Figure 1 Infections of the genitals
What’s wrong with my dick?!? Fear strikes the heart of the man who notices something “not right” with his penis. If you are the type to have a complete OCD meltdown at the first sign of a blemish, this chapter may help reassure you. On the other hand, if you are the don’t ask, don’t tell type, this chapter may be the wake-up call that could save your life or someone else’s. Fortunately, penis cancer is rare and, aside from STDs, many lumps, bumps, and discolorations a man will notice are not harmful. But let’s face it, it’s a jungle out there. The levels of the most common sexually transmitted diseases are at all-time highs, and some cause penis cancer and cervical cancer. It’s important to recognize their various signs and symptoms. When you’re trying to score, you don’t want to end up a “sore loser.” Even if it’s not contagious, a penis problem may still be bothersome or even dangerous. This chapter will help you troubleshoot anything that looks wrong down there and remind you why it’s important to watch where you stick that thing!
Worldwide, more than a million people a day become infected with a sexually transmitted disease.1 In the United States alone, about 20 million new sexually transmitted diseases occur each year, and the number keeps rising—that’s a lot of screwing around! The rates for gonorrhea, chlamydia, and syphilis are at all-time highs, especially for younger people and gay and bisexual men. These diseases are not reliably reported to the public health department, so the situation is likely even worse than we know. Using a condom is your best defense. Most sexually transmitted diseases are spread by one or another combination of contacts between the genitals, anus, and mouth. If you get something, early detection is key because most sexually transmitted diseases are manageable, if not curable. Ignoring an STD can lead to pain, urinary problems, infertility, and even death. The following section describes various sexually transmitted diseases. This section is not meant to substitute for a good doctor, but rather to alert you to get treated if you have any symptoms remotely similar to those described herein.
Some STDs cause a urethral discharge. Chlamydia and gonorrhea, the two most common of all reported STDs, are bacterial infections that can cause a discharge. This is an opaque whitish, yellowish, or greenish fluid. Sometimes you might notice it in your underwear, and other times it’s just a tiny drop that you can only see if you “milk” your urethra. Sometimes there is irritation or even damage to the urethra or the testicles and their ducts, but in many cases there are no obvious symptoms. Either way, the infection can still be contagious and can damage a man’s or woman’s reproductive system, leaving him or her infertile. Infections and irritations of the throat or anus can occur as well.
Chlamydia and gonorrhea are easy for your doctor to diagnose with a urine test, blood test, or urethra swab. Gonorrhea is becoming harder to eliminate with antibiotics, but both infections are usually eliminated with prescription antibiotics. It’s best for both partners to get tested and treated so they don’t pass the infection back and forth.
Ureaplasma and mycoplasma are less common bacterial infections. They may cause itching or burning in the urethra but typically don’t cause a drip.2 Trichomoniasis and gardnerella are other infections that usually don’t cause any symptoms in men but often do in women. Trichomoniasis is actually a tiny parasite that more commonly causes a greenish vaginal discharge in women. Gardnerella vaginalis are common bacteria that can cause vaginal itchiness and odor in women, a common condition known as bacterial vaginosis (BV). In men, it only occasionally causes a frequent urge to urinate. These less common infections are not routinely screened for but can be straightforwardly detected and treated.3, 4
Human papillomavirus (HPV) causes genital warts and is transmitted by skin-to-skin contact. There are numerous strains of this virus, and a few cause cancer of the cervix or the penis.
A fleshy, cauliflower-like wart grows on the skin of the penis or vagina where the virus has entered. It can also occur in the throat or around the anus, depending on the exposure. If it occurs in the urethra, it may cause a drop of blood on the underwear or a tiny bit in the urine. These warts often cluster together in tiny cauliflower-like masses. The virus does not necessarily activate the skin to form a wart, and a person can carry the virus or even pass it along without any obvious clues. An HPV test performed by swabbing the genitals, anus, or throat may detect the virus.
Treatment may include topical prescription medication, or a doctor may freeze, burn, or cut off the lesions. Some strains of the virus that cause this wart can cause penile and cervical cancer, so women should make sure that they have regular cervical cancer screenings.5
Penile warts often come back and have to be retreated. Recently an HPV vaccine (Gardasil 9) has been released that prevents some strains of HPV. It’s best to get the vaccine by age 11 or 12, when the immune system is young and strong and because it works best if given before exposure to the virus.
