Penile cancer: sores that do not heal deserve evaluation

What is adult phimosis? What are the risk factors and symptoms?

Phimosis is a condition in which the skin (foreskin) covering the glans (the head of the penis) is too tight and cannot be pulled back to expose the glans. In some cases, phimosis is a problem during childhood, but in others it can occur in adults.

Risk factors for phimosis in adults include having been diagnosed with phimosis in childhood, having diabetes, having a weakened immune system or having an inflammatory disease of the urinary tract.

Symptoms of phimosis in adults may include difficulty urinating, pain during sexual intercourse, difficulty cleaning the penile area properly and recurrent infections of the glans or urinary tract. In severe cases, phimosis can lead to damage to the glans and even infertility.

If you are concerned that you may have phimosis, it is important to see a doctor for evaluation and treatment. Treatment of phimosis may include applying steroid creams to soften the skin, stretching exercises for the penile skin or, in more severe cases, surgery to remove the excess skin.

Some symptoms that may indicate phimosis in an adult man include:

1. Difficulty retracting the foreskin to expose the glans.
2. Pain during sexual intercourse.
3. Recurrent urinary tract infections.
4. Painful erections.
5. Difficulty urinating, with a weak or interrupted urine stream.
6. Swelling or redness of the foreskin area.

If you are experiencing any of these symptoms, it is important to see a doctor for proper diagnosis and treatment. Phimosis can be treated with surgery to remove the excess foreskin, but in some cases medication or other interventions may be needed.

Erectile Dysfunction (difficulty getting an erection)

Erectile dysfunction is a common sexual problem that affects many men at different ages. It occurs when a man has difficulty getting or keeping an erection firm enough for sexual intercourse.

Several risk factors can contribute to the development of erectile dysfunction, including:

• Age: the risk of developing erectile dysfunction increases with age.
• Chronic diseases: conditions such as diabetes, high blood pressure and heart disease can affect blood circulation and, consequently, the ability to have erections.
• Obesity: excess weight can affect sexual health, including erectile function.
• Tobacco use: smoking can damage the arteries and impair blood circulation, which can lead to erectile dysfunction.
• Excessive alcohol consumption: heavy drinking can affect the ability to have erections.
• Stress and anxiety: these factors can negatively affect sexual health and lead to erectile dysfunction.

The Clínica Uro Onco team is committed to helping patients understand the causes of erectile dysfunction and find effective treatments to improve their sexual quality of life. If you are concerned about erectile dysfunction or have questions about it, do not hesitate to contact us to book a consultation.

Erectile Dysfunction (difficulty getting an erection)

Overview

India is the country with the highest incidence of the disease worldwide (3.32 per 100,000 population). At the other extreme are Israeli-born Jews, with rates close to zero. In the United States, the incidence is 0.2 per 100,000 population, and in 2018 an estimated 1,570 new cases and about 310 deaths were expected. In European countries, penile cancer accounted for less than 0.5% of all cancer cases in 2017.(1)

In Brazil, the incidence of penile cancer is estimated to range from 2.9 to 6.8 per 100,000 population, with the North and Northeast regions accounting for the largest number of cases. Recent statistics indicate that penile cancer accounted for 2.1% of cancers in men (5.7% in the Northeast, 5.3% in the North, 3.8% in the Center-West, 1.4% in the Southeast and 1.2% in the South). These figures are directly related to the low socioeconomic levels of the areas with the highest incidence.(2)

According to data from the Brazilian Ministry of Health, an estimated 850 surgeries for penile cancer are performed each year, and approximately 50% of these procedures take place in the North and Northeast regions of the country.(3)

Most of these men probably delay seeking medical care because of fear or difficulty accessing specialized services.

​Squamous cell carcinoma (SCC) is the most common type of penile cancer. In the early stages, treatment is surgery to remove the lesion. In contrast, in more advanced stages of the disease (groin lymph nodes involved by the disease or even metastases to other organs), the chance of cure is lower and treatment shifts to chemotherapy and symptom control.(4)

The main route of spread is through the lymphatic vessels, but the disease can also reach the bloodstream.

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Penile cancer most often affects men between 50 and 70 years of age. Younger men can also be affected: about 19% of patients are under 40 and 7% are under 30.(5)

In general, the treatment of penile cancer is based on 3 principles: 1. organ preservation, 2. maintenance of sexual function, 3. quality of life.

Risk factors

There is a strong association between the presence of the foreskin and the development of penile cancer. Circumcision is a protective factor when performed in early childhood. Studies in the medical literature indicate that men circumcised shortly after birth have a low probability of developing the disease in adulthood.(6)

In addition, other scientific evidence indicates a lower likelihood of HPV infection in men circumcised in childhood.

The cause of this protective effect is still unknown and is the subject of many scientific studies. It is believed that removal of the foreskin leads to the development of a thicker protective layer on the glans and shaft of the penis, which would make infection by the virus more difficult.

