What Is Penile Cancer?

Rare Cancer Closely Linked to Human Papillomavirus (HPV)

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Penile cancer is a rare cancer that develops in the skin or tissues of the penis. It is closely linked to the human papillomavirus (HPV) and can often start with a lesion on the foreskin, head, or shaft of the penis that turns wart-like and oozes blood or foul-smelling fluid. Surgery, radiation, and chemotherapy are commonly used to treat penile cancer.

When diagnosed and treated early, penile cancer has a five-year survival rate of over 80%.

Male patient and doctor in discussion in exam room
Thomas Barwick / Getty Images

Types of Penile Cancer

About 95% of penile cancers are squamous cell carcinomas. This is the type that forms on the surface of the skin and the lining of hollow organs from cells known as keratinocytes. These cells secrete keratin, a fibrous protein that makes up skin, hair, and nails.

Less common types of penile cancer are basal cell carcinoma, melanoma, Merkel cell carcinoma, and small-cell carcinoma.

Penile Cancer Symptoms

As the predominant type of penile cancer, squamous cell carcinoma of the penis manifests in much the same way as it would on other areas of the skin.

Early Stages

In the early precancerous stage, referred to as carcinoma in situ, penile cancer may present in one of three different ways:

  • Bowen's disease: Characterized by white, scaly patches on the skin that do not rub off (leukoplakia), typically on the shaft of the penis
  • Erythroplasia of Queyrat: Persistent redness, irritation, crusting, or scaling, most commonly on the head of the penis (glans) or foreskin (prepuce)
  • Bowenoid papulosis: Similar to Bowen's disease but with red blister-like bumps (papules)

Erytroplasia of Queyrat is the most common manifestation of penile carcinoma in situ.

Later Stages

As the malignancy progresses, it can manifest in different ways. There may be a notable thickening of the glans or prepuce accompanied by the formation of an ulcerative lesion. Alternately, the irritation and papillary growth on the shaft may start to ulcerate and grow outward like a wart.

Over time, the lesion can spread laterally across the skin, covering large parts of the glans, prepuce, or shaft. Bleeding and the seepage of foul-smelling fluid are common.

In addition to lesions, people with penile cancer will often experience dysuria (pain or burning with urination) and swelling of the inguinal lymph nodes of the groin.

Causes

There are a number of factors that can increase a person's likelihood of developing penile cancer. Among them:

  • Human papillomavirus (HPV): The virus, closely linked to genital warts, cervical cancer, and anal cancer, is spread by sexual contact. HPV accounts for 45% to 85% of all penile cancer cases, mainly involving HPV types 6, 16, and 18.
  • HIV coinfection: Having HIV and HPV increases a person's risk of penile cancer by eight-fold.
  • Penile inflammation: Inflammation of the glans and inner prepuce (balanitis) is associated with a 3.8-fold increased risk of penile cancer. Poor hygiene is a common cause, as are allergic reactions to soap and diabetes.
  • Lack of circumcision: The inability to properly retract the foreskin (phimosis) can lead to a persistent inflammatory response and increase the risk of penile cancer by anywhere from 25% to 60%.
  • Cigarette smoking: Smoking independently increases the risk of invasive penile cancer by 450%. Persistent inflammation triggered by smoking is believed to be the cause, the risk of which increases in tandem with the number of pack-years you have smoked.
  • Older age: Penile cancer is rarely seen in people under 55.

Penile cancer is considered rare in North America and Europe, accounting for less than 1% of all cancers in men. Around 2,000 cases are diagnosed in the United States each year, while around 450 people die annually as a result of the malignancy.

Diagnosis

The diagnosis of penile cancer typically starts with a physical exam and a review of your medical history and risk factors for the disease. Because penile cancer typically manifests with visible lesions, the workup is more straightforward than with other types of cancer and generally starts with evaluating tissue samples.

Biopsy

If penile cancer is suspected, a tissue biopsy will be ordered by your healthcare provider. This may involve an excisional biopsy in which the entire lesion is removed or an incisional biopsy in which only a portion of the lesion is removed.

The procedure, performed under local anesthesia or with a numbing agent, only takes a few minutes and is typically done in a hospital or outpatient surgical center.

