men who are not circumcised will have their foreskin removed first before radiation therapy begins. This is to stop swelling and tightening of the foreskin during treatment which could lead to further problems.
Radiation therapy does not hurt and is usually given in small doses to minimise side effects five days a week for a period of about six weeks. Each treatment only lasts a few minutes but there is also setting-up time. A plastic block or mould is used to hold the penis in the exact same position for each treatment and shields may be used to protect your groin and testicles.
Brachytherapy
Brachytherapy, also known as internal radiation, involves placing radioactive material inside your body either directly into the tumour or next to the tumour. It allows doctors to deliver higher doses of radiation to more specific areas of the body and usually has fewer side effects than external beam radiation.
Chemotherapy
Chemotherapy (sometimes just called “chemo”) is the use of drugs to kill or slow the growth of cancer cells. You may have one chemotherapy drug, or a combination of drugs. This is because different drugs can destroy or shrink cancer cells in different ways.
Your treatment will depend on your situation and stage of the tumour. Your medical oncologist will discuss your options with you.
Chemotherapy is usually given through a drip into a vein (intravenously) or as a tablet that is swallowed. Sometimes for low grade carcinoma in situ cancers, a cream can be applied topically.
Chemotherapy is commonly given in treatment cycles which may be daily, weekly or monthly. For example, one cycle may last three weeks where you have the drug over a few hours, followed by a rest period before starting another cycle. The length of the cycle and number of cycles depends on the chemotherapy drugs being given.
Topical chemotherapy
For low grade carcinoma in situ, lower doses of chemotherapy can be used on the skin in the form of a cream. The cream is applied often twice a day for several weeks to the affected area on the penis and does not cause the side effects people often have with intravenous or tablet chemotherapy. Circumcision is recommended before starting treatment. There is a slight risk of recurrence with this treatment so you must have regular follow-up appointments with your doctor.
Clinical trials
Your doctor or nurse may suggest you take part in a clinical trial. Doctors run clinical trials to test new or modified treatments and ways of diagnosing disease to see if they are better than current methods. For example, if you join a randomised trial for a new treatment, you will be chosen at random to receive either the best existing treatment or the modified new treatment. Over the years, trials have improved treatments and led to better outcomes for people diagnosed with cancer.
You may find it helpful to talk to your specialist, clinical trials nurse or GP, or to get a second opinion. If you decide to take part in a clinical trial, you can withdraw at any time.
For more information, visit Australian Cancer Trials.
Download our booklet ‘Understanding Clinical Trials and Research’
Complementary therapies and integrative oncology
Complementary therapies are designed to be used alongside conventional medical treatments (such as surgery, chemotherapy and radiation therapy) and can increase your sense of control, decrease stress and anxiety, and improve your mood.
Some Australian cancer centres have developed “integrative oncology” services where evidence-based complementary therapies are combined with conventional treatments to create patient-centred cancer care that aims to improve both wellbeing and clinical outcomes.
Let your doctor know about any therapies you are using or thinking about trying, as some may not be safe or evidence-based.
Some complementary therapies and their clinically proven benefits are listed below:
acupuncture – reduces chemotherapy-induced nausea and vomiting; improves quality of life
aromatherapy – improves sleep and quality of life
art therapy, music therapy – reduce anxiety and stress; manage fatigue; aid expression of feelings
counselling, support groups – help reduce distress, anxiety and depression; improve quality of life
hypnotherapy – reduces pain, anxiety, nausea and vomiting
massage – improves quality of life; reduces anxiety, depression, pain and nausea
meditation, relaxation, mindfulness – reduce stress and anxiety; improve coping and quality of life
qi gong – reduces anxiety and fatigue; improves quality of life
spiritual practices – help reduce stress; instil peace; improve ability to manage challenges
tai chi – reduces anxiety and stress; improves strength, flexibility and quality of life
yoga – reduces anxiety and stress; improves general wellbeing and quality of life.
Let your doctor know about any therapies you are using or thinking about trying, as some may not be safe or evidence-based.
Download our booklet ‘Understanding Complementary Therapies’
Alternative therapies are therapies used instead of conventional medical treatments. These are unlikely to be scientifically tested and may prevent successful treatment of the cancer. Cancer Council does not recommend the use of alternative therapies as a cancer treatment.
Nutrition and exercise
If you have been diagnosed with penile cancer, both the cancer and treatment will place extra demands on your body. Research suggests that eating well and exercising can benefit people during and after cancer treatment.
Eating well and being physically active can help you cope with some of the common side effects of cancer treatment, speed up recovery and improve quality of life by giving you more energy, keeping your muscles strong, helping you maintain a healthy weight and boosting your mood.
You can discuss individual nutrition and exercise plans with health professionals such as dietitians, exercise physiologists and physiotherapists.
