What are the signs of penile cancer?

Signs of Penile Cancer

The primary sign of penile cancer is a palpable, visible lesion on the penis, which may present as nodular, ulcerative, or fungating, and can be associated with penile pain, discharge, bleeding, or foul odor if medical treatment is delayed. 1

Common Presentations

• Most penile cancers present as a visible or palpable lesion on the penis, most commonly on the glans (34.5%), followed by the prepuce (13.2%), and shaft (5.3%) 1
• The lesion may be characterized as nodular, ulcerative, or fungating in appearance 1
• The lesion may be obscured by phimosis, which can delay diagnosis 1
• Associated symptoms may include:
  • Penile pain 1
  • Discharge from the penis 1
  • Bleeding from the lesion 1
  • Foul odor (particularly when diagnosis is delayed) 1

Advanced Disease Signs

• Palpable inguinal lymph nodes may indicate more advanced disease 1
• Constitutional symptoms such as fatigue and weight loss may be present in advanced cases 1
• Phimosis may prevent proper examination and hide underlying malignancy 1, 2

Histological Types

• Squamous cell carcinoma (SCC) is the most common variant of penile cancer 1
• The AJCC recognizes 4 subtypes of SCC: verrucous, papillary squamous, warty, and basaloid 1
• The 2022 WHO classification separates penile cancers into HPV-associated and HPV-independent carcinomas 1

Precancerous Lesions

• Penile intraepithelial neoplasia (PeIN) is a precancerous condition with high risk of developing into penile SCC 1
• Clinical manifestations of PeIN include:
  • Bowenoid papulosis (raised papules on penile shaft) 1
  • Bowen's disease (red scaly patch on penile shaft) 1
  • Erythroplasia of Queyrat (shiny erythematous plaque on the glans or inner prepuce) 1

Risk Factors to Consider During Evaluation

• Age over 50 years (median age of diagnosis is 68 years in the US) 1, 2
• Phimosis (25-60% increased risk) 1, 2
• HPV infection (associated with 45-80% of penile cancers) 1, 2
• Tobacco use (3.0-4.5 times increased risk) 1, 2
• Lichen sclerosus (2-9% risk of developing penile carcinoma) 1, 2
• Poor hygiene, chronic inflammation, and history of sexually transmitted diseases 1, 2

Diagnostic Approach

• Physical examination is a reliable method for estimating tumor size and clinical T stage 1
• A biopsy should be obtained when there is doubt about the exact nature of the lesion 1
• MRI can be helpful when there is uncertainty about cavernosal body invasion (T3) or when considering organ-sparing treatment 1
• Ultrasound can be considered if MRI is not available 1

Prognostic Considerations

• Involvement of inguinal lymph nodes, number and site of positive nodes, and extracapsular nodal involvement are the strongest prognostic factors of survival 1
• High histological grade, perineural invasion, and lymphovascular invasion are strong predictors of metastasis 1
• The presence of central node necrosis and/or irregular nodal border of regional lymph nodes helps identify high-risk pathological node-positive penile cancer 1

Clinical Pitfalls

• Delay in seeking medical attention due to embarrassment or stigma is common and can lead to more advanced disease at presentation 1
• Phimosis can obscure lesions and delay diagnosis 1, 2
• Penile lesions may be mistaken for sexually transmitted infections, leading to inappropriate treatment and delayed diagnosis 3
• Verrucous carcinoma rarely invades lymph nodes but can cause inflammatory nodal enlargement that may be misinterpreted as metastatic disease 1