In addition to the lesion, the healthcare provider may also biopsy nearby inguinal lymph nodes to see if there are cancer cells in them. This may be done with minimally invasive fine-needle aspiration (FNA) or surgery to remove one or more lymph nodes. Computed tomography (CT) scans are often used to guide the procedure and locate lymph nodes in deeper tissue.

The samples are then sent to the lab for evaluation under the microscope, typically using immunostains to diagnose and classify HPV-associated penile cancer.

Staging

If cancer is confirmed, other tests will be ordered that determine the extent and severity of the malignancy. This may include imaging tests like ultrasound or magnetic resonance imaging (MRI) to see if and how deeply cancer has invaded tissues inside the penis and surrounding organs.

These tests aim to stage the disease. Staging is a system used to establish how advanced the disease is, the determination of which helps direct the course of treatment and predict the likely outcome (prognosis).

As with many other forms of cancer, penile cancer is staged used the TNM classification system, which looks at three specific factors:

  • T: The size and extent of the main (primary) tumor
  • N: The number of nearby lymph nodes that have cancer
  • M: Whether cancer has spread (metastasized) from the primary tumor or not

Based on these values (and other factors such as the grade of the tumor), the lab can stage the disease on a scale of 0 to 4. There are also various substages that help healthcare providers choose the most appropriate treatment options.

Stage Stage Description
0is The tumor is classified as carcinoma in situ and has not grown into tissue beneath the top layer of skin. It is also called penile intraepithelial neoplasia.
0a This is squamous cell carcinoma that is noninvasive, found on the surface of the penile skin or underneath the surface of the foreskin.
I The tumor has grown into tissue just beneath the top layer of skin but does not involve nearby lymph nodes, lymph vessels, blood vessels, or nerves.
IIa The tumor has grown into tissue just below the top layer of skin or nearby structures (blood or lymph vessels or nerves) and/or is high grade (i.e., more likely to spread). But it has not spread into lymph nodes or other places in the body. Or, this stage of tumor may have grown into the corpus spongiosum (an internal chamber that contains the urethra).
IIb The tumor has grown into one of the internal chambers of the corpus cavernosum (an internal chamber that underlies the top of the penile shaft) but has not spread to lymph nodes or elsewhere.
IIIa The cancer involves the penis as well as one or two inguinal lymph nodes. The tumor may have grown into the corpus cavernosum, corpus spongiosum, urethra, or nearby blood vessels. 
IIIb The same as stage 3a but with the involvement of three or more lymph nodes or lymph nodes on both sides of the groin.
IV The tumor invades adjacent structures near the penis or has metastasized. The tumor may have spread to the nearby prostate gland or scrotum, to lymph nodes on one or both sides of the pelvis, or to distant organs (such as the liver, lungs, or bones) along with lymph node involvement.

Treatment

The treatment of penile cancer is largely informed by the stage of the disease. Surgery remains the main form of treatment and, unlike other forms of cancer, is frequently used in people with stage 4 disease. In stages 1 to 3, cancer remission is the primary aim.

Surgery

The aim of surgery is to ensure the removal of all affected tissues while avoiding the partial or complete amputation of the penis (penectomy), if possible.

Based on the extent of the tumor, this may involve:

  • Wide local recision: This involves removing the tumor with a margin of healthy surrounding tissue, often with the use of wedge resection.
  • Laser ablation and excision: Lasers are used to burn away (ablate) and remove (excise) tissue, typically for a smaller stage 1 tumor or carcinoma in situ.
  • Microsurgery: This is a form of surgery performed under the microscope to leave as much healthy tissue as possible.
  • Partial penectomy: This is the surgical removal of the glans and prepuce.
  • Circumcision: This may be used on its own if the malignancy is limited to the prepuce or with a partial penectomy.

The size and location of the tumor will determine the extent of the surgery. Most experts recommend the removal of 5 millimeters of surrounding healthy tissue (referred to as the margin) while allowing for the removal of as little as 2 millimeters in some cases.

The surgical removal of nearby lymph nodes (lymphadenectomy) may also be performed, but not always. In people with a low-risk tumor and nonpalpable lymph nodes, some experts endorse a watch-and-wait approach.

Radiation and Chemotherapy

The use of radiation and chemotherapy varies by the stage of the disease.