Download our booklet ‘Nutrition for People Living with Cancer’
Download our booklet ‘Exercise for People Living with Cancer’
Side effects of treatment
All treatments can have side effects. The type of side effects that you may have will depend on the type of treatment and where in your body the cancer is. Some people have very few side effects and others have more. Your specialist team will discuss all possible side effects, both short and long-term (including those that have a late effect and may not start immediately), with you before your treatment begins.
One issue that is important to discuss before you undergo treatment is fertility, particularly if you want to have children in the future.
Download our booklet ‘Fertility and Cancer’
Penile cancer and its treatment can sometimes lead to long-term, life-changing side effects. Your doctors will try to use penile-sparing treatments where possible but in some cases, this is not an option. Most men will still be continent (able to control urine flow) after surgery but if the surgery has removed part or all of the penis, how you urinate may change. If your urethra was reconstructed, you may have to sit down to urinate.
Common side effects may include:
Surgery – Erectile dysfunction, pain, discomfort, altered appearance, bleeding, trouble urinating, swelling, itching, lymphoedema if lymph nodes have been removed.
Radiation therapy – Scar tissue formation in the penis and urethra may cause problems urinating, sexual problems, fatigue, nausea and vomiting, skin reaction, loss of fertility, lymphoedema, slight risk of developing other cancers in the future.
Chemotherapy – Fatigue, loss of appetite, nausea and vomiting, bowel issues such as diarrhoea, hair loss, mouth sores, skin and nail problems, increased chance of infections, loss of fertility.
Having penile cancer treatment can affect your self-image and also your ability to have sex. Changes to how your penis looks can cause decreased interest in sex as well as embarrassment. Some men may worry that they won’t be able to satisfy their partner. Sometimes depression and anxiety can make you want to avoid sex. You and your partner, if you have one, may wish to have counselling to help understand the impact the treatment has had on your sexuality and explore other ways of enjoying intimacy and sexual satisfaction. Ask your GP for a referral.
After a partial penectomy, the remaining part of the penis can still become erect with arousal and penetration may be possible. Intercourse, however, is not possible after a total penectomy. But sexual pleasure is still possible after a total penectomy so it’s important to talk to a counsellor, sex therapist or psychologist who can give you support and advice.
Surgical reconstruction of the penis might be possible after a total penectomy. Talk to your doctor to see if this might be an option for you.
Download our booklet ‘Sexuality, Intimacy and Cancer’Sexuality Intimacy and Cancer Booklet
Life after treatment
Once your treatment has finished, you will have regular check-ups to confirm that the cancer hasn’t come back.
Ongoing surveillance for penile cancer involves a schedule of ongoing tests, scans and physical examinations. Let your doctor know immediately of any health problems between visits.
Some cancer centres work with patients to develop a “survivorship care plan” which usually includes a summary of your treatment, sets out a clear schedule for follow-up care, lists any symptoms to watch out for and possible long-term side effects, identifies any medical or emotional problems that may develop and suggests ways to adopt a healthy lifestyle going forward. Maintaining a healthy body weight, eating well and being physically active are all important.
If you don’t have a care plan, ask your specialist for a written summary of your cancer and treatment and make sure a copy is given to your GP and other health care providers.
What if the cancer returns?
For some people, penile cancer does come back after treatment, which is known as a recurrence. If the cancer does come back, treatment will depend on where the cancer has returned in your body and may include a mix of surgery, radiation therapy and chemotherapy.
In some cases of advanced cancer, treatment will focus on managing any symptoms, such as pain, and improving your quality of life without trying to cure the disease. This is called palliative treatment.
Palliative care involves health professionals from a range of disciplines caring for your physical, practical, emotional and spiritual needs. Palliative care can be provided in your home, in a hospital, in a palliative care unit or hospice, or in a residential aged care facility. Services vary because palliative care is different in each state and territory. Speak to your GP, community nurse or cancer specialist about the palliative care services appropriate for you.
When cancer is no longer responding to active treatment, it can be difficult to think about how and where you want to be cared for towards the end of life. But it’s essential to talk about what you want with your family and health professionals, so they know what is important to you. Your palliative care team can support you in having these conversations.
Dealing with feelings of sadness
If you have continued feelings of sadness, have trouble getting up in the morning or have lost motivation to do things that previously gave you pleasure, you may be experiencing depression. This is quite common among people who have had cancer.
Talk to your GP, as counselling or medication—even for a short time—may help. Some people are able to get a Medicare rebate for sessions with a psychologist. Ask your doctor if you are eligible. Cancer Council SA operates a free cancer counselling program. Call Cancer Council 13 11 20 for more information.
For information about coping with depression and anxiety, visit Beyond Blue or call them on 1300 22 4636. For 24-hour crisis support, visit Lifeline or call 13 11 14.
