A VERY LOW BLOW

February 23, 2025

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PENILE cancer is a rare but serious condition that affects the skin and tissues of the penis.

According to consultant urologist Dr Badrulhisham Bahadzor, the disease may present as changes in the skin of the penis, such as thickening, change in colour, or the appearance of a lump or ulcer.

“We do not really know how common penile cancer among Malaysian men is,” he notes.

Risk factors for penile cancer

Several factors can increase a man’s risk of developing penile cancer. Some of these are preventable, while others are beyond control.

The key risk factors include:

> Poor hygiene: Inadequate cleaning of the genital area, especially under the foreskin for uncircumcised men, can lead to chronic inflammation, increasing the risk of penile cancer.

According to Dr Badrulhisham, this is especially the case for men with tight foreskins, a condition known as phimosis.

Obesity can also make it difficult for men to maintain good personal hygiene as a result of the penis being buried within the excess skin fold in the area.

> Use of tobacco: Smoking or using tobacco products increases the likelihood of developing penile cancer. Chemicals in tobacco can damage the DNA in penile cells, leading to cancerous changes.

> Circumcision status: Dr Badrulhisham notes that studies indicate men who undergo circumcision, especially in infancy, face a reduced risk of developing penile cancer.

He adds that men who do not have phimosis even when they are not circumcised are not at increased risk, whereas men with phimosis and are not circumcised are the ones who are at greater risk.

> Age: Penile cancer is more common in older men, typically those over the age of 60. As men age, their risk increases, making regular health check-ups crucial.

> Human papillomavirus (HPV): Dr Badrulhisham says that another notable risk factor is infection.

HPV is also associated with other cancers, such as cervical cancer in women. Vaccination against HPV can help reduce the risk of penile cancer.

Recognising the warning signs

Penile cancer almost always manifests as a skin abnormality, such as a lump, an ulceration, or unusual discolouration of the skin on the penis, says Dr Badrulhisham.

“Most penile cancers develop on the glans (the head of the penis), the coronal sulcus (the widest part of the head) or the prepuce (foreskin).

“They often present as a mass or ulceration, and may be accompanied by a secondary infection.”

Other symptoms may include a persistent foul-smelling discharge, bleeding from the penis, and lumps or swelling in the groin area (suggesting that the cancer has spread to lymph nodes).

According to Dr Badrulhisham, men should always keep a look out for any unusual changes in their penis and not be shy in seeking help if there is an abnormal appearance.

Because these symptoms may resemble other, less serious conditions such as infections, it is essential to consult a doctor for a proper diagnosis.

Some men get painful genital ulcers due to herpes simplex virus (HSV) infection, which is sexually transmitted.

Unlike HPV, which has a clear link to penile cancer, HSV infection is not known to increase the risk of penile cancer.

Dr Badrulhisham notes that sometimes, there is confusion between these two viruses in relation to penile cancers.

He advises that as with any type of cancer, early detection is always better, for many reasons.

Early detection generally means the cancer is still localised and hasn’t spread to other parts of the body, leading to a better overall prognosis.

“When penile cancer is detected early, treatment is often more effective, and the chances of successful recovery is much higher. Early-stage penile cancer requires less invasive treatment options, which can lead to quicker recovery times, preservation of sexual function and fewer complications.

“Advanced cases, however, may require more extensive surgery, radiation, or chemotherapy.”

Diagnosis and treatment

The diagnosis of penile cancer is made through a combination of medical history, physical examination and diagnostic tests.

According to Dr Badrulhisham, when a lesion is suspected to be infective in nature, usually a period of antibiotic or antifungal treatment is instituted, followed by a repeat examination a few weeks later. If the lesion does not resolve, then a biopsy of the lesion is required.

“However, when the area appears highly suspicious of cancer during the first visit, a biopsy will be performed immediately.

“A small sample of tissue from the affected area is cut away and examined by a pathologist for cancer cells,” he says.

The treatment for penile cancer depends on the stage and location of the cancer.

Among the options are:

> Surgery: The most common treatment, surgery may involve removing only the cancerous tissue, or in more advanced cases, part or all of the penis.

Dr Badrulhisham says that some men with evidence of spread to the glands or lymph nodes in the groin area, or who are believed to be at a higher risk of cancer spread, will be subjected to another surgery, aimed at removing all of these glands.

This operation is called Inguinal Lymph Node Dissection, and can be performed as open, laparoscopic or robotic-assisted keyhole surgery.

> Radiation therapy: This can be used to kill cancer cells.

It can be used after surgery if there is a risk that cancer cells are left in the groin.

> Chemotherapy: If the cancer has spread, chemotherapy may be used to destroy cancer cells throughout the body.

Dr Badrulhisham emphasises that early detection of penile cancer reduces the need for invasive treatments, highlighting the critical importance of early diagnosis.

“Definitely, early-stage penile cancer which has not spread beyond the penis has the best five-year survival rate.

“This goes down when the cancer has spread to the nearby lymph nodes in the groin area.

“It is much worse once the spread is beyond these areas.”

Post-treatment and long-term care

Recovery from penile cancer treatment varies based on the type of treatment, which is determined by the extent of the primary lesion and its spread.

So one might expect a speedy recovery for minimally-invasive treatment. The penis may look slightly scarred or disfigured, but it should still be fully functional.

For a patient who needs a partial amputation, the penis will be shorter in length, and this could have an impact on their ability to have satisfactory sexual intercourse.

Multi-modal therapy such as chemotherapy and radiation will be required for more advanced forms of penile cancer, and this usually takes several months before completion.

Patients who have a total amputation of their penis will end up with a new opening of the urinary passage under the scrotum.

A urinary catheter is usually required for a few weeks after surgery, and once that is removed, normal urination is possible, but in a commode- sitting position.

Penile reconstruction after a total amputation of the penis is still experimental surgery.

Challenges and other considerations

Due to the rarity of penile cancer, not much specialised support is available. Dr Badrulhisham advises that there are online communities in which patients can share their experiences, ask questions and receive support from others who understand what they’re going through.

“As doctors, we will try to spend more time during the consultation process and provide education materials so that patients can learn more about the disease, treatment options and coping strategies that can help reduce anxiety.

“Support from family and friends is equally crucial, and for those who draw strength from their faith, religious or spiritual guidance can provide valuable comfort in coping with the emotional challenges of cancer.”

Penile cancer may be rare, but awareness is important and can save lives. Early detection is key.

Dr Badrulhisham exhorts men to always keep a look out for any unusual changes of the organ in question, and not to be shy in seeking help if there is an abnormal appearance.

In addition, preventive measures are related to known risk factors - so stop smoking, lose weight, clean the area well, and if you have difficulty retracting the foreskin, consider having a circumcision or other surgical procedure to help achieve good personal hygiene.

Take charge of your health today and schedule a consultation with a specialist; early detection and proper treatment can make all the difference.