Radiation therapy may sometimes be used to treat stage 1 and 2 tumors, particularly in people who cannot withstand surgery. In other stages, radiation may be used before surgery to reduce the size of the tumor (neoadjuvant radiation) or afterward to clear any remaining cancer cells (adjuvant radiation).

Radiation is also used as a form of palliative care in people with stage 4 cancer to keep the cancer in check, reduce symptoms, and improve the quality of life.

Chemotherapy is most commonly used as a form of neoadjuvant therapy in people with stage 3 penile cancer, either on its own or in combination with radiation. It may also be used if the cancer recurs in the lymph nodes or a distant part of the body.

Prognosis

Penile cancer is highly treatable if diagnosed in the early stages. The prognosis is based on a measure called the overall survival rate. This is the percentage of all people who have survived for a specific period of time after their diagnosis (typically measured in five-year increments) based on data collected by the National Cancer Institute (NCI).

By way of example, a five-year overall survival rate of 60% means that 60% of people with that disease have lived for at least five years. Some may live for far longer.

The NCI categorizes survival times by stages. But, rather than using the TNM system, the NCI describes the survival rate based on the following broad classifications:

  • Localized: The tumor has not spread beyond the primary tumor
  • Regional: Nearby tissues are affected
  • Distant: Metastasis has occurred

For penile cancer, the five-year overall survival rate is as follows:

Stage % Diagnoses 5-Year Survival Rate
Local 57% 82%
Regional 29% 50%
Distant 5% 12%
Unstaged 9% n/a
Overall 100% 65%

It is important to note the survival rates are based on all people with the disease, irrespective of age, cancer type, or health status. As such, the survival rate may be far better for some people and less so for others.

Prevention

There are steps you can take to reduce your risk of penile cancer by mitigating some of the risk factors linked to the disease. These include:

  • HPV vaccination: HPV vaccination is currently recommended for all children 11 to 12 to reduce the risk of HPV-associated cancers. The vaccine can be given to anyone up to age 26 who has not been adequately vaccinated. While it is approved for use up to age 45, the benefits tend to wane as most will have gotten HPV by their mid-20s.
  • Condoms: The consistent use of condoms during sex significantly reduces the risk of getting HPV.
  • Improved genital hygiene: Regularly retracting and cleaning the foreskin reduces local inflammation and the risk of phimosis.
  • Quitting cigarettes: Smoking cessation may not only reduce your risk of penile cancer but other cancer and conditions (like hypertension and heart disease) as well.

Coping

Coping with cancer of any sort can be difficult. With penile cancer, people often have the added fear of disfigurement and the loss of sex function—not to mention the possible loss of the penis itself.

If faced with a diagnosis of penile cancer, there are several things you can do to prepare yourself emotionally:

  • Education and advocacy: When diagnosed, learn as much as you can about the disease so that you can actively participate in treatment decisions and make informed choices. In addition to advocating for yourself, it helps to have someone advocate on your behalf so that you don't feel as if you're being forced into anything.
  • Support building: Accept the emotions you are feeling, but don't leave them bottled up. Seek support from friends or family members with whom you can speak freely and honestly. It also helps to seek a support group, in-person or online, with whom you can share experiences and seek referrals and advice.
  • Counseling: If faced with significant surgery or the loss of some or all of your penis, be proactive and work with a therapist or counselor who can help you come to terms with what's ahead. Couples counseling may also help.
  • Sex after surgery: It is important to remember that a healthy sex life isn't solely reliant on a penis. Talk with your partner (and work with a sex therapist if needed) to explore other ways to enjoy sex, including oral sex, role-playing, fantasy, and sex toys.

A Word From Verywell

Penile cancer can be frightening enough that some people will ignore the early signs and only seek treatment when the symptoms become more overt. Don't.

If diagnosed and treated early, a person with penile cancer will stand a better chance of long-term remission—possibly never seeing cancer again—while limiting the amount of harm that extensive surgery can do.

If significant surgery is needed, don't hesitate to seek a second opinion, if only to put your mind at ease that it is the most appropriate course of action.

If you need a referral to an oncologist specializing in cancers of the genitals, speak with your healthcare provider or a urologist, or call the American Cancer Society at 1-800-227-2345 to be connected to a local chapter near you.

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12 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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