Balanitis xerotica obliterans—usually abbreviated to BXO, is the traditional urological name for male genital lichen sclerosus.

Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects the foreskin and head of the penis. It can cause whitening, inflammation, splitting and progressive scarring of the foreskin. In some men it also narrows the urinary opening or extends into the urethra.

BXO is not simply an infection or ordinary balanitis. Early recognition and treatment can relieve symptoms and reduce permanent scarring. Long-term observation is also important because genital lichen sclerosus is associated with a small but genuine risk of penile squamous cell carcinoma.

Is BXO different from lichen sclerosus?

The names are often used interchangeably:

• Lichen sclerosus is the preferred modern medical term.
• Balanitis xerotica obliterans describes lichen sclerosus affecting the glans penis and foreskin, particularly when scarring has developed.

The condition may involve:

• The inner and outer foreskin
• The glans penis
• The frenulum
• The urinary opening—the meatus
• The fossa navicularis and penile urethra

The disease is usually confined to the genital region in men, although lichen sclerosus can occasionally affect skin elsewhere.

What causes lichen sclerosus?

The exact cause remains uncertain. It is probably produced by a combination of inflammation, immune-system dysfunction, genetic susceptibility, skin injury and local environmental factors.

Possible associations include:

• Autoimmune or inflammatory activity
• Chronic exposure of susceptible skin to trapped urine
• Repeated friction or minor trauma
• A tight foreskin
• Previous inflammation beneath the foreskin
• Obesity and a “buried” penis
• Diabetes or metabolic disease
• Cigarette smoking
• Genetic susceptibility

The moist, occluded environment beneath the foreskin may contribute to continuing inflammation in susceptible men.

Lichen sclerosus is:

• Not caused by poor personal character or behaviour
• Not usually a sexually transmitted infection
• Not contagious
• Not something that can be passed to a partner through ordinary sexual contact

Yeast or bacterial infection may occur at the same time, particularly in men with diabetes, but infection is not the underlying cause of lichen sclerosus.

Who can develop it?

Male genital lichen sclerosus can occur at any age.

It is recognised in:

• Boys with acquired or severe scarring phimosis
• Adolescents
• Younger and middle-aged men
• Older men
• Men with a previously retractable foreskin that has gradually tightened

It is much less common in men who were circumcised early in life, although circumcision does not make the risk absolutely zero.

How does lichen sclerosus present?

The appearance varies considerably. Early disease can be subtle and may initially be mistaken for thrush, dermatitis, recurrent balanitis or ordinary phimosis.

Possible signs include:

• White, pale or porcelain-coloured foreskin
• A white, firm ring around the foreskin opening
• Thickened or hardened skin
• Shiny, crinkled or “cigarette-paper” skin
• Red or inflamed areas
• Small cracks or splits
• Easy bleeding or bruising
• Painful erosions
• Adhesions between the foreskin and glans
• Progressive tightening of the foreskin
• Shortening or scarring of the frenulum
• Whitening around the urinary opening
• Narrowing of the meatus
• Loss of the normal shape or definition of the glans and foreskin

Some men have significant visible disease with surprisingly little discomfort.

Symptoms patients may notice

Symptoms can include:

• Difficulty retracting the foreskin
• Inability to replace or retract the foreskin fully
• Pain during erections
• Splitting or bleeding during intercourse
• Itching, burning or soreness
• Recurrent “balanitis”
• Pain or reduced enjoyment during sexual activity
• Spraying or deflection of the urinary stream
• A weak or narrowed stream
• Straining to urinate
• Dribbling after urination
• Ballooning of the foreskin
• Recurrent urinary infections
• Difficulty emptying the bladder

A narrow urinary opening may be the first sign that the disease has extended beyond the foreskin.

Lichen sclerosus and phimosis

Phimosis means that the foreskin cannot be retracted comfortably behind the glans.

A non-retractile foreskin is normal in young boys and does not automatically indicate disease. However, a previously retractable foreskin that becomes tight, particularly when accompanied by a white scarred ring is suspicious for lichen sclerosus.

Forceful stretching of a scarred foreskin is not recommended. Repeated tearing may cause additional inflammation and scarring.

Paraphimosis, where a retracted tight foreskin becomes trapped behind the glans, requires urgent medical attention.

How is lichen sclerosus diagnosed?

The diagnosis is often made from the history and characteristic appearance.

Assessment should include examination of:

• The complete foreskin
• Glans penis
• Frenulum
• Urinary opening
• Palpable tissue beneath abnormal skin
• Urinary stream and bladder emptying when relevant
• Groin lymph nodes if cancer is suspected

Other conditions that can resemble lichen sclerosus include:

• Fungal or bacterial balanitis
• Irritant or allergic dermatitis
• Psoriasis
• Lichen planus
• Zoon balanitis
• Vitiligo
• Genital warts
• Penile intraepithelial neoplasia: PeIN
• Squamous cell carcinoma

Diabetes testing may be appropriate in men with recurrent inflammation or other risk factors.