A rare variation of genital warts is called giant condyloma acuminatum (Buschke-Lowenstein tumor), caused by two strains, HPV type 6 or 11. It grows very rapidly and can take over the entire penis shaft in a few months. It is a form of cancer but it invades below the skin very slowly and almost never spreads to other organs or lymph nodes. It is treated the same way warts are.6
Molluscum contagiosum is a viral infection that can cause small, whitish, pearly bumps with a dimpled center to appear on the penis and other areas of skin as well. It is passed by skin-to skin contact including but not limited to sex. It does not lead to any other problems and usually goes away on its own but it can take some time so freezing, burning, or cutting by a doctor is an option. Once it’s gone, the person is not contagious.
Crabs and scabies are tiny “love bugs” that are transferred from one person to another with a little bump and grind. Crabs are pubic lice, tiny but visible insects that are “bush dwellers,” living and laying white eggs in the pubic hair. Scabies are tinier bugs called mites that are “cave dwellers,” actually burrowing under the skin and laying eggs there, creating intensely itchy red spots. They are both highly contagious but curable with medicated lotions, shampoos, and detergents. In addition to treating your body, you have to clean your clothes and bedding to get rid of these nasties.7
Genital herpes is a viral infection caused by the herpes simplex type 2 virus. This is different from the herpes simplex type 1 virus that causes cold sores that blister up on the lip. The virus can cause recurring outbreaks of painful small, clear blisters on the shaft of the penis or the labia of the vulva. It can also affect the thighs, buttocks, anus, or mouth, depending on the exposure. But most people who are infected with herpes never actually have an outbreak at all, so they may never even know they have it. For those who do get outbreaks, they can recur several times a year or only occasionally. When genital herpes comes back, it usually reappears as a smaller patch and goes away faster. The blisters crust up and then heal.
Herpes can be diagnosed with a blood test or a test of the fluid from the blisters. There is no cure for herpes. It’s the gift that keeps on giving, but it can be suppressed with prescribed antiviral pills. Treatment minimizes discomfort and decreases the risk of giving it to someone else.
Syphilis, chancroid, and lymphogranuloma venereum (LGV) are bacterial infections that cause ulcers on the penis, vagina, or anus, depending on the contact. Syphilis can take on three distinct forms if left untreated long enough. Syphilis ulcers do not hurt and eventually go away. Without treatment, stage two sets in about a month later with a spotted rash on the palms and soles of the feet. If still untreated, the bacteria go dormant only to reawaken years later, causing severe damage to internal organs and even the brain. Unlike syphilis, chancroid ulcers are very painful. LGV causes very small ulcers, but both chancroid and LGV can give rise to painful pus-filled abscesses in the lymph nodes of the groin.8 LGV can be a real pain in the ass, inflaming the rectum and even causing anal fissures and fistulas.
Syphilis is diagnosed with a blood test and easily cured with good old penicillin. It is on the rise primarily in the male homosexual population. If left untreated, the damage to organs and nerves can be permanent. Chancroid can be hard to diagnose in the lab, so it’s usually diagnosed based on the symptoms. It is curable with a single dose of prescription antibiotics. LGV can be diagnosed by a rectal specimen, needle specimen from a lymph node, or blood test and it can be cured with a 3-week course of prescription antibiotics.
The most lethal sexually transmitted diseases, AIDS, hepatitis B, and hepatitis C are transmitted by blood and semen, typically through breaks in the skin of the penis or walls of the vagina or throat or anus. These infections do not cause any lumps or bumps on the penis. However, having one of the other sexually transmitted diseases increases the odds that you also have HIV or hepatitis or at least makes it easier to catch them since your skin barrier is usually compromised at the site of the sore. HIV, or human immunodeficiency virus, causes AIDS; it is a retrovirus that invades certain white blood cells in your immune system called T cells. In the past, HIV was usually rapidly fatal. Although it cannot be cured, it can be lived with for many years, thanks to advances in medication. Many do not have access to these medications, and HIV continues to be a devastating epidemic worldwide. Although in the United States it is more prominent in the homosexual population, it affects men and women and either can pass it on. Hepatitis B and hepatitis C are also carried in the blood and semen. They can be passed from one person to another from sexual contact, sharing of hypodermic needles, or blood transfusions. These viruses attack the liver and eventually cause liver disease and, often, liver cancer. There is a vaccine for hepatitis B, but not for hepatitis C. Only recently have breakthrough medications provided a cure for hepatitis C. You may not know you have hepatitis B or hepatitis C for many years, so if you suspect you may have been exposed you should get tested right away.
