Sexually Transmitted Diseases in Men - HPV

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Human papillomavirus (HPV)

More than 40 types of human papillomavirus (HPV), which are the cause of genital warts (known as condylomata acuminata or venereal warts), can infect the genital tract of men and women. These warts are primarily transmitted by sexual intimacy. Note that these are generally different from the HPV types that cause common warts elsewhere on the body. Genital warts are smoother and softer lesions than the typically rougher and firmer common warts. Genital warts usually appear as small, fleshy, raised bumps, but they can sometimes be extensive and have a cauliflower-like appearance. In men, the lesions are often present on the penis or in the anal region. In most cases genital warts do not cause any symptoms, but they are sometimes associated with itching, burning, or tenderness.

HPV infection has long been known to cause cervical cancer and other cancer of the genitals and anus (anogenital) in women, it has also been linked with both anal and penile cancer in men. In patients who are simultaneously infected with HIV, the HPV infection is more severe and the associated cancers are even more frequent.

HPV infection is common and does not usually lead to the development of warts, cancers, or specific symptoms. In fact, the majority of people infected with HPV have no symptoms or lesions. Determination of whether or not a person is infected with HPV involves tests that identify the genetic material (DNA) of the virus. Furthermore, it has not been definitively established whether the immune system is able to permanently clear the body of an HPV infection. For this reason, it is impossible to predict exactly how common HPV infection is in the general population, but it is believed at least 75% of the reproductive-age population has been infected with sexually-transmitted HPV at some point in their life. Asymptomatic (those without HPV-induced warts or lesions) people who have HPV infections are still able to spread the infections to others through sexual contact.

How is HPV treated?

Treatment of external anogenital warts

There is no cure or treatment that can eradicate HPV infection, so the only currently possible treatment is to remove the lesions caused by the virus. Unfortunately, even removal of the warts does not necessarily prevent the spread of the virus, and genital warts frequently recur. None of the available treatment options is ideal or clearly superior to others.

A treatment that can be administered by the patient is a 0.5% solution or gel of podofilox. The medication is applied to the warts twice per day for 3 days followed by 4 days without treatment. Treatment should be continued up to 4 weeks or until the lesions are gone. Alternatively, a 5% cream of imiquimod (a substance that stimulates the body's production of cytokines, chemicals that direct and strengthen the immune response) is likewise applied by the patient three times a week at bedtime, and then washed off with mild soap and water 6 to 10 hours later. The applications are repeated for up to 16 weeks or until the lesions are gone. Sinecatechin 15% ointment, a green tea extract with an active product (catechins), is another topical treatment that can be applied by the patient. This drug should be applied three times daily until complete clearance of warts, for up to 16 weeks.

Only an experienced clinician can perform some of the treatments for genital warts. These include, for example, placing a small amount of a 10% to 25% solution of podophyllin resin on the lesions, and then, after 1 to 4 hours, washing off the podophyllin. The treatments are repeated weekly until the genital warts are gone. An 80% to 90% solution of trichloroacetic acid (TCA) or bichloracetic acid (BCA) can also be applied weekly by a physician to the lesions. Injection of 5-flurouracil epinephrine gel into the lesions has also been shown to be effective in treating genital warts.

Alternative methods include cryotherapy (freezing the genital warts with liquid nitrogen) every 1 to 2 weeks, surgical removal of the lesions, or laser surgery. Laser surgery and surgical excision both require a local or general anesthetic, depending upon the extent of the lesions.

What should a person do if exposed to someone with genital warts?

Both people with HPV infection and their partners need to be counseled about the risk of spreading HPV and the appearance of the lesions. They should understand that the absence of lesions does not exclude the possibility of transmission, and that condoms are not completely effective in preventing the spread of the infection. It is important to note that it is not known whether treatment decreases infectivity. Finally, female partners of men with genital warts should be reminded of the importance of regular PAP smears to screen for cervical cancer and precancerous changes in the cervix (since precancerous changes can be treated, reducing a woman's risk of developing cervical cancer). Similarly, men should be informed of the potential risk of anal cancers, although it is not yet been determined how to optimally screen for or manage early anal cancer.

The HPV vaccine

A vaccine is available against four common HPV types associated with the development of genital warts and cervical and anogenital cancer. This vaccine (Gardasil) has received FDA approval for use in males and females between 9 and 26 years of age and confers immunity against HPV types 6, 11, 16 and 18. Another vaccine directed at HPV types 16 and 18, known as Cervarix, has been approved for use in females aged 10 to 15.

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