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Below The Belt – Male Urological Cancers

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Dr Greggory Pinto

By Dr Greggory Pinto

Penile cancer is relatively rare in developed countries, but in some it can represent as high as 20 percent of all male cancers. In the United States, according to the American Cancer Society, penile cancer affects one in 100,000 men. Prostate cancer has an incidence of one in seven American men in their lifetime.

Penile cancer is often unfortunately diagnosed at an advanced stage with poor survival outcomes. Many men are unaware that penile cancer exists, and they often ignore signs and symptoms due to embarrassment and fear.

Penile cancer most commonly takes the form of squamous cell carcinoma, but rarer types such as verrucous carcinoma, melanoma, carcinoma in situ, basal cell carcinoma, adenocarcinoma and sarcoma of the penis are possible.

What are the risk factors for penile cancer?

Circumcision significantly reduces the risk for penile cancer, and the rate of penile cancer in circumcised men is exceedingly low.

Human papilloma virus (HPV) exposure is a very strong risk factor in developing penile cancer, with 30 to 50 percent of penile cancer patients being positive for HPV.

The inner surface of the male penile foreskin has receptors that greatly enhance the transmission of all sexually transmitted diseases including HPV and human immunodeficiency virus (HIV).

A recent systematic review of 81 scientific published studies determined that circumcision was an important tool in reducing a woman’s risk for developing cervical cancer, HPV, bacterial vaginosis and the sexually transmitted disease Trichomonas vaginalis. The evidence for circumcisions being effective in reducing syphilis and chlamydia is mixed but promising, but there is no evidence that it reduces gonorrhea transmission.

HPV vaccines are readily available to males and females and they lower the risk of acquiring certain types of HPV.

Age is a risk factor

The majority of men who developed penile cancer are over the age of 60 and are uncircumcised. Young men rarely develop penile cancer.

Signs and symptoms of penile cancer

Penile cancer may present as painless penile warts or lesions. The lesions may appear as red flat lesions of the head of the penis or anywhere along the shaft or penile foreskin. Infected lesions or non-healing ulcers associated with sexually transmitted diseases may be painful. Advanced penile cancer could lead to groin masses and metastatic spread throughout the body and often urinary obstruction due to invasion of the urethra.

Signs and symptoms of penile cancer may also include a foul-smelling penile discharge, thickening of the penile skin, bleeding from beneath the foreskin, penile skin changes and blue-brown penile growths.

Phimosis is a risk factor

Phimosis is the inability to fully retract the penile foreskin. Men with phimosis usually present with a tight band of foreskin around the glans/head of the penis.

Other risk factors include chronic poor penile hygiene, multiple sexual partners, ultraviolet treatment for the skin condition psoriasis and tobacco use.

Treatment options

Sadly, many penile cancers are advanced at the time of presentation and require a partial amputation of complete penectomy amputation of the penis.

Confirmation of penile cancer is first made by having a surgical biopsy.

Very early diagnosed penile cancer may be treated by laser therapy, cryotherapy involving freezing off the penile cancer, use of topical chemotherapy agents or Moh’s surgery, which is removal of the affected area of penile skin.

A total penectomy requires the creation of a perineal urethrostomy, an opening in the urethra to pee in the perineum, which is the area located between the anus and the scrotal sac. A neo-phallus may be created in an extensive surgical procedure, creating a new penis often from the muscles of the forearm.

More advanced cases of penile cancer often require removal of lymph nodes, radiation and chemotherapy.

Early detection leads to superior cure rates. Stage 1 and 2 penile cancer has an 85 percent penile cancer specific survival rate at five years.

The five-year survival rate for advanced Stage 4 penile cancer is only 11 percent.

Any changes in the appearance or feel of the penis, should warrant urgent urologist attention.

A man is never too old for a circumcision, which is a relatively quick outpatient procedure with minimal to no recovery time required and there are multiple potential health benefits to having a circumcision.

Pre-pubertal boys and girls and up to younger adult men and women are encouraged to receive the HPV vaccine which can significantly lower cervical cancer rates in women and penile cancer rates in men and reduce anal cancer rates in both men and women.

Testicular cancer is relatively rare. There are about 9,000 cases of testicular cancer in the United States every year.

Men in general have about a 0.4 percent chance of developing testicular cancer in their lifetime. About one in two hundred and fifty men will develop cancer of the testicles in their lifetime, whereas about one in six men will develop prostate cancer in their lifetime.

It is, however, the most common cancer found in men between the ages of 15 and 40 years old, when few expect to be afflicted by cancer.

