Penile Lesions
Noticing a penile lesion can be concerning, and it’s natural to feel embarrassed. The good news is that most lesions are treatable, and early diagnosis is key to avoiding complications. While some cases, like certain penile skin cancers, can require more extensive procedures, seeking professional help ensures you get the right treatment and minimizes potential complications. This article explores the different types of common penile lesions, treatment options, and why getting checked is important for your overall health.
Penile lesions can be broadly classified into two categories:
Infectious and non-infectious
- Infectious lesions: These are caused by bacteria, viruses, fungi, or parasites. Sexually transmitted infections (STIs) are a common culprit behind infectious penile lesions.
- Non-infectious lesions: These are penile lesions that are not caused by infections
- Inflammatory lesions: These occur when the skin on the penis becomes irritated and inflamed due to skin conditions (psoriasis, lichen sclerosis, balanitis), allergic reactions, or friction.
- Neoplastic lesions: These are abnormal growths that have the potential to become cancerous. Early diagnosis and management are crucial for these lesions.
The table provides a clear visual representation of the different types of penile lesions.
Infectious penile lesions
There’s a common misconception that penile infections are solely linked to sexually transmitted infections (STIs). While STIs can cause penile infections, it’s surprising to many that the most common identifiable causes are non-STIs infections such as Staphylococcus, Streptococcus, Candida, and Malassezia.
Terminology of penile infections:
- Balanitis – Inflammation or infection of the glans penis.
- Posthitis – inflammation or infection of the penile foreskin.
- Balanoposthitis – inflammation or infection of both the glans and foreskin.
Before we delve deeper into some of the pertinent penile lesions associated with infections, below is a list of risk factors that increase your risk of penile infections:
- Presence of foreskin. The presence of a foreskin is a risk factor for penile infections. Studies show that uncircumcised males have a higher prevalence of balanitis compared to circumcised males (68% lower prevalence in circumcised). Although balanitis does not directly cause penile cancer, it has been observed that men with balanitis have a 3.8-fold increased risk of penile cancer.
- Poor personal hygiene and inability to retract the foreskin (phimosis). poorly retractile foreskin. These factors contribute to a moist environment that can harbor an overgrowth of microorganisms like bacteria and fungus, increasing the chance of infection.
- Morbid obesity. Morbid obesity can increase the risk of penile infections for men with a foreskin. Excess body weight can make it difficult to retract the foreskin fully, hindering proper hygiene of the glans and foreskin. This trapped moisture and difficulty cleaning create a favorable environment for bacteria and fungus to overgrow, potentially leading to infection.
- Sexually transmitted infections (STIs). These infections spread through unprotected sexual contact, including vaginal, anal, oral sex, or even skin-to-skin contact in the genital area. Men with STIs affecting the penis can unknowingly transmit the infection to their partners. Early diagnosis and treatment are crucial to prevent complications and protect your sexual health and that of your partners.
Let us discuss some of the characteristics of the common penile lesions caused by infections.
Herpes Simplex
Genital herpes is a sexually transmitted infection primarily caused by the herpes simplex virus type 2 (HSV-2). While HSV-1 is more commonly associated with facial cold sores, it can also cause genital herpes, although less frequently. HSV-2 infection typically presents with clusters of small, fluid-filled blisters (vesicles) on the penis. These blisters may break open, forming painful ulcers. The most common locations for these lesions are the glans, foreskin, and shaft. Urethritis, an inflammation of the urethra, can occur as a complication, leading to burning pain during urination. After the initial outbreak, recurrences are frequent and they tend to occur in the same region, but not always at the identical site.
Syphilis (Chancre)
Syphilis, a sexually transmitted infection caused by the bacteria Treponema pallidum, is often called “the great imitator” because its symptoms can mimic other diseases, including HIV. Syphilis progresses through distinct stages, each with varying symptoms. The primary stage is characterized by the development of a chancre, the penile manifestation of syphilis infection. This chancre appears as a single, painless, red bump that quickly ulcerates into a sore with clean, well-defined borders and a firm base. While these ulcers heal on their own within weeks, even without treatment, proper diagnosis and treatment of syphilis are crucial to prevent serious complications in later stages.
