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CASE REPORT

Squamous Cell Carcinoma at the Site of a Prince Albert’s Piercing

Rachel S. Edlin, BS,* David S. Aaronson, MD,† Alex K. Wu, MD,† Sarah D. Blaschko, MD,†
Glen Yang, MD,† Bradley A. Erickson, MD,† and Jack W. McAninch, MD†
*Urology, New York University School of Medicine, New York, NY, USA; †Urology, University of California School of
Medicine, San Francisco, CA, USA jsm_1818 2280..2283

DOI: 10.1111/j.1743-6109.2010.01818.x

ABSTRACT

Introduction. Medical practitioners should be aware of genital piercing and its potential complications. General
piercings are associate with complications common to all piercings as well as some unique to urethral piercings.
Specifically, the association between carcinoma and genital piercing is not well recognized.
Aim. The present study is a report of two cases describing squamous cell carcinoma associated with genital piercing.
Methods. Case reports of two men admitted to an academic medical center.
Results. A 60-year-old man with a history of HIV and hepatitis C as well as a Prince Albert piercing presented for
treatment of a urethrocutaneous fistula. A biopsy of indurated granulation tissue surrounding the fistula revealed
invasive, moderately-differentiated squamous cell carcinoma. A 56-year-old man with a history of HIV, hepatitis C,
and a Prince Albert piercing presented following a single episode of gross hematuria. He also reported splitting of
his urinary stream. On physical examination, areas of necrosis were noted on the glans penis; biopsy revealed
invasive, poorly-differentiated squamous cell carcinoma.
Conclusions. The present study is the first to suggest a possible association between squamous cell carcinoma of the
penis/urethra and genital piercing. Patients with genital piercings, especially those with concurrent risk factors such
as HIV and HCV, should be counselled about this rare complication. Edlin RS, Aaronson DS, Wu AK, Blaschko
SD, Yang G, Erickson BA, and McAninch JW. Squamous cell carcinoma at the site of a Prince Albert’s
piercing. J Sex Med 2010;7:2280–2283.
Key Words. Urethral Cancer; Penile Cancer; Genital Piercing; Neoplasms; Squamous Cell

Introduction urethral squamous cell carcinoma arising in

patients with a history of genital piercings.

P atient reporting of genital piercing likely

needs prompting; more commonly, its pres-
ence is only discovered when a thorough physical
Case Report 1

exam is performed. Medical practitioners (both
generalists and specialists) should be aware of
genital piercing and its potential complications. As
with all piercings, complications may include
transmission of hepatitis B and C and HIV as well
as bleeding and infection. Complications unique
to urethral piercings include creation of a fistula
tract by the piercing and possible urethral stric-
ture. Additionally, there is a lesser-known associa-
tion between ear or nose piercings and carcinoma
[1–3]. The present report describes two cases of
A 60-year-old man with HIV (treated with highly
active antiretroviral therapy [HAART]) and hepa-
titis C (HCV) obtained a Prince Albert
piercing—a ring piercing through the distal
urethra exiting through the ventral surface of the
penis—approximately 4 years prior to presenta-
tion. The patient reported no complications until
9 months prior to presentation when he noticed
urine leakage around the piercing and pain with
intercourse. At that time, he removed the piercing.
Because neither symptom improved with time, the