Is a biopsy always necessary?

Not every typical case requires a biopsy before treatment. However, biopsy is important when:

• The diagnosis is uncertain
• Treatment has not produced the expected response
• An erosion or ulcer does not heal
• There is a persistent red or thickened area
• A lump or hardened area can be felt
• The skin bleeds easily without an obvious cause
• Pigmentation changes unexpectedly
• Penile intraepithelial neoplasia or cancer is suspected

When circumcision is performed for suspected lichen sclerosus, the foreskin should usually be sent for pathological examination.

A biopsy should be taken from any suspicious persistent lesion rather than relying only on the appearance.

Medical management

The goals of medical treatment are to:

• Suppress inflammation
• Relieve discomfort and itching
• Prevent further scarring
• Preserve foreskin and urinary function where possible
• Identify patients who require surgery or biopsy

General skin care

Helpful measures include:

• Washing gently with water or a non-soap cleanser
• Avoiding perfumed soaps, antiseptics and harsh products
• Drying the glans and foreskin gently after urination
• Applying a bland barrier ointment or emollient
• Avoiding forceful foreskin retraction
• Using adequate lubrication during sexual activity
• Stopping smoking
• Managing diabetes carefully
• Addressing obesity or a buried penis where relevant

Good hygiene means gentle care. Repeated scrubbing or strong antiseptics can worsen inflamed genital skin.

Potent topical corticosteroids

A prescribed potent or ultrapotent topical corticosteroid is the usual first-line medical treatment.

Clobetasol propionate 0.05% ointment is commonly used in specialist practice. A typical initial course may involve a small amount applied to the affected skin once daily for one to three months, but the exact regimen should be determined by the treating doctor.

Patients should be shown:

• Exactly where to apply the medication
• How much to use
• How long to continue
• Whether treatment should be reduced gradually
• When follow-up is required

When used correctly for a defined course, topical corticosteroids can reduce inflammation, soreness and early tightening. They cannot always reverse established dense scar tissue.

Possible steroid-related effects include irritation, secondary infection, skin thinning or visible small blood vessels, although these are uncommon with appropriate genital use and medical supervision.

Other topical treatments

Topical calcineurin inhibitors such as tacrolimus or pimecrolimus may occasionally be considered by a dermatologist or experienced specialist when corticosteroids are unsuitable.

They are not generally preferred over potent topical corticosteroids as initial treatment. They can cause burning or irritation, and persistent suspicious lesions must be biopsied rather than repeatedly treated empirically.

Antifungal or antibiotic medication is only useful when a secondary infection is actually present. It does not treat the underlying lichen sclerosus.

When should circumcision be considered?

Circumcision is an important and often definitive treatment for foreskin lichen sclerosus.

It should be considered when there is:

• Established scarring phimosis
• Painful or recurrent splitting
• Difficulty with hygiene
• Recurrent balanitis
• Paraphimosis
• Failure to respond adequately to a prescribed steroid course
• Rapid recurrence after apparently successful medical treatment
• Significant functional or sexual difficulty
• Concern about premalignant or malignant change
• A need to obtain tissue for diagnosis

Complete circumcision removes the diseased foreskin and eliminates the moist, urine-exposed environment beneath it. Many men experience long-term resolution when the disease is limited to the foreskin.

Partial circumcision or simply making a slit in the scarred foreskin is generally less reliable because affected skin remains and may scar again.

Will circumcision cure lichen sclerosus?

Circumcision is often highly effective when the condition is limited to the foreskin. However, it is not an absolute guarantee of cure.

Disease may persist or recur on the:

• Glans
• Coronal sulcus
• Frenulum
• Urinary opening
• Urethra

Ongoing symptoms or abnormal skin after circumcision should therefore be reviewed rather than assumed to be normal postoperative scarring.

Circumcision appears to reduce the risk associated with chronic inflammation and phimosis, but it does not completely eliminate the future risk of penile cancer.

Surgery for meatal narrowing

Lichen sclerosus can scar the urinary opening, producing meatal stenosis.

Symptoms may include:

• A thin urinary stream
• Spraying or deflection
• Prolonged urination
• Straining
• Discomfort
• Incomplete emptying

Treatment may require a meatotomy or meatoplasty, in which the opening is enlarged and reconstructed.

Simple dilatation may provide temporary improvement but often does not control active scar disease. Medical treatment of the surrounding lichen sclerosus and continued surveillance may still be required.