Hemophilus Ducreyi (Chancroid)
Chancroid is a sexually transmitted infection caused by the bacterium Haemophilus ducreyi. While more prevalent in developing countries, it’s crucial to consider chancroid as a possibility if you have a recent travel history to such regions. This condition is also associated with commercial sex work and their clientele.
The hallmark symptom of chancroid is a single, painful ulcer on the penis. These ulcers can appear on the foreskin, glans, or corona. Unlike the ulcers in syphilis, chancroid ulcers are typically deep, have irregular edges, and cause significant discomfort. Left untreated, the infection can spread to the lymph nodes in the groin, causing them to become swollen and tender. Untreated chancroid ulcers can persist for months and potentially lead to scarring. Additionally, chancroid increases the risk of contracting HIV.
Granuloma inguinale
Granuloma inguinale, also known as donovanosis, is a sexually transmitted infection (STI) caused by the bacteria Klebsiella granulomatis. This condition is more prevalent in tropical and subtropical regions like Papua New Guinea, parts of India and Africa, the Caribbean, and South America. In developed countries like Singapore, cases typically arise from sexual contact with someone who has been in these high-risk areas.
The initial symptom of granuloma inguinale is usually a single, painless, firm bump (papule or nodule) appearing on the genitals. The most common locations on the penis are the corona (the head), glans (the tip), and foreskin (prepuce). If left untreated, this nodule can ulcerate (break open) and form a painless sore. These ulcers tend to grow progressively larger over time without treatment.
Genital warts
Genital warts, also known as condylomata acuminata, are caused by the human papillomavirus (HPV), the most common sexually transmitted infection globally. An estimated 9-13% of the world’s population is infected with HPV. While there are over 100 HPV subtypes, strains 6 and 11 are the most frequent culprits behind genital warts. Uncircumcised men have a slightly higher risk of developing HPV-related penile inflammation (balanoposthitis).
Genital warts often don’t cause any symptoms. They typically manifest as flesh-colored bumps (papules) with a rough, cauliflower-like surface. These bumps are usually small, measuring just a few millimeters in diameter. In some cases, multiple warts can cluster together, forming larger lesions.
Non-infectious penile lesions
As previously discussed, non-infectious penile lesions can be classified into inflammatory lesions and neoplastic lesions.
Inflammatory penile lesions
Inflammatory lesions of the penis can sometimes be associated with existing skin conditions. These skin conditions often have extragenital manifestations, meaning they appear on other areas of the body besides the genitals. Let us discuss some of the characteristics of the common inflammatory penile lesions.
Psoriasis
Psoriasis is a chronic inflammatory skin condition that causes the skin cells to multiply too quickly, leading to thick, red, and scaly patches. It often first appears between the ages of 16-22 or 57-60. While commonly seen on elbows, knees, scalp, and back, up to 40% of psoriasis patients experience penile involvement.
Psoriasis on the penis typically appears as raised, red patches with silvery scales. Itching and emotional distress are common symptoms. Factors that can worsen psoriasis include stress, excessive alcohol and tobacco use, skin infections, and certain medications. Additionally, up to 25% of people with psoriasis develop psoriatic arthritis, which affects the joints.
Lichen Sclerosus
Penile lichen sclerosus, also known as balanitis xerotica obliterans, is a chronic inflammatory skin condition that can affect men of any age, with an average diagnosis of around 42 years old. It’s a relatively common condition, affecting roughly 1 in 300 men. Lichen sclerosus is concerning because it’s considered a pre-cancerous condition, meaning it carries an increased risk (4-6%) of developing squamous cell carcinoma of the penis.
The initial signs of lichen sclerosus often appear as white, thin patches of skin with a wrinkled texture, resembling crinkled paper or cellophane. These lesions primarily affect the glans (head) and foreskin (prepuce) of the penis. Common symptoms include difficulty retracting the foreskin (phimosis), painful erections, problems urinating (obstructive voiding), and itching, burning, or bleeding in the genital area. In some cases, the narrowing of the foreskin due to the lesions might become severe enough to obstruct urination, leading to urinary retention as the initial complaint.
