WARTS, PRECANCEROUS LESIONS, EARLY CANCER
The most frequent benign tumor of the penis is condyloma acuminatum or verruca, commonly known as venereal (includes anal) warts. It is usually observed at the base of the glans and in the recess between the glans and a phimotic prepuce. Warts are made up of multiple villi projecting in a cauliﬂower-like appearance from a pedicled base. This highly contagious sexually transmit- ted viral infection is caused by subtypes of human papillomavirus (HPV) and is spread through skin-to-skin contact during oral, genital, or anal sex. Warts are caused by HPV strains 6, 11, 30, 42, 43, 44, 45, 51, 52, and 54; types 6 and 11 are responsible for 90% of genital warts cases. HPV also causes cervical and anal cancers; types 16 and 18 account for 70% of cancer cases.
There is no cure for HPV, but the treatment of visible warts is recommended, as it might reduce infectivity. Warts may disappear without treatment, but there is no way to predict whether they will grow or disappear. Topical solutions such as podophyllotoxin, imiquimod, sinecatechins, and trichloroacetic acid are routine, ﬁrst-line treatments for small lesions. Surgical ablation with liquid nitrogen or lasers, and formal surgical excision are popular treatments for larger lesions. 5-Fluorouracil cream has been used to treat intraurethral lesions with mixed success.
Verrucae develop luxuriantly under moist conditions and if untreated, they progress to a large size with considerable ulceration and infection. Such giant condylomata are termed Buschke–Löwenstein tumors and can be grossly indistinguishable from carcinoma of the penis. At this stage, the lesion generally requires surgical excision. Verrucae should also be differentiated from the erosive, ﬂat lesions of syphilis and those due to epitheliomas. Bowenoid papulosis is a term used to describe high-risk genital warts caused by HPV types 16 and 18. These lesions are often ﬂatter and darker than verrucous lesions and are found in clusters. Bowenoid papulosis is of concern because although the appearance is similar to typical warts, histologically, they show early features of superﬁcial squamous cell carcinoma.
Rarely lymphoma, myoma, and angiomyoﬁbromas can involve the penile shaft. Angiokeratoma, or telangiectases, of small penile vessels can also appear as purple warts. Nevi and pigmented moles are uncommonly found on the penis. Fordyce spots, small (1 to 3 mm), white, raised bumps on the penile shaft skin, are naturally occurring sebaceous glands. Leukoplakia of the prepuce or glans, a common complication of chronic inﬂammation, occurs in solitary or grouped, discrete, white plaques; the skin becomes indurated, thickened, and leathery, with the surface assuming a bluish-white appearance. Within the plaque, hyperkeratosis, dermal edema, and lymphocytic inﬁltration are present and this lesion is commonly associated with in situ squamous cell carcinoma and verrucous carcinoma of the penis. Complete surgical excision of leukoplakia is mandatory.
Balanitis xerotica obliterans is a progressive, sclerosing lesion of the preputial skin and meatus that presents with a ﬁnely wrinkled or puckered appearance of white parchment. Although not entirely clear, it may be related to lichen sclerosus et atrophicus, which has a similar appearance. These lesions may undergo periods of exacerbation and remission but only rarely resolve and may lead to precancerous leukoplakia.
Erythroplasia of Queyrat presents with characteristic solitary or multiple irregular, erythematous plaques on the glans penis or preputial skin. When it occurs on the penile shaft, it is termed Bowen disease. The plaques can be smooth, velvety, scaly, or verrucous and the edges are sharply marginated. Most commonly found in uncircumcised men, these lesions are synonymous with carcinoma in situ of the penis and therefore complete excision is necessary
Squamous cell carcinoma of the penis often begins as a small excrescence in the coronal sulcus and near the frenulum in uncircumcised men. It may present with simple induration, but later becomes ulcerated and develops into a large, fungating, often infected and foul-smelling mass. The entire glans penis may become involved, with extension into the corporal bodies and urethra. At presentation in 85% of cases, inguinal lymph nodes are indurated from either infection or metastasis. Disturbingly, more than half of affected patients have true lymph node metastases at the time of diagnosis. Partial phallectomy or total penectomy with perineal urethrostomy and radical lymph node excision is the treatment of choice.