Sexual Health

Penile cancer

Penile cancer is a rare malignancy, usually squamous cell carcinoma, presenting as a persistent penile lesion or unexplained foreskin or glans symptoms; suspected cases need prompt cancer-pathway referral and confirmed disease is managed through a specialist supra-urology MDT.

In a nutshell

Penile cancer is usually squamous cell carcinoma presenting as a persistent lesion on the glans or foreskin. The high-yield action is prompt NICE cancer-pathway referral, with STI assessment in parallel when appropriate. Diagnosis is by biopsy; confirmed disease is managed through a specialist supra-urology MDT, with organ preservation when oncologically safe and risk-adapted inguinal-node staging.

Classic presentation

A person with male reproductive organs has a persistent non-healing penile ulcer, mass or plaque, sometimes hidden by phimosis, or unexplained persistent foreskin or glans symptoms. Examine fully, assess both groins and do not repeatedly treat presumed balanitis.

Key points

Most penile malignancies are squamous cell carcinoma; PeIN may be HPV-associated or HPV-independent.
NICE referral is indicated for a penile mass or ulcerated lesion after STI exclusion, a lesion persisting after STI treatment, or unexplained or persistent foreskin or glans symptoms.
Biopsy is the main diagnostic test; specialist histology determines invasion and nodal-risk features.
A clinically normal groin does not exclude occult nodal disease; staging is risk-adapted and specialist.
Organ-preserving treatment can preserve function but carries a greater local-recurrence and surveillance burden.
Major surgery, nodal treatment, radiotherapy and chemotherapy belong within the specialist supra-urology MDT pathway.

First-line investigation

Full genital and bilateral groin examination, appropriate STI assessment without referral delay, and specialist biopsy of the suspicious lesion; MRI, ultrasound, nodal staging and systemic imaging are selected according to local extent and risk.

Management

Recognise the referral trigger

Refer on the suspected-cancer pathway for a penile mass or ulcerated lesion after STI exclusion, a persistent lesion after STI treatment, or unexplained or persistent foreskin or glans symptoms.¹

Examine, biopsy and stage with the specialist team

Retract the foreskin when possible, document the lesion and both groins, obtain histology, and use MRI, ultrasound or nodal and systemic staging only when the specialist pathway indicates it.^3,6,4

Preserve function when safe, but prioritise oncological control

Selected PeIN or localised disease may receive topical, laser or organ-preserving surgery; larger or deeper disease may need partial or total penectomy, radiotherapy or multimodal treatment.^3,5

Treat nodes and advanced disease through the MDT

Use risk-adapted surgical staging for selected clinically node-negative disease, biopsy suspicious palpable nodes, and involve specialist oncology for node-positive, recurrent or metastatic disease.^3,4,7

Make recurrence and function part of the treatment plan

Provide specialist surveillance of the penis and groins, self-examination education where appropriate, rapid review of new changes, and ongoing sexual, urinary, psychological and lymphoedema support.^3,4

Exam traps

Do not keep treating a persistent penile lesion as balanitis; follow the NICE cancer-referral criteria.
A positive STI result does not make a persistent or suspicious lesion benign, and referral should not be delayed unnecessarily.
Retract the foreskin and examine both groins; phimosis can hide the primary and a normal groin examination cannot exclude occult metastasis.
Do not use CT or PET as a substitute for risk-adapted nodal staging in clinically node-negative disease.
Topical or laser treatment requires histological selection and close follow-up; it is not a way to avoid diagnosing invasion.
Major surgery, nodal dissection, radiotherapy and chemotherapy require specialist MDT planning.

Illustrations

Sensitive clinical image, hidden — Penile carcinoma with inguinal lymphadenopathyPaired clinical photographs showing an ulcerated penile tumour on the glans and associated left inguinal lymphadenopathy. Sensitive image.DickGrayson07, Wikimedia Commons · CC-BY-SA-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.