Trouble under the hood (updated)

Dear Dr. G,

I am a guy in my mid-twenties and since my teenage years, I have always noticed some difficulties to fully retract my foreskin. This often results in regular smelly inflammations of the glans penis.

I understand this is a condition called phimosis, and quite a common condition mostly resolves on its own.

I admit sex with tight foreskin is not particular easy. Despite the occasional cracks in the skin and pain on penetration, I get by with several sexual relationships without much complaint.

I recently had a shock of my life when I retracted my foreskin to wash, and revealed a growth in the glans penis just under the foreskin.

I went to the doctors, who told me the lump is a genital wart.

He elaborated this is most likely sexually transmitted and will cause cancer. He advised me to have a circumcision and consider vaccination for the HPV.

With the looming troubles under my cover, I would like to put Dr. G on the spot for his opinion on HPV and Penile cancer.

I have not heard of penile cancer, is the cancer of the penis really possible?

What are the symptoms of penile cancer?

Who is at risk? Is HPV the main cause of penile cancer?

I often thought HPV only affects women. Does it also infect men?

I understand the vaccine is only for women, why is the doctor offering it to me?

Lastly, with the emergence of the genital warts, do I really need the circumcision and the vaccine?

Yours truly,
Troubled Thomas

Penile cancer is a malignancy which arises in the foreskin, glans or shaft of the penis. The typical symptoms are abnormal growths, which may result in ulceration, pain and foul-smelling discharge. Although penile cancer is relatively uncommon, it can affect more than thirty thousand men per year with mortality as high as fifty per cent. Penile cancer is associated with many modifiable risk factors such as smoking, phimosis (non-retractable foreskin), chronic inflammation, multiple sexual partners and HPV (Human Papilloma Virus) infections. Hence, cancer of the penis is often considered a preventable malignancy.

One of the preventive measures against penile cancer is the removal of the foreskin. Circumcision during infancy or childhood is known to have partial protection against penile cancer. However, the protective effect of circumcision in adulthood is questionable. It has been suggested the removal of foreskin ensures better personal hygiene, reduce risk of smegma and HPV transmission.

HPV or Human Papillomavirus is a common virus that is transmissible through direct skin-to-skin contacts. There are more than 150 subtypes of HPV viruses, and nearly forty are known to be transmissible by sexual contacts. Therefore the virus is often considered the most common form of sexually transmitted infection, and nearly all sexually active men and women would get the virus at some point in their lives.

For most cases of HPV transmissions, there is no identifiable symptom. However, for certain strains such as HPV6 and 11, the infections may result in the emergences of genital warts. In more serious cases, the transmissions of HPV 16 and 18 are also linked to 70% of cervical cancers globally.

In addition, scientists have also associated other cancers such as penis, anus, mouth and throat with many strains of HPV infections. The Centre for Disease Control and Prevention (CDC) postulated around 40% of penile cancer annually in the United States. In addition, around half of the men presented with penile cancer also have genital warts, which increases the risk of invasive cancer by nearly four-folds.

Since the associations of HPV infection with cancers have been identified in 1982, scientists have been working hard to create a vaccine that can prevent the transmission of the virus in the first place. The first HPV vaccines became available in 2006 against the crucial HPV subtypes 6,11,16 and 18, providing protection of up to 70% of cervical cancers and genital warts.

The quadravalent vaccine that has been available in the last decade provides the 70% protection against cervical cancers; many researchers still do not consider the coverage to be adequate. The development of the new vaccine that prevents the transmission of nine types of HPV was approved by the US Food and Drug Administration (FDA) in 2014 has been shown to be successful as the additional protection against HPV 31,33,45,52 and 58 have been demonstrated to prevent up to 90% of the cancers, and this has generated excitement amongst physicians advocating vaccination.

For the last decade, the World Health Organization (WHO) has put the vaccine on the list of essential medicine and recommends routine vaccinations for girls in countries that can afford them. The vaccines have also been shown to provide protection for boys from genital warts, certain cancers and even potential of generating the herd immunity for the future. In addition to adolescent vaccination, the efficacy of the HPV vaccine in non-sexually active men is also scrutinized. It is believed such protection also extends to the risk reduction of genital warts and progression to penile cancer. However, routine vaccination programs for boys are routine only in a handful of countries.

As we are approaching the final few days of November, the Men’s Health Awareness Month aims to highlight many health issues faced by men in different stages of life. Admittedly, many of the sexual health matters can be embarrassing and taboo, however the association of sexual health with testicles, prostate and penis cancers is obvious. The spirit of Movember November allows men to generate conversation about sexual health and bringing about knowledge and empowerment for men to take charge of their health.

The American political philosopher and political revolutionary, Thomas Paine once said: “Real man smiles in trouble, gathers strength from distress and grows brave by reflection.” When uncircumcised men with trouble under their penile cover are putting Dr. G on the spot about the needs for vaccination and circumcision. His view is the cuts and jabs are inevitable for Thomas, however for everyone else, the dialogue of this issues will ensure that: “Real men smile before getting into trouble, gather strength from knowledge and grow brave by keeping healthy!”