What if the disease involves the urethra?

In some men, scarring extends from the meatus into the penile urethra and occasionally further towards the bulbar urethra.

Assessment may include:

• Urinary flow-rate testing
• Post-void residual ultrasound
• Flexible cystoscopy
• Retrograde urethrogram
• Voiding cystourethrogram
• Urethral ultrasound in selected cases

Short strictures may sometimes be managed endoscopically, but repeated dilatation or urethrotomy has a significant recurrence risk when active lichen sclerosus remains.

Longer or recurrent strictures may require urethroplasty. Oral lining tissue, usually buccal mucosa from the inside of the cheek, is commonly used for reconstruction.

The European Association of Urology recommends that genital skin should not be used as a graft for lichen-sclerosus-related urethral strictures, because the disease can affect the graft and recurrence rates are poor.

Complex cases are best managed by a urologist experienced in reconstructive urethral surgery.

Other surgical options

Depending on the extent of disease, specialist procedures may include:

• Frenuloplasty in carefully selected cases without extensive LS
• Complete circumcision
• Meatotomy or meatoplasty
• Excision or biopsy of suspicious lesions
• Glans resurfacing when premalignant disease is present
• Oral-mucosa graft urethroplasty
• Staged urethral reconstruction
• Perineal urethrostomy for severe or recurrent extensive stricture disease

The operation should be tailored to the location and activity of the condition. Preserving diseased genital skin simply to avoid circumcision may produce repeated scarring and further procedures.

Lichen sclerosus and penile cancer

Male genital lichen sclerosus is associated with squamous cell carcinoma of the penis and with penile intraepithelial neoplasia, which is a precancerous change.

Published studies have reported widely differing cancer rates among men with genital lichen sclerosus, from close to zero in some groups to approximately 12.5% in highly selected specialist series. Frequently quoted estimates place the risk at roughly 2–6%, but the precise lifetime risk for an individual man remains uncertain.

This does not mean that most men with lichen sclerosus will develop penile cancer. Penile cancer remains rare, and appropriate treatment of inflammation and phimosis is expected to reduce risk.

It is also reported that lichen sclerosus is found in a substantial proportion of penile cancer specimens. This association cannot be reversed to mean that the same proportion of men with lichen sclerosus will develop cancer.

Risk is likely to be greater when there is:

• Long-standing uncontrolled inflammation
• Severe phimosis
• Persistent ulceration or thickening
• Poor visibility of the glans
• Cigarette smoking
• Immune suppression
• Coexisting penile intraepithelial neoplasia
• Failure to attend follow-up

Warning signs that require prompt review

A man with current or previous lichen sclerosus should seek medical assessment for:

• A persistent ulcer or sore
• A new lump or firm area
• Skin thickening
• An irregular red or velvety patch
• A warty or cauliflower-like growth
• Unexplained bleeding
• Offensive discharge
• Increasing pain
• A lesion that does not respond to prescribed steroid treatment
• A new lump in the groin

These findings do not necessarily mean cancer, but they should not be treated repeatedly as thrush or simple inflammation without further investigation.

Follow-up and self-examination

Lichen sclerosus can recur, and cancer-related changes may develop many years after initial treatment.

Patients should become familiar with the normal appearance of their penis and perform regular self-examination. When possible, the entire glans, foreskin and urinary opening should be inspected.

Medical follow-up should be tailored to disease severity. More frequent review is appropriate during active treatment, after surgery or when urethral involvement is present. Once stable, periodic or annual review may be appropriate, together with lifelong self-monitoring.

Circumcised men should still report new or persistent abnormalities.

The outlook

When recognised early, male genital lichen sclerosus can often be controlled successfully with appropriate topical corticosteroid treatment, good skin care and follow-up.

Established scarring is less likely to resolve with medication alone. Circumcision is usually highly effective for disease confined to the foreskin, while meatal and urethral disease may require more specialised reconstruction.

The important message is not to ignore a foreskin that is becoming progressively white, scarred or tight. Early assessment may prevent painful erections, urinary obstruction and more complex surgery.

The bottom line

Balanitis xerotica obliterans is the older name for male genital lichen sclerosus involving the foreskin and glans.

It commonly presents with white or scarred skin, acquired phimosis, splitting, painful erections or urinary-stream changes. Potent prescribed topical corticosteroids are the first medical treatment for suitable early disease, while circumcision is often required for established phimosis, recurrent disease or failure of medical treatment.

Meatal or urethral involvement requires urological assessment and may need reconstructive surgery.

The risk of penile squamous cell carcinoma is small but real. Persistent thickening, ulceration, bleeding, a lump or a lesion that does not respond to treatment requires prompt examination and often biopsy.

