Genital Warts in Men

Genital Warts in Men

Genital Warts in Men; Diagnosis and Treatment

HPV causes anogenital diseases for men. The most known patology developed due to HPV is genital warts. Other than genital warts, GPV might cause anal, penile or throat-mouth cancers in men. These types of cancer in men can be blamed on HPV type 16.

Every year in the USA, 22.000 HPV related cancers are diagnosed and 7.000 of these are diagnosed for men. Additionally, among sexually active men in the US, 250.000 genital wart cases are diagnosed, caused by HPV types 6 and 11.

Genital warts diagnosed in men are important for many different health reasons and need to be treated. The biggest problem we face in our country, is the fact that men do not recognize this disease, they do not go to the doctors, get treatment and spread the disease as a consequence. Above, you can see a genital wart located on the mouth of the urethra.

 

Work on HPV infection on men are new and we still lack detailed information on the issua.

Frequency of HPV and genital warts on men

According to research carried out by Dunn and his friends, the frequency of genital HPV amont men (transmitted sexually) is around 40%. Different groups have different frequencies in the research. For example, students, soldiers, man on sexually transmitted disease clinics, husbands of women who has CIN have been surveyed. Among these groups the frequency of HPV can change due to the type of the group and show a fluctuation between 6% to 45%.The most frequent HPV infection rates are among men whose wives have CIN, at 50-75%.
The prevalence of HPV frequency in men is steady. The prevalence is the sum of all the cases during a determined period, whether it’s new or old. For example, the total number of genital sigil cases in 2013 in Istanbul (sum of old and new patients) give us the prevalence rates of HPV in Istanbul.

It is strange that men’s prevalence rates do not differ due to age, while for women the HPV frequency changes with age groups. It is especially high on first contact (ages 25 to 30), then it falls and increases again during perimenopausal period. But in males the prevalence of HPV infections is the same (sum of old and new patients) in all age groups. For example, a research carried out in Italy has shown that the prevalence of HPV for women after the first encounter is around %13-14, while until the age of 40 it is at 5% and below, after 40 it raises to 8% for a while. The rates around the world are similar to this. But the rates for men do not differ due to age.

Also, interestingly the most frequent HPV infection among women is the “high risk” HPV, while the rates of high and low risk infections are the same for men. This data also supports the following information about the HPV types and the reasons for its development.
In 2013 Patel and co research, for which the English, Spanish, Italian and German literature were monitored, the median for incidence of genital warts for men in Europe was around 195/100.000.

Incidence: The number of new cases that occur within a limited time period (generally 1 year). For example, new genital warts patients diagnosed in 2013, gives us the genital warts incidence in 2013. Therefore, the data above shows us that in Europe, there are new 195 genital warts for every 100.000 people.
How does the disease develop in men? Can the virus be cleaned from the body?

A subject that is overlooked for men is how the disease develops after being infected sexually. The limited amount of work is about heterosexual males.

One research has monitored 290 men for 15.5 months and in this period old+new prevalence rates for HPV infection was at 52.8%. New infection incidence for each month is 43.2/1000. This data shows that the chance of having a HPV infection due to sex is around 29.2%. 19% of this is high risk, while 16% is low risk HPV incidents. (A portion of patients carry both high and low risk HPVs)

5.1% of all newly infected men have HPV type 16 and HPV type 18, while 3.4% have HPB types 6 and 11.

The cleansing period for the body from the virus is 5.9 months according to this research!! 75% of all diagnosed men can get rid of all the HPV DNA within 12 months. saptanamamaktadır. Also, there is no difference between high or low risk HPVs!! (Partridge JM et al: Genital human Papillomavirus infection in men: incidence and risk factors in a cohort of university students. J Infect Dis 2007, 196:1128–1136)

The same research shows that the high and low risk HPV rates are the same. Root of the penis, glans of the penis and the area over the testicles are where HPV tests are most frequently positive. But it should be noted that the research was carried out on male samples, with high probabilities of changing sexual partners frequently.

How is it infected?

Heterosexual transmission of HPV (from women to men or from men to women) has dymanics which are not fully understood and is still being investigated and debated on. But the root cause is sexual contact.

