Penile cancer

How it presents

Almost always on the glans or the foreskin, as a lesion that will not heal. It can take very different forms, and part of the problem lies there: it is mistaken for trivial things.

• An ulcer or sore that has gone weeks without closing.
• A red or whitish patch, velvety, treated as a fungal infection or dermatitis without improving.
• A thickening or a lump, sometimes warty in appearance.
• Persistent bleeding, discharge or odour beneath the foreskin.
• A lesion hidden beneath a foreskin that will not retract: what cannot be seen cannot be monitored, and it is how the most advanced cases are diagnosed.

It frequently does not hurt, and that is precisely why it gets postponed.

What makes it more likely

• Phimosis and a foreskin that cannot retract, with the chronic inflammation that goes with it.
• Lichen sclerosus, the genital skin condition that hardens and narrows the foreskin over the years.
• Persistent infection with high-risk HPV, above all type 16.
• Recurrent balanitis and difficult hygiene from retained secretions.
• Smoking, which is an independent risk factor.
• Previous PUVA phototherapy and immunosuppression.

The two routes of origin —the HPV-associated one and the HPV-independent one arising from lichen sclerosus— are explained in detail in the guide to HPV in men, including the premalignant lesions of each.

How it is confirmed

• Biopsy of the lesion. It is the only diagnosis. No scan and no trial of treatment substitutes for it.
• Examination of both groins, looking for enlarged nodes.
• Imaging to assess depth and extent, and chest and abdominal studies where the risk justifies it.

Treatment preserves the organ wherever it can

It is the most important change of recent decades and it deserves saying plainly: amputation is no longer the automatic answer. Today the strategy is matched to the depth of the lesion.

The groin nodes: where the outlook is decided

This is the part least explained to patients and the one that most determines the result. Penile cancer drains to the inguinal nodes, and their involvement counts for more than the size of the tumour.

• Normal groins on examination do not mean clear groins. A significant proportion of patients have microscopic metastases that are neither palpable nor visible on imaging.
• For that reason, in tumours of sufficient risk, surveillance is not enough: the groin must be staged surgically.
• Classic inguinal lymphadenectomy is effective but carries notable morbidity: leg lymphoedema, wound healing problems, infection.
• Dynamic sentinel node biopsy allows the first draining node to be studied and spares full lymphadenectomy to those who do not need it, with far less morbidity. It requires nuclear medicine and experience.

What genuinely prevents it

• Treating phimosis and lichen sclerosus instead of living with them for years. Circumcision, where indicated, is both treatment and prevention.
• HPV vaccination, which protects against the high-risk types of the virus-associated route.
• Stopping smoking.
• Having any lesion that does not heal in four to six weeks looked at. It is the simplest measure and the one that catches most cases in time.

A rare tumour, highly dependent on experience

Why it matters who looks after you

It is a rare cancer, and that rarity is precisely the problem: many doctors will see very few cases in an entire career, and the decisions it demands do not permit improvisation.

• Biopsying rather than treating onMost of these tumours first went through weeks of antifungal or antibiotic creams. Deciding to biopsy in good time is what most changes the result.
• Preserving the organ where the tumour allowsSparing techniques exist, they work, and they require mastering. Amputating more than necessary because they are not in your repertoire is avoidable and permanent harm.
• Deciding correctly about the groinStaging the at-risk patient surgically even when nothing is palpable, and not operating on the groin of someone who does not need it. That is where the outlook is won or lost.
• Sustaining the follow-upSparing surgery recurs locally more often, and that recurrence is salvaged without cost to survival only if somebody is looking for it.

Put plainly: in this tumour, unnecessary mutilation and late diagnosis are the two ways of failing, and neither has anything to do with manual skill.

A urologic oncologist is a urologist who additionally completed a postgraduate fellowship devoted solely to urological cancer. Mine was at Centro Médico Nacional Siglo XXI, accredited by UNAM. It can be verified. What exactly changes →