This article provides general information and does not replace personalised medical assessment. Do not use potent topical corticosteroids on genital skin without appropriate medical advice.

So guys, if you cannot retract the foreskin and has the typical appearance discussed in this article, take the time to review with your GP to have this checked out. There is effective management for this which will also then reduce your risk for penile cancer. Do not vary your head in the send and ignore this, have it seen to and let your GP refer you to your local Brisbane urologist, Dr Jo Schoeman.

References and further reading

• British Association of Dermatologists—Lichen sclerosus in males
• British Association of Dermatologists—Guidelines for the management of lichen sclerosus
• European Association of Urology—Penile Cancer Guidelines
• European Association of Urology—Urethral Stricture Guidelines
• DermNet—Lichen sclerosus in men

Penile cancer is rare, but early diagnosis matters

Penile cancer is an uncommon cancer affecting the skin and tissues of the penis. In Australia, approximately 165 men were estimated to be diagnosed with penile cancer in 2025, with the average age at diagnosis around 68 years. About 95% of penile cancers are squamous cell carcinomas (SCC).

Although the diagnosis can understandably be frightening, there is an important message:

When penile cancer is detected early, treatment is frequently curative and, in many men, much or all of the penis can be preserved.

Modern treatment has therefore moved increasingly towards penile-preserving therapy whenever this can be achieved safely.

Treatment in Australia will depend on:

• whether the abnormality is precancerous or invasive cancer
• the size and location of the tumour
• how deeply it has invaded
• the grade of the cancer
• whether lymph nodes in the groin are involved
• whether cancer has spread elsewhere
• the man’s general health and personal preferences.

Because penile cancer is rare, patients with invasive or complicated disease benefit from discussion by a multidisciplinary team (MDT) involving urology, medical oncology, radiation oncology, radiology, pathology and specialist nursing.

 

What causes penile cancer?

There is rarely one single identifiable cause.

Important risk factors include:

• infection with human papillomavirus (HPV)
• smoking
• phimosis, where the foreskin cannot be retracted
• chronic inflammation of the penis
• penile intraepithelial neoplasia (PeIN)
• increasing age
• some chronic penile skin disorders
• immunosuppression.

HPV plays an important role in a proportion of penile cancers, although penile cancer can certainly occur without HPV infection.

What symptoms should men look for?

Penile cancer often begins as a visible or palpable abnormality, particularly involving the glans or foreskin.

Symptoms can include:

• a red or discoloured area that does not disappear
• persistent irritation or inflammation
• thickening of the skin
• a lump
• a wart-like growth
• an ulcer or sore that does not heal
• bleeding
• persistent discharge
• an unpleasant smell from beneath the foreskin
• increasing difficulty retracting the foreskin
• pain or tenderness
• swelling of the end of the penis
• a lump beneath the foreskin
• enlarged lymph nodes or lumps in the groin.

More advanced disease can occasionally cause difficulty passing urine, fatigue or unexplained weight loss.

A persistent penile lesion deserves examination

Most rashes, spots and lumps on the penis are not cancer. Infection, inflammation, dermatitis and benign skin conditions are much more common.

The important issue is persistence.

A penile ulcer, lump, bleeding area or unusual skin change that does not resolve should not be hidden away in the hope that it will disappear.

Embarrassment is considerably easier to treat than advanced cancer.

How is penile cancer diagnosed?

Examination

The first step is careful examination of the penis and foreskin.

The urologist will assess:

• the site of the lesion
• its size
• whether it involves the glans, foreskin or shaft
• whether deeper tissues appear involved
• whether the foreskin can be retracted
• whether there are enlarged lymph nodes in either groin.

Both groins are particularly important because penile cancer usually spreads first through the lymphatic system to the inguinal lymph nodes.

Biopsy

The diagnosis usually requires a biopsy.

A small piece of the abnormal tissue is removed and examined by a pathologist.

Depending upon the lesion, this may be:

• a punch biopsy
• an incisional biopsy, taking part of the lesion
• an excisional biopsy, removing the whole small lesion.

A biopsy determines whether cancer is present and, importantly, identifies the type and grade of the tumour.

Histological confirmation is particularly important before treatments such as topical therapy, laser treatment or radiotherapy.

What is PeIN?

Penile intraepithelial neoplasia (PeIN) is a precancerous or very early cancerous change confined to the surface epithelium.

It has previously been described using terms such as carcinoma in situ.

PeIN is important because it can progress to invasive squamous cell carcinoma. Current European guidelines estimate progression to invasive disease despite treatment in approximately 2.6–13% of patients.

The good news is that PeIN can often be treated without removing part of the penis.

Treatment: from creams to major surgery

There is no single operation or treatment for penile cancer.

