Evaluation and Management of Glans Penis Lesions – EAU Guideline Recommendations

Initial Clinical Assessment

Immediate detailed physical examination is required for any glans penis lump, with systematic documentation of morphology, size, color, borders and lesion count; up to 20 % of lesions that appear benign may harbor invasive cancer. (European Association of Urology) 1
The examination must assess depth of invasion by evaluating the relationship of the lesion to the submucosa, tunica albuginea, urethra, corpus spongiosum and corpus cavernosum. (EAU) 3
Both inguinal regions should be inspected and any palpable lymph nodes recorded for number, laterality and characteristics. (EAU) 4

When malignancy cannot be excluded clinically, obtain a pretreatment incisional or excisional biopsy (punch or scrapings are insufficient). (EAU – strong recommendation) 3
Punch biopsies frequently miss invasive disease, leading to under‑diagnosis. (EAU) 3
Up to 20 % of patients presumed to have non‑invasive disease are found to have invasive cancer on definitive pathology. (EAU) 5
A biopsy is mandatory before any nonsurgical (e.g., topical or ablative) therapy is considered. (EAU) 4

Penile MRI (artificial erection not required) should be performed when there is uncertainty about corporal invasion or when organ‑preserving surgery is being contemplated. (EAU) 4
If MRI is unavailable, high‑resolution penile ultrasound is an acceptable alternative. (EAU) 4

Patients with high‑risk primary tumors (≥ T1b) should undergo surgical nodal staging using dynamic sentinel‑node biopsy (DSNB). (EAU) 4
For low‑risk T1a G2 disease, active surveillance is permissible provided the patient can adhere to strict follow‑up. (EAU) 2
If DSNB is not feasible, inguinal ultrasound with fine‑needle aspiration of sonographically abnormal nodes is recommended. (EAU) 3

Image‑guided core biopsy of palpable nodes must be obtained before definitive treatment. (EAU) 4
If the initial biopsy is negative but clinical suspicion remains, repeat biopsy or surgical node excision is advised. (EAU) 6
Whole‑body staging with 18F‑FDG PET‑CT or contrast‑enhanced CT of chest/abdomen should be performed to exclude distant metastases. (EAU) 4

Inadequate sampling (punch biopsy) can miss invasive disease; incisional or excisional biopsy is essential. (EAU) 3
Approximately 50 % of palpable inguinal nodes at initial presentation are inflammatory; however, nodes that become palpable during follow‑up are malignant in nearly 100 % of cases. (EAU) 6
Even T1 G2 tumors carry a 13‑29 % risk of lymph‑node metastasis. (EAU) 6

Surgical options (circumcision, wide local excision, partial glans resurfacing) achieve recurrence rates of 0‑20 %. (EAU) 5
Topical therapy with imiquimod yields response rates of 40‑100 % (recurrence ≈ 20 %); 5‑fluorouracil shows responses of 48‑74 % (recurrence ≈ 11 %). (EAU) 5
Laser ablation (Nd:YAG or CO₂) provides response rates of 52‑100 % with recurrence 7‑48 %. (EAU) 5
Clinical response must be verified; any doubtful area should be re‑biopsied because incomplete response may mask invasive carcinoma. (EAU) 5

Organ‑preserving surgery is preferred when feasible, requiring negative margins with a minimum of 1 mm clearance. (EAU) 5
Local recurrence in higher‑risk tumors adversely affects survival, challenging earlier assumptions that recurrence is benign. (EAU) 4

Early, accurate diagnosis enables organ‑preserving strategies that maintain sexual function, urinary function and the patient’s sense of masculinity. (EAU) 1
Surgical excision provides complete histopathologic staging, which is superior to ablative modalities for treatment planning. (EAU) 5