Testicular cancer makes up about one percent of cancers in all men but it accounts for 13 % of cancers in men age 15 to 40 years old

The average age at diagnosis is 33 years old.

There are several misconceptions regarding testicular cancer; it is not caused by wearing tight underwear or by frequent masturbation.

Risk factors

The risk factors of testicular cancer include a first degree relative having a history of testicular cancer or a personal history of testicular cancer involving the other testicle, the occurrence of an undescended testicle that is not surgically treated by age 13, material exposure to certain toxins or hormones during pregnancy, reduced sperm formation, infertility and certain gene mutations and hypospadias, which is a congenital abnormality of the penis and urethra.

Caucasian men have a much higher incidence of testicular cancer than men of African ancestry. White race is a risk factor for testicular cancer.

Studies have shown however that men of African ancestry usually present for treatment at a more advanced stage than their Caucasian male counterparts.

Almost all testicular cancers originate in the germ cells.

There are two main types of germ cell tumours, seminomas and non-seminomas.

Seminomas have an excellent prognosis for cure and there is no poor prognosis even when there is advanced spread of the seminoma cancer throughout the body.

Non-seminoma testicular cancer also has a slightly less promising but still a very good cure rate.

Non-seminomas usually are more aggressive and spread more rapidly than seminomas.

Testicular tumours may have a non-seminoma and seminoma component, mixed germ cell tumours and they are treated as non-seminomas.

Seminomas are more sensitive to radiation.

Rarer forms of testicular cancer include lymphomas, rhabdomyosarcomas or even rarer metastatic spread from another primary cancer.

As with all cancers, early diagnosis leads better cure rates. Most germ cell testicular tumours have a 99 percent five-year survival rate when diagnosed at an early stage.

Fear, embarrassment or at times ignorance often leads men to hide or ignore signs of a testicular cancer.

Men often mistake early signs of testicular cancer with a wrongly self-diagnosed sexually transmitted disease and there is often a prolonged delay in seeking the attention of a urologist.

Ninety percent of testicular cancers are painless and usually present as a pea or marble sized small mass in one or rarely both testicles. Men with testicular cancer often experience a vague heaviness on the affected side of their testicle or an increase in fluid around the affected testicle and they may have breast enlargement or pain. Advanced prostate cancers may present with abdominal pain or back pain, possible enlarged lymph nodes in the neck and lung metastasis that could present with shortness of breath, cough, or chest pain.

Cancer of the testicles can spread to the lymph nodes around the aorta, the main artery of the body. Advanced cancer of the testicles could lead to a deep vein thrombosis of usually the legs, which present with pain and swelling but less commonly the upper limbs may be affected.

Early diagnosis of testicular cancer does not require regular visits to your urologist or routine screening blood tests; it simply involves men doing self-exams, in the shower for example, once a month.

If a man detects an abnormality, then promptly seek the confidential opinion of a urologist.

Early diagnosis could mean a straightforward outpatient curative surgery versus advanced testicular cancer requiring often multiple surgeries with chemotherapy and radiation therapy.

How to do a testicular self-exam

Take hold of your testicle between your thumbs and forefingers and then gently roll it, feeling for lumps and masses. Then repeat the process for the other side. In the shower the warmth and humidity relax your scrotum and makes the process easier.

Any change in size, consistency, texture of the testicle or if lumps or masses are felt, should initiate a prompt visit to a urologist.

A urologist would start with a thorough history then a physical exam and imaging of the testicles with an ultrasound may be ordered with a staging CT scan or MRI scan.

There are specific testicular tumour markers blood tests that may be taken that may be elevated depending on the type of testicular cancer. These testicular tumour marker blood tests are not routine screening tests, but specific blood tests requested only when there is an abnormal physical exam or abnormal imaging result.

Do not let fear, embarrassment or misconceptions prevent you or a male that you love being diagnosed with advanced testicular cancer or advanced penile cancer.

Monthly self-exams of the testicles and periodic self-exams of the penis are the key, along with the willingness to seek immediate confidential and compassionate urology care when any concerns present themselves.

• Dr Greggory Pinto is a board certified Bahamian urologist and laparoscopic surgeon. He has trained in Germany, South Africa and France, and is a member of the European Association of Urology. He can be contacted at OakTree Medical Center, #2 Fifth Terrace & Mount Royal Avenue. Telephone: (242) 322-1145 (6) (7); e-mail: welcome@urologycarebahamas.com, or visit the website:www.urologycarebahamas.com.


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