All the sexually transmitted diseases, from AIDS to Zika, can be prevented by using a condom. All these diseases require skin-to-skin or body fluid–to–body fluid contact and, short of abstinence, condoms or dental dams are the only way to ensure that doesn’t happen. A vasectomy does not provide any protection against sexually transmitted diseases, nor do birth control pills, IUDs (intrauterine devices), or diaphragms. Long-term monogamous relationships lower your risk as well.
The following sections describe various lumps and bumps that are not sexually transmitted diseases. Some are due to infections, but not typically from sex. Other conditions are due to inflammation, an overactive immune center, or just variations from the norm. Cancer is rare but dangerous, so recognizing it early can save your life.
Jock itch, a close cousin of athlete’s foot, is caused by the fungus tinea cruris. It hides in moist places like gym showers and used wet towels, sweaty underwear, and sweaty socks. It infects dark, moist places like the crease between your thighs and scrotum, causing redness and itching. The rash may have crusty or blistery borders and its center may be brownish. Protect yourself by drying off well and putting on clean underwear after athletic activity. As proud as you may be of your package, don’t wear clothes that are too tight because they can break down your skin and let the infection take hold easier. If you have athlete’s foot, you need to treat it or you can spread it to your groin, even just by passing your feet through your underwear as you get dressed. Consider putting on your socks before your underwear. Also use shower shoes when you are in a gym, and make sure to change your underwear after it gets damp from sweat.
You can treat jock itch yourself with a variety of over-the-counter sprays or ointments. The key is to treat for a full 2 weeks even if it seems to clear up after 1 week because some of the fungus will become spores when you treat it. Spores are like little biological bunkers that are protected from the medication. Then they reemerge a week later. If you keep treating for 2 weeks, you will knock the rest of the fungus out; if not, you run a high risk of the infection coming right back. If your rash doesn’t clear up, see the doctor for an evaluation. You may be prescribed stronger sprays, ointments, or even oral antifungal pills.
Another common fungus is Candida albicans. It likes to hang out under the foreskin where it’s moist and dark and is more common in men with diabetes. Reddish dots or larger flat splotches form on the head of the penis or just under it, on the foreskin. Pain or itchiness is common, and sometimes the foreskin can get so inflamed it contracts and narrows, making it hard to pull back.
A doctor will commonly refer to candida as a “yeast infection.” She will treat it with prescription antifungal ointments. As with jock itch, it’s best to treat for a full 2 weeks even if the visible rash clears up so that hidden spores are wiped out too. More severe cases may be treated with prescription antifungal pills. Circumcision may be recommended in cases where it keeps coming back or the foreskin is damaged. The fungus can be passed back and forth between sexual partners.
Cellulitis is a bacterial infection of the skin and underlying fatty tissues that causes redness and swelling. The bacteria may be an aggressive strain of the staphylococcus that normally live on your skin or a nasty strain of bacteria that came from your stool, such as clostridium or streptococcus. These infections are more likely if you have poor circulation and an impaired immune system from diabetes or malnutrition or alchoholism. Cellulitis may get its start from a pimple or cut on your groin or genitals or it may spread from a rectal fissure or fistula.
The bacterial infection causes the skin to become red, swollen, and tender wherever it occurs. This may be on the scrotum, shaft of the penis, groin, or anal areas. It is common to have a fever too. In some cases the bacteria get walled up by the tissues, creating an abscess, which is a pocket of pus. Pus is comprised of your immune cells battling it out with bacteria. In the worst-case scenario, the bacteria do not stay contained and actually kill the tissue they are infecting, causing areas that are dusky or black rather than red and swollen. This is called gangrene and it is the telltale sign of flesh-eating bacteria, which can be lethal, spreading quickly up the torso, leaving dead skin, fat, and muscle in their path.
Don’t hesitate to see a doctor if you have redness, swelling, pus, or dead tissue on some part of your privates. Antibiotics will almost certainly be required, and you may need to be hospitalized. If you have an abscess, antibiotics alone cannot eliminate it because the bacteria are walled off from the antibiotics—it will have to be surgically cut and the pus drained out. If you have gangrene, it has to be surgically removed. If you have flesh-eating bacteria, the infected skin, fat, and muscle will have to be cut away. Otherwise, the bacteria will spread rapidly—within hours—and destroy more and more of your flesh, including all the skin on your penis, scrotum, and pelvis. This can be lethal.