Modern management follows a ladder, beginning with the least invasive treatment capable of reliably controlling the cancer.

1. Circumcision

For abnormalities confined to the foreskin, circumcision may remove the lesion completely.

Circumcision is also frequently an important first step when PeIN involves the glans and foreskin because it allows the glans to be properly examined and treated.

For superficial disease, contemporary guidelines regard circumcision as an important primary surgical treatment.

2. Treatment with creams

Selected cases of biopsy-confirmed PeIN can be treated with medication applied directly to the penis.

The two most commonly used treatments are:

5-fluorouracil (5-FU)

5-FU is a topical chemotherapy medication.

It destroys abnormal rapidly dividing cells in the superficial layers of the penis.

Treatment usually produces inflammation of the treated area, which can include:

• redness
• burning
• crusting
• discomfort
• erosion of the surface skin.

Imiquimod

Imiquimod is different. Rather than being conventional chemotherapy, it stimulates the local immune system to attack abnormal cells.

It can similarly cause substantial redness, swelling, ulceration or crusting during treatment.

These reactions can look alarming but often indicate that the medication is producing its intended biological effect.

Current EAU-ASCO guidance supports either 5-FU or imiquimod for appropriately selected biopsy-confirmed PeIN.

Importantly, the area must be reassessed after treatment.

If the abnormality persists, repeat biopsy or alternative treatment may be necessary. Repeated courses of topical treatment should not simply continue indefinitely when the lesion has failed to respond, because invasive cancer may be hiding beneath the surface.

3. Laser and other local treatments

Very superficial lesions can sometimes be treated using laser therapy.

Depending upon expertise and availability, other local treatments such as photodynamic therapy or cryotherapy have also been used.

These approaches can preserve the penis but require careful long-term surveillance because local recurrence is possible.

4. Penile-preserving surgery

One of the major changes in penile cancer surgery has been the move away from automatically removing a substantial portion of the penis.

Whenever oncologically safe, the aim is:

remove the cancer, obtain clear margins and preserve as much normal penis as possible.

Operations may include:

Wide local excision

The cancer and a margin of surrounding tissue are removed.

The defect may be closed directly or reconstructed with a skin graft.

Glans resurfacing

The abnormal surface layer of the glans is removed while preserving the deeper erectile tissue.

A skin graft is then placed over the glans.

This can be particularly useful for extensive superficial disease.

Glansectomy

If cancer is confined to the glans but is too extensive or invasive for simpler treatment, part or all of the glans may be removed.

Reconstruction can then be performed, often using a skin graft to create a new glans-like surface.

Current guidelines favour organ-preserving surgery for appropriately selected PeIN and T1–T2 tumours involving the glans or prepuce, provided the patient understands the need for careful follow-up.

5. Partial penectomy

More deeply invasive cancer may require removal of part of the penis.

This is called a partial penectomy.

The surgeon attempts to retain enough penile length to permit comfortable urination and, where possible, sexual function.

This may be necessary when cancer extends more deeply into the erectile tissues and cannot be reliably removed using penile-preserving techniques.

6. Total penectomy

Occasionally a cancer is too large, too proximal or too deeply invasive for part of the penis to be safely preserved.

A total penectomy may then provide the best opportunity for cure.

This understandably sounds confronting. It is generally reserved for circumstances in which less radical treatment would compromise cancer control.

Current EAU-ASCO recommendations support total penectomy with perineal urethrostomy for large invasive tumours that cannot safely be treated by partial penectomy.

What is a perineal urethrostomy?

This is sometimes mistakenly referred to as a “perineotomy”.

Following total removal of the penis, urine still needs a pathway from the bladder to the outside world.

The urethra is therefore brought to the skin of the perineum, the area between the scrotum and anus.

This opening is called a:

Perineal urethrostomy

The patient subsequently passes urine through this opening while sitting on the toilet.

A catheter is generally left temporarily while the area heals.

Once healed, most men can empty their bladder normally through the new opening and do not require a permanent catheter.

Potential problems include:

• narrowing or stenosis of the opening
• spraying
• infection
• wound complications
• occasionally the need for further surgery.

A perineal urethrostomy does not mean that the bladder or kidneys have stopped functioning. It simply changes the final few centimetres of the urinary plumbing.

The lymph nodes are extremely important

Treating the penis itself is only one half of penile cancer management.

The other half is determining whether cancer has reached the inguinal lymph nodes in the groin.

Penile cancer generally spreads in a predictable sequence:

Penis → inguinal lymph nodes → pelvic lymph nodes → distant organs

Lymph-node involvement is the single most important prognostic factor in penile cancer.

What if there are no enlarged lymph nodes?

Unfortunately, normal-feeling groins do not completely exclude microscopic cancer.

