In most cases, the first sign of penile cancer are changes in color, skin thickening, or a build-up of tissue. Later signs are a painless ulcer or growth on the penis, especially on the glans (the head of the penis) or foreskin but also sometimes developing on the shaft. Most penile cancers do not cause pain, but some can cause ulcers (sores) and bleeding.

Sometimes the cancers appear as a reddish, velvety rash, small crusty bumps, or flat growths that are bluish-brown. They may not be visible unless the foreskin is pulled back. A persistent discharge, usually with a foul odor, may be present beneath the foreskin.

If the cancer spreads from the penis, it most often travels to lymph nodes in the groin. If cancer has progressed to a more advanced stage, the lymph nodes in your groin may be swollen. Lymph nodes are bean-sized collections of immune system cells that fight infection. You, your partner, or your doctor may often be able to feel the swollen nodes in your groin area.

However, swollen lymph nodes in the groin area can be caused by other conditions, such as infection. A number of benign conditions, such as genital warts, can produce similar signs. If you have any of these signs or symptoms, go see your doctor right away. Remember, the sooner you receive a correct diagnosis, the sooner you can start treatment and the more effective your treatment will be.

Because penile lesions affect the skin tissue on the surface of the organ, a visual examination of the penis can usually detect cancers and other abnormalities. Swelling at the end of the penis, especially when the foreskin is constricted, is another common sign that penile cancer may be present.

Biopsy Procedures

A biopsy is needed to make an accurate diagnosis. In this procedure, a small piece of the skin tissue is cut out and sent to a laboratory. There, a pathologist (a doctor specializing in laboratory diagnosis of diseases) looks at the tissue under a microscope to see whether cancer cells are present.

Excision or incision: The type of biopsy depends on the nature of the abnormality. If your doctor finds nodules (swollen lumps) or plaques (raised, flat areas) that are smaller than1 cm (about 3/8 inch), the entire lesion will be removed by excision biopsy.

An incision biopsy, in which only a portion of the affected tissue is removed, will be performed on lesions that are larger or ulcerated (a break in the skin or it appears to have a sore) or that appear to grow deeply into the tissue. These biopsies are usually done in a doctor’s office, clinic, or outpatient (1 day) surgical center with the patient under local anesthesia (numbing medication). The tissue is then sent to a laboratory, where a pathologist (a doctor who specializes in diagnosing disease in tissue samples) examines it under a microscope. The results are usually available within 1 to 2 days.

Fine needle aspiration: Fine needle aspiration (FNA) is a type of biopsy that can be done in a doctor's office or clinic. It is often done to see if enlarged lymph nodes contain cancer. Anesthesia may not be needed in some cases, but if it is, local anesthesia may be injected into the skin over the mass. Your doctor will place a thin needle directly into the mass for about 10 seconds and withdraw cells and a few drops of fluid. These cells can be viewed under a microscope to determine if cancer is present.

If the mass is deep inside your body and the doctor cannot feel it, imaging methods such as ultrasound or a CT scan can be used to guide the needle into the enlarged lymph node. FNA is not used in every case but is one alternative to lymph node dissection for some patients.

Sentinel node biopsy: Sentinel lymph node biopsy is a way to decide if the groin lymph nodes contain cancer if they are not enlarged. In this procedure, a radioactive tracer is injected into the region around the tumor the day before surgery. A radiation detection device will let the doctor know whether the lymphatic channels around the cancer drain into the left groin or right groin. This tells the doctor which side is likely to contain cancer if it has spread. On the day of surgery, a blue dye is injected into the region of the tumor.

In this procedure, a radioactive tracer and a blue dye are injected into the region of the tumor. The lymphatic vessels will carry the dye and radioactive material to a sentinel node, the first lymph node receiving lymph from the tumor and the one most likely to contain a metastasis if the cancer has spread. The surgeon finds this node during the operation either visually (by the blue dye) or with a Geiger counter (radioactive tracer) and removes it. If the sentinel node contains cancer, more lymph nodes are removed. If the sentinel node does not have cancer cells, the surgeon doesn't have to remove any more lymph nodes.

Using this approach, fewer patients need to have as many lymph nodes removed. Removing lymph nodes carries a risk of side effects such as lymphedema (fluid accumulation in tissues) and problems with wound healing.

If your doctor is considering this procedure, it might be useful to determine how many sentinel node biopsies he/she has done. Experience is very important. It is also important to note that all doctors do not yet perform sentinel lymph node biopsy. Discuss the procedure with your doctor.

Imaging Tests

Imaging tests like those listed below are generally not useful in examining people with early penile cancer. If the doctor thinks the cancer is advanced or has spread, then one or more of these tests may be ordered.

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures of the part of the body being studied as it rotates around you. A computer then combines these pictures into an image of a slice of your body. This test can help tell if your penile cancer has spread into your liver or other organs.

Often after the first set of pictures is taken you may be asked to drink 1 or 2 pints of a radiocontrast agent. This “dye” helps outline the intestine so that it certain areas are not mistaken for tumors. You may also receive an IV (intravenous) infusion through which the contrast dye is injected. This helps better outline structures in your body. A second set of pictures is then taken.

The injection can cause some flushing (redness and warm feeling). Some people are allergic and get hives; rarely more serious reactions like trouble breathing and low blood pressure can occur. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays and you need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. Also, you might feel a bit confined by the ring you have to lay in when the pictures are being taken.

CT scans can also be used to guide a biopsy needle precisely into a suspected metastasis. For this procedure, called a CT-guided needle biopsy,you'll remain on the CT scanning table while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½-inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. A contrast material might be injected just as with CT scans but is used less often.

MRI scans are most helpful in looking at the brain and spinal cord. But they have also been used in looking at penile tumors. It is useful if the penis is erect, so the doctor may inject s substance called prostaglandin into the penis to make it erect. MRI scans are a little more uncomfortable than CT scans. First, they take longer -- often up to an hour. Also, you have to be placed inside a tube, which is confining and can upset people with claustrophobia (fear of enclosed spaces). The machine also makes a thumping noise that you may find disturbing. Some places provide headphones with music to block this out.

Ultrasound: This is a very common test that is often used in pregnant women to look at the fetus. But it can be applied anywhere in the body. This test works by "bouncing" high frequency sound waves off the tumor and reading their pattern. It is sometimes useful for determining how deeply the cancer has penetrated into the penis. It can also spot enlarged lymph nodes in the groin.

Chest x-ray: This test may be done to determine if penile cancer has spread to the lungs.