Figure 1 Infections of the genitals
Contact dermatitis on the penis is inflammation of the skin from contact with something irritating. Sometimes a chemical in a new bath soap or laundry detergent can irritate the penis, causing mild burning or itching in the head or shaft or the urethral opening. This is more likely if you travel a lot, since you are then exposed to various bath soaps and detergents on the towels and sheets of different hotels. This irritation will usually just go away with time, but it can be improved with over-the-counter cortisone ointment, applied twice a day for a few days.
A number of rashes of the penis are due to areas of skin that grow too fast or die too soon. Psoriasis is a condition where a patch of skin grows new layers too quickly as a reaction to inflammation from the person’s own immune system. Normally the skin cells last about a month before they are replaced in an orderly fashion. When psoriasis flares up, new skin cells form about every 3 to 5 days, well before the old ones are ready to drop, and this causes a buildup of reddish, thickened, scaly, itchy or painful skin on the penis and scrotum as well as other parts of the body, most commonly the elbows, knees, scalp, and lower back.9 It may flare up due to increased stress, excessive alcohol intake, or a bad infection that triggers the immune system.
This condition is diagnosed by a doctor, usually based on appearance, but a skin biopsy can confirm it. Psoriasis is normally managed with a prescribed steroid cream that shortens the episodes. It is not an infection and is not contagious, so your partner can be reassured.10
Lichen sclerosus is the opposite of psoriasis. In this case the immune system shuts down skin cells’ growth. The skin becomes fibrous, whitish, and tight. It happens on the foreskin, shaft skin, and sometimes the urethral opening of the penis. It affects the female genitals too, but in men it is given a special name, balanitis xerotica obliterans (BXO). Sometimes this condition can progress to penis cancer.
If BXO occurs on the foreskin, it can be hard to pull the foreskin back or the skin may stick to the underside of the head of the penis. If BXO affects the opening of the urethra, it may narrow it, making it hard to urinate. The affected areas can crack and bleed more easily than normal skin.
Like psoriasis, this condition is typically diagnosed by a doctor and treated with prescription steroid cream. Occasionally surgery may be required to fix a very narrowed urethral opening. Other autoimmune conditions that suck the life out of skin cells include lichen planus, which leaves the skin of the head of the penis looking cobblestoned, and lichen niditus, which covers the penis skin in tiny white dots.11
Several lumps and bumps are normal variations of the skin or minor changes that can be left alone. Angiokeratomas are tiny blobs of blood vessels that pop up on the head of the penis or scrotum. Sometimes they are on the abdominal wall and thighs. These are dark red or bluish in color and range in size from 1 to 6 millimeters. Usually they don’t cause any bother, but they can bleed if you pick at them or scratch them.12 Pearly papules are tiny bumps in rows just under the head of the penis. Often mistaken for warts, they are completely normal, not infectious, and require no treatment. They are more common in uncircumcised men, occurring in 1 in 3, than in circumcised men (fewer than 1 in 10).13
A few other common bumps on the penis and scrotum do not require treatment. Some guys are born with small, irregular skin growths on the penis or scrotum that may be considered birthmarks. Doctors call these skin tags. If a skin tag is very bothersome, it can be surgically removed. In addition, glands around the hair follicles can make tiny bumps that contain an oily substance called sebum, giving the appearance of “chicken skin.” This is normal, but sometimes a gland may get clogged and slowly fill up to become a hard, whitish nodule under the skin that looks almost like a buried pearl. These are called sebaceous cysts and they are common and require no treatment. They do not pop like pimples, so don’t try to squeeze them—you run the risk of injuring yourself and possibly getting an infection. If they really bother you, they can be surgically removed.
Fortunately, cancer of the penis is very uncommon, particularly in the modern industrialized world. Penis cancer can be very aggressive and lethal, and the cure rates are poor because guys tend to avoid getting checked out due to embarrassment or fear. Early detection is your best chance to survive and to keep your penis.
Penis cancer is thought to be due to infection by HPV type 16, which also causes cervical cancer and genital warts. It is also thought to be due to gunk stuck in the junk. Fluids and toxins that become trapped under the foreskin in uncircumcised men create chronic inflammation, which can lead to cancer. Guys who are circumcised as infants almost never get penis cancer. Guys who are circumcised later get it much less often than men who are not circumcised. Uncircumcised men still get it only rarely, especially if they observe modern hygiene practices.