Men with higher-risk primary tumours may therefore require further lymph-node assessment despite having no palpable lumps.

This may involve:

• ultrasound of the groins
• ultrasound-guided needle biopsy of abnormal nodes
• dynamic sentinel lymph-node biopsy
• inguinal lymph-node dissection in selected circumstances.

Current EAU-ASCO guidance recommends surgical lymph-node staging for patients at significant risk of microscopic metastatic disease, particularly T1b disease or higher.

What if a groin lymph node is enlarged?

An abnormal lymph node may be assessed using ultrasound and needle biopsy.

If metastatic penile cancer is confirmed, treatment may involve:

• inguinal lymph-node dissection
• pelvic lymph-node dissection in selected patients
• chemotherapy
• radiotherapy
• combinations of these treatments.

Patients with clinically node-positive disease are generally staged with CT or FDG-PET/CT to assess pelvic and distant disease before definitive treatment.

Early treatment of lymph-node disease is extremely important.

Radiation therapy

Radiotherapy has an important but selective role in penile cancer.

Treatment of the primary cancer

Selected smaller T1 or T2 cancers can potentially be treated with radiation instead of surgery.

Treatment can involve:

External beam radiotherapy

Radiation is directed at the tumour from outside the body.

Brachytherapy

Radioactive sources are temporarily positioned within or very close to the tumour, allowing a concentrated radiation dose to be delivered while limiting exposure to surrounding tissues.

Radiotherapy may therefore provide another means of preserving the penis in appropriately selected patients.

Potential complications can include:

• skin irritation
• ulceration
• fibrosis
• narrowing of the urethra
• changes in penile sensation
• erectile dysfunction
• tissue damage or necrosis in uncommon circumstances.

Radiotherapy is also used in selected patients for regional lymph-node disease, as part of chemoradiotherapy for advanced disease, or for palliation of symptoms from metastatic cancer.

Chemotherapy

Chemotherapy is generally reserved for more advanced penile cancer, particularly when significant lymph-node disease or metastatic disease is present.

In Australia, contemporary treatment may involve platinum-based combination chemotherapy.

One regimen used in advanced disease is:

TIP: paclitaxel + ifosfamide + cisplatin

Australia’s eviQ cancer treatment resource includes TIP as an option in neoadjuvant, adjuvant and metastatic penile cancer settings.

For bulky or fixed inguinal lymph-node disease or pelvic lymph-node involvement, chemotherapy may be given before surgery.

This is called neoadjuvant chemotherapy.

The aim is to:

1. treat microscopic disease throughout the body,
2. shrink the cancer in the lymph nodes,
3. determine whether the cancer is responding,
4. make subsequent surgery more effective or technically achievable.

Current international guidance recommends cisplatin- and taxane-based neoadjuvant chemotherapy for suitable patients with extensive inguinal or pelvic nodal disease, followed by surgery when appropriate.

Chemoradiotherapy

Radiotherapy and chemotherapy can sometimes be combined.

This may be considered for selected patients with:

• locally advanced disease
• unresectable cancer
• extensive lymph-node disease
• disease where major surgery is unsuitable
• palliative treatment requirements.

The evidence is evolving, and these decisions should generally be made through a specialist penile cancer MDT.

What about immunotherapy?

Immunotherapy is an exciting area of cancer treatment, but its role in penile cancer is still developing.

Checkpoint inhibitors such as pembrolizumab and related drugs have demonstrated activity in some patients with advanced penile cancer, and newer combinations of chemotherapy and immunotherapy are being investigated.

However, response rates to checkpoint inhibitors alone are relatively modest and there is not yet sufficient evidence to use biomarkers such as HPV or PD-L1 routinely to determine which penile cancer patients should receive immunotherapy.

Clinical trials are particularly important for men whose cancer progresses despite standard platinum-based chemotherapy.

What happens to sexual function?

This depends enormously on treatment.

After topical treatment, circumcision, laser therapy, glans resurfacing or limited local excision, satisfactory sexual function may often be preserved.

After glansectomy or partial penectomy, intercourse may remain possible depending upon remaining penile length, erectile function and reconstruction.

After total penectomy, penetrative intercourse using the penis is no longer possible.

This does not mean that intimacy, sexual sensation or orgasm automatically disappears.

Sexual rehabilitation, psychological support and discussion with the patient and his partner can be an important component of recovery.

These conversations should ideally begin before treatment, not after it.

What is the prognosis?

Penile cancer is potentially highly curable when diagnosed before it has spread to lymph nodes.

The most important predictor of survival is not simply the size of the penile lesion but whether cancer has reached the lymph nodes.