Lichen Planus
Lichen planus is a skin condition that can affect various areas of the body, including the mouth, nails, hands, feet, and scalp. About one-quarter of people with lichen planus also experience genital involvement. In men, the glans (head) of the penis is the most commonly affected area.
For uncircumcised men, lichen planus on the penis often appears as lacy, white patches with a net-like pattern. Itching and soreness are frequent complaints. In some cases, the lesions might ulcerate (develop open sores) or become hardened. Ulceration or hardened lesions warrant a biopsy to rule out squamous cell carcinoma, a type of skin cancer.
Contact Dermatitis
Allergic contact dermatitis is an itchy, red, and inflamed skin reaction triggered by direct contact with an allergen, a substance that’s harmless to most people. While more common in women due to nickel in jewelry or nail products, men can also experience it on the penis. Certain professions like hairdressers and healthcare workers are more prone due to exposure to various chemicals.
For men, allergic contact dermatitis of the penis often stems from condom use. Symptoms typically include a well-defined rash at the base of the penis, along with swelling or itching during intercourse. This can happen because different condom brands use varying combinations of vulcanizers, antioxidants, and lubricants, any of which can trigger an allergic reaction. Other potential allergens for penile dermatitis include feminine hygiene products or douches that come in direct contact with the penis.
Zoon Balanitis
Zoon balanitis, also known as plasma cell balanitis, is an inflammatory condition affecting the head of the penis (glans) in middle-aged or older men. It’s caused by an abnormal increase in immune cells called plasma cells. This condition typically presents as a single, smooth, red-orange patch on the glans, which may extend to the foreskin (prepuce) in uncircumcised men. The surface of the patch might have tiny red dots resembling cayenne pepper flakes, sometimes surrounded by a yellowish area. Symptoms are usually mild, with some men experiencing slight pain or itching.
Neoplastic penile lesions
Neoplastic conditions of the penis can be further divided into benign conditions, pre-malignant conditions, and malignant conditions.
Benign lesions
Pearly penile papules
Pearly penile papules are tiny, harmless bumps found around the head of the penis (glans). These bumps, which can be dome-shaped or thread-like, are usually flesh-colored and arranged in one or more rows along the rim (corona) or the groove (sulcus) of the glans. Studies show they occur in 8% to 43% of men, more frequently in those who are uncircumcised. They tend to become less noticeable with age.
There’s no need to worry about pearly penile papules. They’re a normal part of male anatomy and not caused by sexual activity, hygiene habits, or any infection. Unlike genital warts, they are not contagious. Most importantly, they are not cancerous or pre-cancerous.
Pre-malignant lesions
Bowenoid papulosis
Bowenoid papulosis is a precancerous condition caused by the human papillomavirus (HPV), most commonly type 16. It spreads through close skin-to-skin contact, often during sexual intercourse. This condition is considered a high-grade squamous intraepithelial lesion (HSIL) by pathologists, meaning it carries a risk of developing into invasive squamous cell carcinoma (cancer) if left untreated.
Bowenoid papulosis appears as multiple, well-defined bumps (papules) on the penis. These bumps are typically red-brown to purple and usually less than 1 centimeter in size. The surface of the papules can vary – they might be flat, smooth, bumpy, or wart-like. In some cases, several papules can grow together to form larger patches.
While the penis is most commonly affected, with lesions appearing on the shaft, bowenoid papulosis can also involve the foreskin, glans, scrotum, and even the anus.
Penile carcinoma-in-situ
Penile carcinoma in situ (CIS) is a precancerous condition, meaning it has the potential to develop into cancer if left untreated. It’s more frequent in uncircumcised men over 60 years old and is primarily caused by the human papillomavirus (HPV). About 5-30% of CIS cases can progress to invasive penile cancer, highlighting the importance of early diagnosis and treatment.
