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Paper text:
implantation of penile nodules under the foreskin is usual among southeastern asian men and prisoners in indonesia .
the main objective of these penile implants is the improvement of sexual pleasure during intercourse .
there is no direct relationship between the use of these adornments and carcinoma of penis in the literature .
however , in most cases of penile cancer , external factors can influence the development of the disease .
a 48-year - old man , hailing from french guyana , searched for help as he was suffering from a painful penile destructive lesion .
he reported that it began as a wart at the penile shaft 6 months earlier , and then grew towards the glans .
he tried to treat it by first immersing his penis in sulphuric acid and afterward exfoliating it with 
pedra pome ( a stone usually used to exfoliate skin ) , without any improvement .
he said that his first sexual intercourse was at 13 years of age , and that he had never used condoms .
he was diagnosed with syphilis at 22 years of age , which was completely cured as a result .
when he reached the age of 33 , he implanted three nodules under the foreskin penile shaft , which he called 
she was a native of french guyana and told him that he should do these implants in order to marry her .
he also said that sometimes he had sexual intercourse with goats , which is common in rural parts of french guyana , although not necessarily culturally acceptable .
he was evaluated by the urologist who noted the lesion with bilateral lymphadenopathy and was submitted to a total penectomy .
the subsequent histology confirmed epidermoid cancer which had infiltrated the glans , coronal sulcus , foreskin , corpora cavernosa , corpus spongiosum and penile urethra .
he was discharged on the third postoperative day with a programmed bilateral inguinal lymphadenectomy ( figs  1 and 2 ) . 

implantation of penile nodules has been done for thousands of years in different parts of the world .
there are several reasons for these implants , one of which is mainly self - enhancement to improve sexual performance and penile aesthetics . in french guyana , the practice of penile implantation is known as  bouglou and the objects usually used as implants are domino fragments and toothbrush handles ; these procedures are not carried out under hygienic conditions .
bleeding , swelling and infection are frequent complications and usually need immediate treatment , resulting in difficult scarring lesions . in 2010 , fischer et al .
demonstrated that men with penile adornments suffered from painful inflammatory processes for many years after the implantation .
these men also have a greater risk of acquiring sexually transmitted diseases ( stds ) from the instruments used in insertion , by open wounds during sexual intercourse , and by condom perforation . in this case report , the reason for implanting the penile nodules was the partner 's sexual satisfaction .
other studies suggest that these penile adornments try to compensate for the subjective small size of their penis , their lack of virility and/or their poor sexual performance .
yap et al .   showed that the penile implants are common in the prison population .
in fact , ex - prisoners who escaped from suriname introduced this practice in french guyana during the civil war in the 1980s , and it probably migrated to brazilian amazonia because of gold - digging and other trade activities between the brazilian state of amapa and french guyana . apart from sexual attraction , 
bouglou implants are also considered distinctive marks of those belonging to a specific group such as prisoner gangs and gold - diggers .
the patient was not drug addicted but confirmed sexual promiscuity , and it is known that men with penile implants have a high probability of using illicit drugs , of being sex workers and of being tattooed or having piercing implanted in prison , which indicates a risky lifestyle for several transmissible diseases .
bouglou implants , the patient developed penile cancer , which was definitely aggravated by self - treatment and delayed medical search .
nowadays , it is proved that epidermoid carcinoma can be caused by mutilating circumcision scars .
men with penile lesions deriving from these scars have a 4- to 6-fold elevated risk of developing squamous cell carcinoma .
it is possible that uncorrected - implanted penile nodules provoke local and repetitive trauma that can elicit chronic inflammation , which can play a role in the pathogenesis of carcinoma .
penile cancer is frequently found in poor countries . in brazil , it represents almost 2% of all male cancers .
some brazilian areas have a high incidence , corresponding to 17% of all male malignant neoplasms .
social , cultural , hygienic and religious habits are considered important risk factors for penile cancer .
other risks are chronic inflammatory conditions , early onset of sexual activity , sexual promiscuity , condyloma history and tobacco smoking . human papillovirus ( hpv ) infection is associated with half of penile cancer cases .
the prevalence of penile cancer is higher in the sixth decade of life , with almost 79% of brazilian patients older than 45 years of age .
factors related to this paraphilia may favour a chronic inflammatory process and , consequently , dysplasia , such as penile contact with animal external genital mucosae , resulting in microtraumas and exposition to animal anogenital secretion , which can be carcinogenic to human beings .
thus , the relationship between penile cancer , zoophilia and stds can reflect the zoophilic lifestyle , as these men have a greater number of sexual relationships with prostitutes and turn out to be more exposed to stds , compared with those who do not have sex with animals .
, a multiplicity of causes can lead to penile cancer , including those previously reported in the research literature ( as mentioned above ) , such as promiscuity , hpv and zoophilia .
one risk factor that may be important in this part of the world is penile adornment . because of the rarity of both penile cancer and penile adornment , it is difficult to establish the relative importance of the chronic inflammation associated with the penile adornment in the pathogenesis of this cancer . to our knowledge
, there is only one other article which suggests a possible association between squamous cell carcinoma and penile adornments , but none in a south american amazonian man .
all authors are involved in the treatment of the patient and wrote and finalized the manuscript .
implantation of penile nodules under the foreskin aims at improving male and female sexual pleasures during intercourse . 
 this case discusses the characteristics of the south american penile adornment  
 bouglou as well as the risk factors for penile cancer in this region of amazonia . 
 this is a case report of a 48-year - old man whose penis presented a destructive gland / penile shaft lesion and three adornments in the penile shaft , reported as  bouglou. the diagnosis of penile cancer 
 was confirmed after total penectomy . 
 this study is the first that suggests a possible association between squamous cell carcinoma and these penile adornments .