Current EAU-ASCO data report approximate five-year cancer-specific survival according to nodal stage of:

Lymph-node stage	Approximate 5-year cancer-specific survival
N0 – no lymph-node metastases	95%
N1	80%
N2	65%
N3 – advanced nodal disease	35%

These are population figures, not predictions for an individual patient.

Prognosis depends upon the tumour’s stage and grade, lymph-node involvement, response to treatment, general health and other pathological features.

The figures do, however, demonstrate why early diagnosis and appropriate assessment of the groin lymph nodes are so important.

Follow-up after treatment

Penile cancer requires ongoing surveillance.

Follow-up may include:

• examination of the penis or reconstructed area
• examination of both groins
• assessment of the perineal urethrostomy where applicable
• imaging in higher-risk patients
• biopsy of suspicious recurrent lesions
• monitoring urinary and sexual function
• psychological and sexual-health support.

Penile-preserving treatment requires particularly careful surveillance because local recurrence can occur.

Importantly, a local recurrence identified early can often still be successfully treated.

Do not ignore a change in the penis

Penile cancer is uncommon, and most penile skin problems are benign.

Nevertheless, a persistent:

lump, ulcer, red patch, bleeding area, discharge, thickened foreskin or lesion that simply will not heal deserves examination.

There should be no embarrassment in asking your GP or urologist to have a look.

For early disease, treatment may be surprisingly conservative: sometimes circumcision, a cream, laser treatment or limited surgery is all that is required.

Even when invasive cancer is present, modern penile cancer surgery increasingly focuses on preserving penile tissue, urinary function and quality of life whenever this can be achieved without compromising cure.

For advanced disease, treatment becomes more complex and may involve partial or total penectomy, perineal urethrostomy, lymph-node surgery, radiotherapy and chemotherapy.

The crucial message is simple:

The earlier penile cancer is diagnosed, the greater the opportunity to cure it while preserving the penis.

Australian and international resources

Cancer Council Australia: Penile Cancer

Cancer Institute NSW: Penile Cancer

eviQ Australian Penile Cancer Chemotherapy Protocol

2026 EAU-ASCO Penile Cancer Guidelines

This information is intended for patient education and does not replace individual medical assessment. Treatment of penile cancer should be tailored to the tumour stage, pathology, lymph-node status, general health and preferences of the individual patient.

So, if you have noticed a lesion on your penis and it is growing, don’t ignore it and hope it will go away, go see your GP and come see your friendly Brisbane Urologist, Dr Jo, to discuss management options with you.

Foreskins come in all shapes and sizes. Some are short, some sit neatly over the tip of the penis, and others extend well beyond the glans, occasionally giving the penis the appearance that it has ordered the extra-long sleeve option.

A long foreskin, sometimes described medically as a redundant or elongated prepuce, is usually simply a normal anatomical variation. Length alone is not a disease and does not automatically require treatment.

The important question is not “How long is it?” but rather:

Does it cause any problems?

What is a long or redundant foreskin?

The foreskin, or prepuce, is the fold of skin covering the glans (head) of the penis. Its length varies considerably between men.

In some men, the foreskin extends only slightly beyond the glans when the penis is flaccid. In others, there may be a considerable amount of skin extending beyond the tip.

The appearance can also change substantially between the flaccid and erect states. A foreskin that looks impressively generous when flaccid may retract quite normally during an erection.

There is therefore no particular measurement at which a foreskin suddenly becomes “too long.”

If it retracts comfortably, causes no symptoms and can be kept clean, there is generally no medical reason to shorten it.

Can a very long foreskin cause problems?

Most men with a long foreskin have no problems whatsoever.

Occasionally, however, additional foreskin can contribute to several issues.

Hygiene

A longer foreskin may make cleaning beneath the foreskin slightly more important.

Smegma, dead skin cells and moisture can accumulate underneath the foreskin if it is not regularly retracted and washed. This may produce irritation or an unpleasant smell.

Fortunately, the solution is usually wonderfully low-tech: water, gentle washing and regular hygiene.

Aggressive scrubbing, strong soaps, antiseptics and fragranced products can actually irritate this rather sensitive real estate.

Recurrent balanitis

Balanitis is inflammation of the glans. When both the glans and foreskin are inflamed, the condition is called balanoposthitis.

Symptoms may include:

• Redness
• Swelling
• Itching or burning
• Discomfort
• Discharge
• Unpleasant odour
• Difficulty retracting the foreskin

Recurrent inflammation deserves assessment because there may be an underlying cause such as infection, dermatitis, diabetes or a chronic inflammatory skin condition.

Difficulty retracting the foreskin

A long foreskin and a tight foreskin are not the same thing.

A very long foreskin that retracts easily is generally harmless. If the opening is too narrow to retract comfortably over the glans, however, this is phimosis.