Sometimes penis cancer affects only the skin, but if left untreated, it can invade and spread. If a guy is unable or unwilling to pull back his foreskin, he may not realize he has a cancer hidden under it and it may become invasive before it bothers him enough to seek treatment.
Cancer that just affects the skin without invading deeper or spreading can mimic some of the other lumps and bumps outlined in this chapter. It can be mistaken for yeast infections, large genital warts, or autoimmune rashes like psoriasis or BXO. Usually it is a lot more irregular or “angry” in appearance, but sometimes the only way to be sure is to perform a biopsy of the area. This is particularly important if the “rash” doesn’t clear up with treatment the way it is expected to. There are two main types of superficial penis cancer. One is called erythroplasia of Queyrat. Erythroplasia means “red area” and Queyrat is the name of the doctor who first wrote about it. It is a velvety red patch on the inner foreskin and/or head of the penis. The other type is called Bowen’s disease (Bowen was the doctor who wrote about it first). It looks very different, appearing as a flat, dull, patchy brownish and scaly area. About half the time it hurts or itches but about half the time it doesn’t, so you have to roll back the foreskin and look for it.14 Both variations are treated the same way. If the cancer is just on the foreskin, then a circumcision will take care of it. But if it’s on the head of the penis, then very delicate surgery called Mohs micrographic surgery is required, where fine slices are taken, like a super-precise deli slicer, just until the cancer is gone. This is done to preserve the precious real estate that is the head of the penis. Alternative treatments include laser burning, topical medications, and radiation.15
Although rare, invasive penis cancer is aggressive and often lethal. It can move throughout the body quickly and is hard to cure once it has spread. These cancers usually start from the skin itself and so they are called “squamous cell cancer” because the scientific name for skin cells is squamous cells. Invasive penis cancer often looks very irregular and “angry.” It may have rough and irregular borders, ulcers, and bleeding. The cancer may invade the fatty tissue under the skin or deeper still into the blood-filled chambers of the penis or the urethra. It can then travel through the blood vessels and lymph channels and spread to lymph nodes and other organs of the body. A doctor will diagnose the cancer with a biopsy and will attempt to determine whether or not it has spread with radiology scans. If the cancer is caught very early into its invasion, it may be treated much like superficial penis cancer but with larger surgical removal of that area, which may require skin grafting, laser burning, topical medication, or radiation. Otherwise, more aggressive surgery is required. This means surgical removal of part or even all of the penis. Radiation can be used as an alternative. The surgeon may also need to take out lymph nodes in the groin or the pelvis at that time or at a follow-up surgery, depending again on how invasive the cancer is. Radiation and chemotherapy will be required if the cancer has spread into the lymph nodes.16
Figure 2 Staging of penis cancer
Zoon balanitis (written about by Dr. Zoon) is an inflammation that looks like a shiny reddish or brownish patch on the head of the penis and the shaft just below it, sometimes with small, darker spots. It usually doesn’t hurt or itch, and sometimes it may bleed. It occurs in uncircumcised men in their fifties and sixties. It is thought to be due to irritation of the head of the penis by trapped fluids and toxins under the foreskin. Guys may be more at risk if they don’t or can’t pull back their foreskin to clean under it. It can look a lot like erythroplasia of Queyrat, the superficial form of penis cancer mentioned earlier.
The doctor will often diagnose Zoon balanitis with a biopsy. The treatment is usually circumcision, as it does not go away with antibiotics or antifungal ointments. Once the foreskin is gone, the irritation causing the abnormal patch is removed and the skin heals itself. Other treatments include prescription steroid creams or immune-suppressing creams. Zoon balanitis is not contagious and does not become cancerous.17
A lump under the skin of the shaft of the penis is almost never a cancer. The most common cause is Peyronie’s disease, an overgrowth of collagen in that spot. It can be tender and make erections painful. Peyronie’s disease is covered extensively in Chapter 17. The other explanation is a clotted vein. It too can be tender. It requires no treatment, although aspirin can help dissolve the clot slowly. This type of clot is too small to be of any risk to your lungs the way larger blood clots can.
If you see something or feel something unusual on your penis, make sure you get checked out by a doctor. Most lumps and bumps of the penis are easily diagnosed and easily treated. Never let embarrassment or shame get between your penis and proper care.