Other known etiological factors are: poor genital hygiene, phimosis, HPV infection, exposure to UV radiation, smoking, balanitis xerotica obliterans and chronic lichen.(7)

Socioeconomic status is also a variable associated with an increased incidence of penile cancer. The risk is 43% higher among men living in countries where more than 20% of the population lives below the poverty line, compared with countries where less than 10% of men live below that line.

In addition, there are reports of a familial association with penile cancer. Some scientific studies have shown a 2- to 17-fold higher risk of the disease in sons of men with penile cancer; however, no genetic alteration has been identified as responsible to date.(2,7,8)

Race

Data on the incidence of penile cancer among racial groups are limited. Some scientific studies have shown that Black patients are more likely than white men to develop a more aggressive form of penile cancer. However, these studies do not address socioeconomic factors that could influence such indicators, such as access to early medical care.

Data from the Brazilian literature have shown that, among patients with penile cancer, 75% were white, 23% Black and 2% East Asian. Ninety percent of cases come from SUS (Brazil’s public health system). This suggests that penile cancer tends to affect men who are poorer, uncircumcised and with poor hygiene habits. Race does not appear to be a determining risk factor.

Phimosis

The most important risk factor for the development of penile cancer is phimosis. Among men with phimosis or excess foreskin, low socioeconomic status and poor personal hygiene are the most important risk factors.

Among patients with penile cancer, 25% have a history of phimosis and 60% have phimosis at the time of diagnosis.

Studies in the medical literature suggest that neonatal circumcision is associated with a lower risk of penile cancer, and they also show that phimosis is more common in men with the disease (35%) than in men who have never had penile cancer.(6,9,10)

What are the benefits of circumcision for men’s health?

Circumcision can bring significant benefits to men’s health. Circumcised men have a lower risk of penile HPV infection and are up to three times less likely to develop penile cancer than uncircumcised men. Studies show that circumcision performed shortly after birth drastically reduces the incidence of penile cancer. In addition, the practice is associated with a lower rate of aggressive tumors in adults. In countries such as Denmark, where circumcision is rare, the decline in the incidence of penile cancer has been attributed to improvements in personal hygiene. Therefore, circumcision can be an effective preventive measure, especially when performed early.

Smegma

The protective effect of circumcision is probably due to the absence of smegma buildup, a substance that has been shown to induce cancer in animal experiments. However, the specific mechanism has yet to be clarified.{Updating}

STDs

A common risk factor associated with penile cancer is a history of sexually transmitted diseases (STDs), such as gonorrhea, chlamydia and syphilis. However, there is no evidence of a causal link between these infections and penile cancer.

Smoking

Smoking is an important risk factor and is associated with most cases of penile cancer. In addition, there are reports in the literature that men who smoke have a higher risk of developing aggressive forms of the disease.

Balanitis (Inflammation) and Genital Trauma

Genital micro-trauma and chronic balanitis are associated with an increased risk of penile cancer. After adjusting for a history of reddish lesions and genital ulcers, reports in the medical literature show that small abrasions and micro-tears of the penile skin are associated with a 4-fold higher risk of developing penile cancer compared with men without such a history.(4,5)

Genital ulcers

Benign ulcerative lesions, such as chancroid, syphilitic ulcer and donovanosis, are the main diagnoses that can be confused with penile cancer in its early stages. Therefore, every man with an ulcerated lesion lasting more than 4 weeks or that does not respond to initial treatment should be investigated.

Clinical features and diagnosis

Approximately 2/3 of penile cancer cases have localized disease at diagnosis, and the main complaint is a visible or palpable lesion on the penis. These lesions may be nodular, ulcerated or inflammatory in appearance. Attention must be paid to lesions hidden by the foreskin, which are very common in our setting. The main symptoms related to penile cancer lesions are pain, itching, foul odor, bleeding and urinary complaints.

Physical examination of the suspicious area can define the tumor’s location, the size of the lesion and the depth of invasion into the structures of the penis (corpora cavernosa, corpus spongiosum, urethra and surrounding organs). This information is essential for treatment planning.

The most common location of penile cancer is the glans (50%), followed by the foreskin (20%) and both glans and foreskin (30%). The lesion may look like a wart (38%), an ulcer (52%) or a nodule (10%).

The lymph nodes in the groin should be checked and, if palpable, it is important to define their diameter, side, consistency and mobility. In addition, swelling (edema) of the leg/scrotum and the presence of skin infiltration/perforation are important findings.(12–14)

About 50% of lymph nodes detected on initial palpation are not related to the penile tumor, so it is important to reassess any change at each follow-up visit.

Tests such as ultrasound (US) or magnetic resonance imaging (MRI) can be used as complementary tools to define the depth of infiltration, but the definitive diagnosis is made by biopsy or by removal of the suspicious lesion itself.

References