Symptoms of penile CIS can vary, but common ones include pain, itching, and changes in the appearance of the penis. Other symptoms may include redness, crusting, scaly patches, ulcers, bleeding, burning during urination (dysuria), discharge, or difficulty retracting the foreskin (phimosis). The lesions themselves often appear as raised, red, and velvety patches with irregular borders. Ulceration can sometimes develop. These lesions can occur on various parts of the penis, including the glans (head), urethral opening (meatus), frenulum (the small tissue bridge under the head), coronal sulcus (the groove around the head), and foreskin (prepuce).
Malignant Lesion
Penile Carcinoma
Penile cancer, while uncommon especially in developed countries, is more prevalent in developing regions. The risk increases with age, with a peak around 60 but can occur in younger men as well. Human papillomavirus (HPV) infection plays a role in about a third of penile cancer cases, with areas of high HPV prevalence having a higher incidence of the disease.
Several factors can increase the risk of penile cancer. These include being uncircumcised, having difficulty retracting the foreskin (phimosis), chronic penile inflammation, lichen sclerosus (a skin condition), smoking, ultraviolet A (UVA) light therapy, and having multiple sexual partners.
Penile cancer often presents with a delay in seeking medical attention, averaging around six months or longer. Early signs can be a painless lump or ulcer on the penis. Over time, the skin may thicken, and a wart-like growth might develop, sometimes with a foul odor. Changes in skin color and rashes may also occur. Penile cancer can be exophytic or endophytic.
Exophytic SCC: This appears as a large, irregular mass that may grow outwards. In some cases, it can arise from the inner foreskin and cause phimosis, where the foreskin becomes difficult to retract, hiding the mass.
Endophytic SCC: This type presents as ulcers or lesions that burrow deeper into the penis tissue.
Extramammary Paget disease of the penis
Extramammary Paget disease (EMPD) is a rare skin cancer that primarily affects people over 50, with a peak around 65. While EMPD itself affects the skin, it can sometimes be associated with another cancer elsewhere in the body such as the rectum, bladder, urethra, prostate, endocervix, or stomach. It’s more common in Caucasians, but interestingly, ethnicity plays a role in who gets it: Caucasian women are more likely to develop EMPD, while in Asian populations, men are more susceptible.
EMPD typically appears as a single, red, or pink, scaly patch that is irregularly shaped. It most often affects the area around the anus in men, but it can also show up on the scrotum, groin, and penis. The patch often itches intensely, which can lead to scratching and cause the skin to become thickened and leathery. Burning, pain, and irritation are other common symptoms.
Treatment at The Clifford Clinic
The ideal treatment of penile lesions depends on the diagnosis. Some of the common approaches are as follow:
Preventive measures
Protect yourself from sexually transmitted infections (STIs). Condoms, when used consistently and correctly, are a highly effective way to prevent the spread of most STIs, including HIV.
Practice safe sex. Condoms when used correctly and consistently is an effective method of preventing most sexually transmitted infections (STIs), including HIV and unplanned pregnancies, and the only method of contraception that can do both.
Vaccinate against STIs. HPV vaccine significantly reduces the risk of genital warts (by 88% since its recommendation in 2006) and HPV-related cancers.
Circumcision. The presence of a foreskin is a major risk factor for penile lesions.
Topical creams
Corticosteroid creams are a common treatment for inflammatory skin conditions like psoriasis, lichen sclerosus, lichen planus, and contact dermatitis. These creams work by reducing inflammation in several ways. They can block certain chemical reactions in the skin, regulate the activity of immune cells, and narrow blood vessels in the affected area.
Podophyllotoxin cream and imiquimod cream are topical medications that can also be self-applied at home to treat genital warts.
Vitamin D3 analogues, tacrolimus, and pimecrolimus creams are also used to treat inflammatory penile lesions such as psoriasis.