Another factor that has an effect on the infection rates is the shaving of the hair around the genital area before sexual encounter due to being more practical!! After the hair is removed by hair removal creams and gillettes, a part of the epitel tissue is mechanically lifted and when there is contact with a woman with genital warts, the contact area is larger and so is the risk of infection. Also, the warts that are damaged while removing the hair, might cause the area we call basal plate which is under the damaged epitel tissue to be infected even deeper. The treatment becomes harder on these kinds of instances and the disease might reoccur. I will rewrite these sentences again and again on the treatment section, since it is very important for the message to be understood clearly.

Infection might occur on both oral and anal sex as well. Anal sex is the most important one in terms of the frequency of infections. Because it is normal to see tearing in the anal canal during sexual contact and it increases the infection rates of women. It also increases the infection rates of men if there is bleeding.

Do condoms decrease infection rates, are they a viable protection?

Condoms can decrease the probability of infection but as it only covers areas until the root of the penis, the root area is contactable, and infection is a possibility. But it is better than nothing to use condoms and most importantly, it provides protection against HIV, which is the AIDS virus. Therefore, it is recommended to use it. It is also recommended to use condoms for 6 months after treatment to patients and especially the married couples. The other male group is recommended to use it continuously.

Does circumcision protect against HPV?

Circumcision provides protection against both HPV and HIV viruses. Although there are different views on circumcision, it is proven that it provides protection against HPV virus. Banura and co.’s research show that the infection rates for circumcised men are lower than those who are not. (Banura et al. Infectious Agents and Cancer 2013, 8:27)

Which HPV types cause genital warts for men? Or what types of HPV do genital warts contain which are diagnosed in men?

In general, the types of HPV that cause genital warts are; 6, 11, 42. 44, 51, 53 and 83. According to different publications, 70 to 90% of all genital warts are HPV types 6 and 11.

But the question we gynecologists ask ourselves frequently is: Why do we detect high grade cervical lesions in women whose boyfriends or husbands are diagnosed with genital warts? Isn’t that true? If the main causes of genital warts are types 6 and 11, then why are these lesions detected in women. Because it is a very low probability that types 6 and 11 would cause CIN II and III.

The research carried showed that the warts detected in men (and also women too) most likely contain more than one type of HPV and some of these are high risk HPV types of 16 and 18. Gabriella Anic and co.’s “HPV in Men” study have provided very important data.

2487 men between the ages of 18 to 70 that DID NOT have genital warts took part in this research and were monitored between 2005 and 2009. In 2009, genital warts were detected in 120 patients. When the HPV types that caused these warts were examined, it was noted that 45.5% of the patients were infected with more than one type, while 12.5% were positive for HPV types 16 and 18.

The pictures below show 2 male patients, whose wives I was treating for pre-cancerous lesions in the cervix area. After typecasting, both patients’ warts have shown more than one and oncogenous, high risk HPV types.

 

Kofoed and co.’s research carried out in Denmark, have shown that only 2.7% of all cases had HPV type 16. Although 74% of all cases were determined to have HPV types 6 and 11, 33% had more than one HPV types that include high risk ones.

In conclusion, the gynecologists should know that genital warts may consist of more tha one HPV type, some of these might be the oncogenous types 16 and 18, and inform the patient and the wife accordingly, arranging the treatment himself if he is knowledgeable. Otherwise he should direct the patient to a medical center where their treatment can be completed.

How should diagnosis be made for genital warts in men? Which tests should be applied?

The diagnosis should firstly be made by the eyes and seeing the infected area. But in both men and women, the flat condylomas are present. Therefore, in order to lower the recurrence rates, a peniscopy should be done by applying 5% acidic acid on the penis. When looked at with a magnifier, genital warts and the lesions that mimic the warts can be differentiated. Büyük büyütme ile bakıldığında siğiller ile genital siğilleri taklit eden lezyon ayırdedilebilir (Ex: Molluscum contagiosum, herpes simplex etc.)

Below, you can see the warts that reacted to the acetic acid applied on the penis area during a peniscopy.

Peniscopy helps make a more healthy diagnosis and therefore increases the effectiveness of treatment. Nicolau & co.’s research published have shown this clearly. (Sao Paulo Med J. 1997 Jan-Feb;115: 1330-1335)

Other than peniscopy, if the male patient has anal condyloma and is homosexual, an anal smear has to be taken. To have anal condyloma genital warts, the patient does not need to be homosexual. Due to reasons we can not fully comprehend, women that do not have anal sex might also have condylomas around the anal area.

