Precancerous conditions of the penis

Precancerous conditions of the penis are changes to penis cells that make them more likely to develop into cancer. These conditions are not yet cancer. But if they aren’t treated, there is a chance that these abnormal changes may become cancer.

The most common precancerous conditions of the penis are:

• penile intraepithelial neoplasia (PeIN)
• balanitis xerotica obliterans (BXO)
• Buschke-Lowenstein tumour
• bowenoid papulosis
• leukoplakia

Penile intraepithelial neoplasia (PeIN) is the most common precancerous condition of the penis. PeIN is a general term used to describe precancerous conditions of the penis that may develop into invasive squamous cell carcinoma (SCC) if they are not treated.

PeIN refers to abnormal cell changes, called carcinoma in situ, that occur on the skin surface of the penis.

• PeIN on the glans (head) or foreskin of the penis is also called erythroplasia of Queyrat.
• PeIN on the shaft of the penis is also called Bowen’s disease.

Erythroplasia of Queyrat and Bowen’s disease have similar features, behave the same and are associated with similar types of human papillomavirus (HPV) infection. They are typically treated in the same way.

The following risk factors may increase a man’s chance of developing PeIN:

• HPV infection
• inability to fully pull back (retract) the foreskin over the glans (called phimosis)  
• poor genital hygiene
• long-term (chronic) irritation, inflammation and infection of the penis
• weakened immune system
• smoking
• exposure to ultraviolet (UV) light, including PUVA therapy
• having multiple sexual partners – this can increase the chance of becoming infected with HPV
• exposure to arsenic – this is a risk factor only for Bowen's disease
• not being circumcised

Although there is some evidence that circumcision reduces the risk of penile cancer, there is not enough evidence to recommend circumcision as a way of preventing cancer of the penis. The Canadian Paediatric Society does not recommend routine circumcision of newborn boys. Decisions about circumcision are highly personal and depend more on religious and cultural reasons than on medical reasons.

The signs and symptoms of PeIN include:

• one or more abnormal growths or sores (ulcers) on the penis – may be raised or flat with irregular borders, white or red, crusty or scaly, and they may bleed and be itchy
• painful urination
• discharge from the penis
• inability to fully pull back the foreskin over the glans

If you have symptoms or your doctor thinks you might have PeIN, tests will be done to make a diagnosis. Tests may include:

• medical history and physical exam
• biopsy of the abnormal area

Because PeIN is considered carcinoma in situ, it is treated the same as stage 0 penile cancer.

Balanitis xerotica obliterans (BXO) is an inflammatory condition of the skin that affects the foreskin and the glans of the penis. It may also be called penile lichen sclerosus.

There are no known risk factors for BXO.

The signs and symptoms of BXO include:

• a scaly, whitish patch that usually involves the opening of the urethra (meatus)
• itching or burning
• loss of sensitivity to the glans
• painful urination
• painful erection
• weak or decreased urine stream
• discharge from the penis
• inability to fully pull back the foreskin over the glans
• inability to return the pulled-back foreskin back over the glans (called paraphimosis)

If you have symptoms or your doctor thinks you might have BXO, tests will be done to make a diagnosis. Tests may include:

• physical exam
• biopsy

Treatment options for BXO include:

• topical steroid cream – topical means the drug is put directly onto the skin with a cream or gel
• topical tacrolimus (Protopic)
• surgery to open the urethra if it is narrowed
• circumcision for men who have not been circumcised
• laser surgery

Buschke-Lowenstein tumour is most commonly found on the glans of the penis. It is sometimes referred to as a low-grade cancer related to verrucous carcinoma of the penis. Buschke-Lowenstein tumour is a slow-growing tumour that may grow as big as 15 cm.

The signs and symptoms of Buschke-Lowenstein tumour include:

• an abnormal growth or sore (ulcer) on the penis – it may look like a genital wart with a cauliflower-like appearance
• tumour or abnormal area that has a foul odour
• enlarged lymph nodes in the groin – usually related to a secondary infection

If you have symptoms or your doctor thinks you might have a Buschke-Lowenstein tumour, tests will be done to make a diagnosis. Tests may include:

• medical history and physical exam
• biopsy
• MRI

Buschke-Lowenstein tumour is treated the same as carcinoma in situ or stage 0 penile cancer.

Bowenoid papulosis has an extremely low chance of developing into cancer. It affects younger men more often than older men.

An HPV infection may increase a man’s chance of developing bowenoid papulosis.

The signs and symptoms of bowenoid papulosis may include one or many warty, raised areas that vary in size and are reddish or the same colour as your skin. These occur on the shaft of the penis or the nearby perineal skin.

If you have symptoms or your doctor thinks you might have bowenoid papulosis, tests will be done to make a diagnosis. Tests may include:

• medical history and physical exam
• biopsy

Treatment options for bowenoid papulosis include:

• surgery
• laser surgery
• cryosurgery
• topical chemotherapy (given as a cream applied to the skin) with 5-fluorouracil (Efudex, 5-FU), podophyllin (Pod-Ben-25, Podofin) or retinoic acid
• topical immunotherapy with imiquimod (Aldara)
• curettage and electrodessication

Leukoplakia has the potential to become squamous cell carcinoma (SCC).

The following risk factors may increase a man’s chance of developing leukoplakia:

• HPV infection
• inability to fully pull back the foreskin over the glans  
• poor genital hygiene
• long-term irritation, inflammation and infection of the penis
• not being circumcised

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Although there is some evidence that circumcision reduces the risk of penile cancer, there is not enough evidence to recommend circumcision as a way of preventing cancer of the penis. The Canadian Paediatric Society does not recommend routine circumcision of newborn boys. Decisions about circumcision are highly personal and depend more on religious and cultural reasons than on medical reasons.

The signs and symptoms of leukoplakia are abnormal whitish areas or spots that may form on the opening of the urethra.

If you have symptoms or your doctor thinks you might have leukoplakia, tests will be done to make a diagnosis. Tests may include:

• medical history and physical exam
• biopsy

Leukoplakia is usually treated with surgery.