Penile cancer is a rare malignant tumour of the penis that most often develops on the glans or foreskin. In more than 95% of cases it is a squamous cell carcinoma, which arises from the outermost skin and mucosal cells. At an early stage, the chances of a cure are very good, and today the penis can often be largely preserved through organ-preserving treatments — what matters most is having any suspicious change examined early. In Switzerland, around 80 men develop penile cancer every year; more than 40% of those affected are 75 or older at diagnosis, though the disease can also occur in younger men. Because it is rare, and changes in the intimate area are sometimes pushed aside out of embarrassment, diagnosis is not always made early — a urological examination is straightforward, however, and should not be delayed if a change persists.
Warning signs: which changes should be checked
Penile cancer often causes no pain at an early stage. Particularly suspicious are skin or mucosal changes that persist for several weeks, increase, or fail to heal despite treatment — for example a non-healing wound on the glans or foreskin, a reddish, whitish or brownish skin change, a velvety, scaly or weeping patch, a hardened area or a palpable lump, a wart-like or irregularly growing change, recurring bleeding, foul-smelling or bloody discharge under the foreskin, increasing difficulty retracting the foreskin, new pain or swelling, or enlarged lymph nodes in the groin. Most changes on the penis are benign and due, for example, to inflammation, a skin condition or mechanical irritation; a reliable distinction based on appearance alone is not always possible, however. A change that does not heal completely or that recurs should therefore be assessed by a urologist.
Precursors of penile cancer. One possible precursor is penile intraepithelial neoplasia, or PeIN: altered cells are initially found only in the outermost skin or mucosal layer, with deeper tissue layers not yet affected. PeIN can look different in different cases — for example as a red, velvety, whitish, scaly or wart-like change — and can develop on the glans, foreskin or shaft of the penis. Not every PeIN progresses to invasive cancer, but because progression is possible, it should be treated consistently and monitored afterwards.
Causes and risk factors
Penile cancer usually does not have a single cause. In some cases, infection with certain types of human papillomavirus (HPV) plays a role; other tumours develop independently of HPV, on a background of chronic skin changes or inflammation. Known risk factors include a long-standing narrowing of the foreskin (phimosis), chronic inflammation of the glans and foreskin, lichen sclerosus (a chronic inflammatory skin condition), certain high-risk HPV types, smoking, a weakened immune system, and pre-existing precancerous changes on the penis. HPV infection is very common and can go unnoticed for a long time; detecting it says nothing about when infection occurred or about a relationship, and only a small proportion of infections lead to a precancerous change or cancer.
The role of circumcision
Circumcision — the complete removal of the foreskin — can play both a preventive and a therapeutic role in penile cancer.
Preventive significance. Circumcision performed in infancy or childhood is associated with a lower risk of later invasive penile cancer, likely mainly because it avoids phimosis and the chronic inflammation associated with it. Circumcision does not, however, offer complete protection — HPV-related precancerous changes can also occur in circumcised men — so routine circumcision of adult men solely to prevent penile cancer is not recommended. What matters more is having pronounced phimosis, recurring inflammation or lichen sclerosus properly treated.
Circumcision for a precancerous change. If a precancerous change is located on the foreskin, circumcision is often the first and most important treatment step: it allows complete removal of the affected foreskin, treatment of any coexisting phimosis, precise histological examination of the removed tissue, better assessment of the entire glans, and simpler subsequent local treatment and follow-up. After the procedure, we check whether any suspicious changes remain on the glans.
Circumcision for invasive penile cancer. If a small invasive tumour is entirely confined to the foreskin, a sufficiently wide circumcision can already be the definitive treatment. If the tumour affects the glans or deeper structures of the penis, however, circumcision alone is not enough, and depending on location, size and depth of invasion, further organ-preserving or surgical treatment becomes necessary.
Prevention
Complete protection against penile cancer is not possible, but the risk of disease can be reduced through HPV vaccination, ideally before first sexual contact, not smoking, regular, gentle intimate hygiene, treatment of phimosis and of chronic inflammation and skin conditions, and prompt assessment of any persistent change. Excessive cleaning with harsh soaps or disinfectants is not helpful and can further irritate sensitive skin — water or a mild product suitable for the intimate area is usually enough. HPV vaccination protects against several HPV types that can cause precancerous changes and genital warts, but it cannot clear an existing HPV infection.
Diagnosis
The assessment begins with a detailed conversation and a careful examination of the entire penis, assessing the appearance, size, location and extent of the change; both groins are also examined for enlarged lymph nodes. If a precancerous change or penile cancer is suspected, we take a small tissue sample (biopsy) under local anaesthesia — small changes can sometimes be removed completely in the same step. Histological examination shows whether a change is benign, a precursor, or invasive cancer, how deeply the tumour has invaded, how aggressive the tumour cells appear, whether an HPV-associated tumour is present, and whether the change was completely removed. For larger or deeper tumours, an MRI of the penis can be useful; a CT scan or PET/CT is used mainly when enlarged lymph nodes or advanced disease are suspected.