Antibiotics/Antivirals
Antibiotics are effective for treating certain infectious penile lesions. Antibiotics are used to treat bacterial skin infections caused by Streptococcus and Staphylococcus. It is also used to treat STIs such as syphilis infection chancroid, and granuloma inguinale. The type of antibiotic and its administration (pills or injections) depends on the specific infection.
Viral infections of the penis, such as those caused by Herpes Simplex, typically require antiviral medication.
Laser ablation/Cryotherapy
CO2 laser ablation and cryotherapy offer minimally invasive options for treating some penile lesions. These procedures are effective for conditions like genital warts and potentially Zon’s balanitis. While they can be used for precancerous lesions (carcinoma in situ), surgical excision remains the preferred approach. This allows for a definitive tissue sample to exclude underlying malignancy.
Surgery
Surgical options for penile lesions typically involve local excision or circumcision.
Local excision removes only the affected tissue, ideal for isolated penile lesions.
Circumcision involves the removal of the entire foreskin. It can be used to treat precancerous lesions, and curative for cancers that are isolated to the penile foreskin. Circumcision is commonly used as a preventive measure and it has the following benefits:
- Reduced risk of HIV acquisition: A Cochrane review of 3 large randomized controlled trials involving 11,500 men has shown that circumcision can decrease a man’s risk of acquiring HIV and HPV.
Reduced risk of STI: Studies have shown that circumcision was protective against HPV infection due to the decreased likelihood of being infected with HPV. There is also evidence to suggest that male circumcision can decrease the rate of HPV infection in female partners. - Reduced risk of penile cancer: Circumcision has been linked to a lower risk of penile cancer, although this cancer is rare overall.
- Improved hygiene: Removing the foreskin simplifies cleaning and can help prevent urinary tract infections and inflammation.
- Improve sexual function and satisfaction: Circumcision may improve sexual health as it has been shown to improve sexual function in both men and women with >90% of both parties reporting that they were “very satisfied” with the outcomes of circumcision.
Penile cancer treatment typically involves surgery. The type of surgery (penis-preserving or not) depends on the severity of the cancer. For definitive diagnosis and treatment planning, consultation with a urologist is essential. The complexities of penile cancer management are beyond the scope of this article.
Summary of treatment of penile lesions
Diagnosis | Primary management | Alternative management |
Infectious Lesion | ||
Herpes Simplex | Oral antiviral agents | Circumcision as a form of risk reduction. Circumcision have been shown to reduce HSV-2 acquisition by 25%. |
Syphilis (Chancre) | IM penicillin | IM ceftriaxone Oral doxycycline, tetracycline or erythromycin. |
Chancroid | Oral azithromycin | Oral erythromycin or IM Ceftriaxone Circumcision reduces the risk of contracting chancroid from an infected partner by 3 to 4 times. |
Granuloma inguinale | Oral azithromycin | Oral Bactrim, doxycycline or erythromycin. |
Genital warts | Podophyllotoxin cream, imiquimod cream | HPV vaccination as preventive management. Cryotherapy, CO2 laser, scalpel excision. Circumcision decrease the prevalence of HPV transmission by 35%. |
Non-Infectious Lesions (Inflammatory) | ||
Psoriasis | Topical corticosteroids | Vitamin D3 analogues, tacrolimus (Protopic), or pimecrolimus (Elidel) |
Lichen sclerosus | Topical corticosteroid | Circumcision is a definitive treatment to reduce the risk of malignant transformation. |
Lichen planus | Topical corticosteroids | Circumcision for isolated foreskin lesion. |
Contact dermatitis | Topical corticosteroids | Identification of allergens with patch testing and allergen avoidance. |
Zoon balanitis | Circumcision | Topical corticosteroids CO2 laser ablation |
Non-Infections Lesions (Neoplastic) | ||
Bowenoid papulosis | Circumcision for foreskin lesion | Cryotherapy CO2 laser ablation |
Carcinoma in situ | Circumcision for foreskin lesion | Mohs micrographic surgery Topical imiquimod |
Penile carcinoma | Circumcision for foreskin lesions Mohs micrographic surgery | Partial or radical penectomy |
IM – intramuscular