J Sex Med 2010;7:2280–2283 © 2010 International Society for Sexual Medicine

Squamous Cell Carcinoma at the Site of a Genital Piercing
Figure 1 Case report 1. A and B are
intraoperative photographs depicting
the urethrocutaneous fistula and tumor.
C and D are representative images
from the biopsy specimen at 200¥ and
400¥ magnification, respectively.
patient presented for medical attention. He denied
a history of hematuria, other genital lesions, and
cancer. On exam, the patient was noted to have a
urethrocutaneous fistula with surrounding indura-
tion and velvety granulation tissue, a normal
appearing urethral meatus, circumcised foreskin,
and nonpalpable inguinal lymph nodes
(Figure 1A–B). A biopsy of the indurated tissue
was obtained and revealed invasive, moderately-
differentiated squamous cell carcinoma
(Figure 1C–D). Subsequently, the patient under-
went partial penectomy and bilateral superficial
lymphadenectomy with pathology demonstrating
poorly differentiated squamous cell carcinoma
(pT2N0M0).
Case Report 2
A 56-year-old man with HIV (treated with
HAART), HCV, a history of a Prince Albert pierc-
ing removed approximately 15 years ago, and
multiple urethra fistulae presented after he expe-
rienced a single episode of gross hematuria. The
patient also reported splitting of his urinary
stream. He denied any other genital lesions such as
condyloma or a history of cancer or urethritis.
Examination revealed areas of necrosis on the
glans penis, circumcised foreskin, and nonpalpable
inguinal lymph nodes. Cystoscopy revealed a
dense fossa navicularis stricture. A biopsy of the
glans penis revealed invasive, poorly-differentiated
squamous cell carcinoma and the patient under-
went partial penectomy and bilateral superficial
lymph node dissection (pT3N0M0).
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Discussion
This is the first report of genital piercing being
associated with the development of squamous cell
carcinoma. As the genital piercings in these cases
go through the urethra, it is possible that the
urethra is the site of origin of this cancer. Squa-
mous cell carcinoma of the distal urethra would
look similar to squamous cell carcinoma of the
penis microscopically. Despite the questionable
site of tumor origin (penis vs. urethra), linking
these two cases of squamous cell carcinoma
remains the history of a genital piercing.
Risk factors for squamous cell carcinoma of the
penis include an uncircumcised phallus, poor
hygiene, history of phimosis, multiple sexual part-
ners, human papilloma virus infection, and expo-
sure to tobacco products [4]. Both of the above
patients are circumcised and both deny a history of
condylomata or tobacco use. Interestingly, an
additional association has been noted between
increased incidence of squamous cell carcinoma
and chronic inflammation. Squamous cell carci-
noma has been reported to develop from scars
from mutilating circumcisions [5]. Thomas and
Nangia [6] reported a case of squamous cell carci-
noma of the penis as a result of significant penile
trauma followed by more than a year of chronic
irritation and inflammation. Tseng et al. [7] per-
formed a population-based case control study and
reported that patients with penile injury had a 4.6-
fold increased risk of squamous cell carcinoma.
Genital piercing causes focal and repetitive trauma
to the penis and urethra, which may lead to
chronic inflammation. Of note, there have been
J Sex Med 2010;7:2280–2283
2282
two prior case reports describing the development
of basal cell carcinoma at the site of nasal alar
piercings [2,3]. Similarly, an additional case report
describes basal cell carcinoma developing on the
earlobe following a decade of biannual auricular
acupuncture [1]. All three reports suggest that
local inflammation caused by the piercings may
serve a putative role in the pathogenesis of carci-
noma. We are unaware of any additional studies
regarding piercings and the development of
carcinoma.
While chronic inflammation may play a role in
the development of penile carcinoma, Ng et al. [3]
suggest that the steel jewelry used in piercings may
be additionally oncogenic. Steel usually contains
chromium, nickel, and occasionally cobalt, which
have been implicated in oncogenesis, primarily by
altering the signal transduction of growth factor
receptors and p53.
Finally, both patients described here are
co-infected with HCV and HIV (on HAART).
The relationship between the development of
squamous cell carcinoma and HCV is unknown.
As Ena et al. [8] described, though, this correlation
may be relevant. This RNA virus has a direct
oncogenic role in liver carcinoma and in B-cell
non-Hodgkin’s lympohma as well as an indirect
oncogenic role as it decreases immunosurveil-
lance. In contrast, while the HIV virus itself is not
considered to be oncogenic, a number of cancers
are well known to occur with increased frequency
in those infected with HIV. Relevant to penile/
urethral squamous cell carcinoma, this is thought
to be a consequence of impaired immunity and
failure to clear the oncogenic virus HPV, which
not only has a well established role in anogenital
carcinogenesis, but also a strong association with
squamous cell carcinoma [9]. Regarding HPV
co-infection, neither patient reports HPV positiv-
ity nor a history of condylomata although both do
report high-risk sexual activity. And, HIV-positive
men have a higher prevalence of penile HPV as
well as more aggressive HPV-related squamous
cell carcinoma of the penis [10,11]. Notably, both
patients are treated with HAART. Crum-
Cianflone et al. [12] report an analysis of prospec-
tively collected data from nearly 4,500 patients
that demonstrated no significant associations
between the incidence of cutaneous non-AIDS-
defining cancers and the receipt of HAART [12].
Although, HAART enables HIV patients to live
longer, thus allowing greater time for HPV-
mediated oncogenic progression to malignant
disease [10]. As such, it is plausible that HPV
J Sex Med 2010;7:2280–2283
Edlin et al.
co-infection is relevant in these cases, particularly
in the context of HIV, HAART, and genital pierc-
ings coupled with their resultant inflammation.
Conclusions
We report two cases of squamous cell carcinoma of
the penis/urethra following genital piercing. This
association has not been previously reported.
Patients with any type of genital piercing, espe-
cially those with concurrent risk factors such as
HIV and HCV, should be counselled about this
rare complication.
Corresponding Author: Rachel Edlin, BS, New York
University School of Medicine—Urology, 564 First
Ave., Apt. 12H New York, NY 10016, USA. Tel:
7327786463; Fax: (415) 476-1239; E-mail: Rachel.
Edlin@gmail.com
Conflict of Interest: None.
Statement of Authorship
Category 1
(a) Conception and Design
Rachel S. Edlin; David S. Aaronson
(b) Acquisition of Data
Rachel S. Edlin; David S. Aaronson; Alex K. Wu;
Sarah D. Blaschko; Glen Yang
(c) Analysis and Interpretation of Data
Rachel S. Edlin; Bradley A. Erickson; David S.
Aaronson; Jack W. McAninch
Category 2
(a) Drafting the Article
Rachel S. Edlin; David S. Aaronson
(b) Revising It for Intellectual Content
Rachel S. Edlin; David S. Aaronson; Alex K. Wu;
Sarah D. Blaschko; Glen Yang; Bradley A. Erickson;
Jack W. McAninch
Category 3
(a) Final Approval of the Completed Article
Rachel S. Edlin; David S. Aaronson; Alex K. Wu;
Sarah D. Blaschko; Glen Yang; Bradley A. Erickson;
Jack W. McAninch
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