Phimosis can cause discomfort, recurrent infections, painful erections or difficulty with sexual activity.

Paraphimosis

Occasionally a tight foreskin is pulled behind the glans and becomes trapped there. The foreskin swells and cannot be returned to its normal position.

This is called paraphimosis.

Unlike having a long foreskin, paraphimosis is not merely an interesting anatomical conversation starter. It can compromise blood flow to the glans and requires urgent medical attention.

Problems during sex

Some men with considerable redundant foreskin notice excessive movement or bunching of the skin during intercourse.

Others experience:

• Irritation
• Small tears
• Discomfort
• Difficulty using condoms
• Foreskin becoming trapped behind the glans
• Problems associated with an accompanying short frenulum

Importantly, many men with long foreskins have completely normal and comfortable sexual function.

Urination

A long foreskin may occasionally balloon during urination or cause the urinary stream to spray.

A little post-urination dribbling from urine retained beneath a long foreskin can also occur.

If the foreskin opening is normal and there are no other symptoms, this is often more inconvenient than medically significant. Persistent ballooning associated with a very narrow opening, pain or difficulty passing urine should be assessed.

Does a long foreskin increase the risk of cancer?

Having a long foreskin by itself does not mean that a man will develop penile cancer.

Penile cancer is uncommon, particularly in Australia. Important risk factors include persistent HPV infection, smoking, chronic inflammation and certain foreskin disorders such as lichen sclerosus.

Any persistent penile ulcer, lump, thickened area, bleeding lesion, unusual discharge or change in the skin should therefore be examined rather than waiting for it to disappear.

The penis, regrettably, has never been particularly good at diagnosing itself.

Does a long foreskin need treatment?

Usually, no.

If the foreskin:

• Retracts comfortably
• Can be cleaned easily
• Does not cause recurrent infections
• Does not interfere with urination
• Does not cause pain during erections or intercourse
• Does not bother the patient cosmetically

then no treatment is required.

The medical principle here is refreshingly simple:

If it isn’t causing a problem, there may be nothing to fix.

Conservative management

When symptoms are minor, treatment may involve improving foreskin hygiene and treating any underlying inflammation or infection.

Where there is associated mild phimosis, a doctor may recommend a course of topical corticosteroid cream combined with gentle stretching.

Forceful stretching should be avoided. Small tears can produce scarring, and scarring can make the foreskin progressively tighter, turning a relatively minor problem into a considerably more stubborn one.

Surgical options

Surgery may be considered when there are significant or recurrent problems.

Circumcision

Circumcision removes the foreskin and permanently exposes the glans.

It is a reliable treatment for recurrent balanitis, troublesome phimosis and certain chronic foreskin diseases.

Potential complications include bleeding, infection, altered sensation, cosmetic dissatisfaction, wound problems and, rarely, more significant complications.

Foreskin-preserving surgery

Not every foreskin problem requires complete circumcision.

Depending upon the anatomy and underlying problem, procedures such as preputioplasty can widen a tight foreskin while preserving much of the foreskin.

In selected men with excessive redundant skin but an otherwise healthy foreskin, surgical shortening may also be discussed.

The appropriate operation depends upon the reason for treatment rather than simply the number of centimetres of foreskin involved.

What about appearance?

Some men simply dislike having a long foreskin.

That is a legitimate concern to discuss with a urologist, but cosmetic surgery deserves careful consideration because surgery permanently changes normal anatomy.

It is particularly important to distinguish between a genuinely troublesome anatomical issue and anxiety created by comparisons with pornography, photographs or other men.

There is an enormous range of normal penile anatomy.

Normal does not come in one factory setting.

When should you see a urologist?

Consider seeking medical advice if you have recurrent infections, difficulty retracting or replacing the foreskin, painful erections, tearing or bleeding, problems during intercourse, difficulty passing urine, persistent skin changes or simply uncertainty about whether your foreskin is normal.

A foreskin that suddenly becomes swollen and trapped behind the glans requires urgent assessment, particularly if the glans becomes increasingly swollen, painful or discoloured.

The bottom line

A very long foreskin is usually a variation of normal anatomy rather than a medical condition.

There is no prize for having the shortest foreskin, and fortunately no excess-baggage fee for having the longest.

What matters is function.

If your foreskin retracts normally, stays healthy, allows comfortable erections and intercourse, and can be kept clean, its length alone is unlikely to require treatment.

If it becomes tight, painful, repeatedly inflamed or simply troublesome, however, a urological assessment can determine whether conservative treatment or surgery is appropriate.

When it comes to foreskins, longer isn’t necessarily better or worse. Sometimes it is simply… longer.

So, if this does not answer your questions, come see your Brisbane Urologist, Dtr Jo Schoeman for peace of mind.