Treatment of Genital Warts on Men

1. Patient training and looking after the genital area: The patient must definitely learn to examine themselves and inform their doctors in case their warts reoccur. They should not shave at all for 3 months but ideally for 6 months. As I have detailed above, whichever method is used, the shaving of hair around the genital area damages the surface epitel and increases the chances of infection and recurrence. It is sufficient to shorten the hair without bleeding. Males must use condoms. The condom using period for monogamous males is at least 6 months. Vaccination for males is also mentioned below.

2. Important points on choice of treatment:

The request and previous experiences of tha patients: An operation might be considered if the patient has been treated before, has used medical treatment and failed.
Medical Capabilities: The medical center that tha patient goes to might not have devices that allow destructive treatment. Or the patient might have another systematic disease.
Medical Capabilities: The medical center that tha patient goes to might not have devices that allow destructive treatment. Or the patient might have another systematic disease.
The experience of the clinician or doctor: In today’s concept, it is believed to more important for every clinic and doctor to develop their own treatment and monitoring routines for the best results.

3.Medical Treatment:

Podophyllin: An herbal based antimitotic medicine. The patient must be really careful while using it, since it is very toxic for the skin. It is hard to use. It should not contact the surrounding environment. The treated condyloma area should not exceed 10cm2, while the daily dose of podophyllin used should be below 0.5ml.

Imiquimod (5% and 3,75%): Immunemodulator, antiviral, antiproliferate. İmiquimod (%5 ve % 3.75): A molecule of imidazoquinoline group, with immunmodülatör, antiviral, antiproliferative properties. It is especially effective on interferon levels. Clinical trials have shown that it has cured 40 to 77% of patients with warts. This is toxic for normal skin. It is common to see symptoms such as rashness, burning and itching during the treatment. But its most important side effect is that it causes loss of color on skin like vitiligo. The recurrence rates after its application for warts is between 9 ro 23% according to different publications. It should be used 3 times a week for a maximum of 12 to 16 times. If 12 weeks of treatment does not yield results, then it might cause even more warts.

Sinecatechins (in 15% oil): It is a green tea extract. It is 50 to 60% effective thanks to 8 different extracts. It is approved by the FDA in the USA.

Asetic Acid (Tri – Bi): It is controversial to use on males. Its necessity is a question by itself.

4. Operational Treatment:

The important part is the method of treatment the surgeon has decided on. Laser coagulation is expensive and not common. Its use is unnecessary for glance. The cosmetic results are similar.
Important point: To prevent reocurrance, the patient needs to pay attention to preventive precausions. Extensive lesions might be removed via local anesthesia. General anesthesia is used on selected and very extensive cases and anal condylomas.
A. Criocautery: The destruction of lesions via freezing. The results gained by using some sprays might not always put a smile on your face. Especially of the lesions are big and widespread. When common criocautery is used, the main problem is that the same tips are used repeatedly. It takes a long time to change them for each lesion. When the same tip is used its effect is not enough or does destruction on a wide area.

B. Electrocauterisation: This is my preferred method. It is effective and can solve lesions with one session via local anesthesia. General anesthesia is applied if the lesions are extensive and there is extended anal warts. The patient can continue their life normally and all lesions heal in a 20 day period.

Source

  1. Lenzi A, Mirone V, Gentile V et al. Rome Consensus Conference – statement; human papilloma virus diseases in males. BMC Public Health. 2013; 13:117
  2. Patel H, Wagner M, Singhal P et al. Systematic review of the incidence and prevalence of genital warts. BMC Infect Dis. 2013 Jan 25;13:39.
  3. Weaver BA. Epidemiology and natural history of genital human papillomavirus infection. J. Am. Osteopath Assoc. 2006; 106: p 2-8.
  4. Kofoed K1, Sand C, Forslund O, Madsen K. Prevalence of human papillomavirus in anal and oral sites among patients with genital warts. Acta Derm Venereol. 2014; 94(2):207-211.
  5. Banura C, Mirembe FM, Orem J et al. Prevalence, incidence and risk factors for anogenital warts in Sub Saharan Africa: a systematic review and meta analysis. Infect Agent Cancer. 2013 Jul 10;8(1):27.
  6. Nicolau SM, Martins NV, Ferraz PE et al. Importance of peniscopy, oncologic cytology and histopathology in the diagnosis of penile infection by human papillomavirus. Sao Paulo Med J. 1997 Jan-Feb;115: 1330-1335.

 

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