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.