Why are the groin lymph nodes important? Penile cancer usually spreads first via the lymphatic channels to the lymph nodes in both groins, so the state of these nodes is one of the most important factors for further treatment and prognosis. Enlarged lymph nodes can be caused by inflammation but may also contain tumour cells; conversely, despite an unremarkable examination by touch, small metastases not yet visible on imaging may already be present. Whether further examination of the groin lymph nodes is needed depends on the depth of invasion and the histological features of the primary tumour; possible examinations include an ultrasound of the groins, a targeted needle biopsy of a suspicious lymph node, a dynamic sentinel lymph node biopsy, surgical removal of selected or multiple groin lymph nodes, and a CT or PET/CT where lymph node involvement is confirmed or suspected. In sentinel lymph node biopsy, the first lymph nodes into which lymph from the penis drains are specifically examined — a specialised technique that can detect small metastases while avoiding unnecessarily extensive lymph node surgery. Assessment and treatment should take place at an experienced centre where risk is increased.
Treatment of penile cancer
Treatment depends on the location and size of the tumour, its depth of invasion, its histological type, the aggressiveness of the tumour cells, any lymph node involvement, age and coexisting conditions, and the patient's personal wishes. The aim is complete removal or destruction of the tumour, while preserving length, appearance, sensitivity, sexual function and the ability to urinate as well as possible.
Treatment of a precancerous change. PeIN confined to the outermost skin layer can often be treated while preserving the organ: depending on location and extent, options include circumcision, local treatment with imiquimod or 5-fluorouracil, laser treatment, targeted surgical removal, or superficial removal of the affected glans skin followed by skin coverage. With drug-based or laser treatment, careful follow-up is especially important; if the change persists or recurs, a further biopsy is often needed.
Organ-preserving treatment of a localised tumour. Even with an already invasive but localised penile cancer, organ-preserving treatment is now often possible: depending on the findings, options include a sufficiently wide circumcision for a tumour of the foreskin, complete local removal of the tumour, partial removal of the superficial glans skin, removal of the glans with plastic reconstruction (glansectomy, in which the glans is removed while the shaft of the penis is preserved and the surface can be reconstructed with a skin graft), laser treatment in selected situations, or radiotherapy or brachytherapy for suitable tumours. Organ-preserving procedures lead to local recurrence somewhat more often than partial removal of the penis; with consistent follow-up, however, these recurrences can often be detected early and treated again.
Partial or complete removal of the penis. For large tumours that have grown deep into the erectile tissue or are unfavourably located, organ-preserving treatment may not be oncologically safe. A partial penectomy — partial removal of the penis — may then become necessary, preserving sufficient length where possible to allow urinating while standing. Complete removal of the penis is only needed for very extensive tumours; urine is then passed through a newly created urethral opening in the perineal area. These procedures can have significant physical and psychological effects, which is why thorough counselling, reconstructive considerations, and psycho-oncological or sexual medicine support where needed are all part of treatment.
Treatment of affected lymph nodes. If tumour cells are found in the groin lymph nodes, the affected nodes usually need to be removed surgically. Depending on the extent, removal of further groin lymph nodes or of pelvic lymph nodes, chemotherapy before or after surgery, radiotherapy, or a combination of several approaches may also be needed. Early treatment of limited lymph node involvement can still allow a cure.
Advanced penile cancer and prognosis
In far-advanced disease, treatment is planned on an interdisciplinary basis; platinum-based chemotherapy, surgical approaches and radiotherapy are used in particular. Immunotherapies and targeted drugs may be considered in selected situations, for example with certain molecular features of the tumour or after established treatments have been exhausted; given how rare penile cancer is, participation in a clinical trial should also be considered where possible. Depending on the extent of the disease, the treatment goal may be cure, long-term disease control, or symptom relief.
Chances of a cure depend mainly on the tumour stage and on involvement of the groin lymph nodes. If a small tumour is detected early and is confined to the penis, the chances of a cure are very good; even limited involvement of individual groin lymph nodes can still be curable. With extensive lymph node involvement or distant metastases, the prognosis is less favourable. Early diagnosis not only improves the chances of a cure but also increases the likelihood of preserving the penis and its functions.
Follow-up care
Regular check-ups after treatment are important to detect local recurrence or changes in the groin lymph nodes as early as possible. Follow-up can include examination of the penis, palpation of both groins, checking the surgical or treatment site, guidance on self-examination, ultrasound or further imaging where needed, a repeat tissue sample for a suspicious finding, and counselling on sexuality, body image and quality of life. Particularly careful check-ups are needed after organ-preserving treatment; patients should also get in touch between scheduled appointments if they notice a new change on the penis or swelling in the groin.
Changes on the penis can come with feelings of shame or anxiety. For us, though, they are a routine part of urological care and are naturally assessed with discretion and respect. Most changes are not cancerous, but a persistent abnormality, or one that does not heal completely, should not be treated repeatedly as presumed inflammation without a confirmed diagnosis. Our goal is a swift, reliable assessment: if a precancerous change or penile cancer is found, we coordinate further diagnostics and treatment that preserves the organ as much as possible, working with Lucerne Cantonal Hospital.