Gardasil (human papillomavirus vaccine), the vaccine that can prevent most cases of cervical cancer in girls, has won the FDA’s blessing as a vaccine to prevent anal cancer, a huge victory for men!

The FDA’s  approval for Gardasil as an anal cancer vaccine opens the way for the medication’s maker, Merck and Co. Inc., to market the vaccine to boys and young men between the ages of nine and 26 – an option that will be most meaningful for men who have sex with men, but valuable to all.  Nobody likes getting HPV on their penis.  It really can devastate many boys and men.  When the HPV ends up on their anal area – the risk of anal cancer is high.  Although this is most commonly seen in homosexual men, it is not infrequent for heterosexual men to be at risk.  It is easy to imagine how HPV can start on the shaft, and with a scratch here, and an itch there – end up on the back side.

This is a great win for men – and we hope that the approval by the FDA will quickly translate to coverage amongst insurance companies to make the vaccine accessible quickly to this new population.

What are anal warts?

Anal warts (also called “condyloma acuminata”) are a condition that affects the area around and inside the anus. They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may grow larger than the size of a pea. Usually, they do not cause pain or discomfort to afflicted individuals. As a result, patients may be unaware that the warts are present. Some patients will experience symptoms such as itching, bleeding, mucus discharge and/or a feeling of a lump or mass in the anal area.

Anal warts, thought to be caused by the human papilloma virus, can grow larger and spread if not removed.

It is important to know that Anal warts can be found both heterosexuals and in men who have sex with men.  Either way, it is nothing to be ashamed of – and it is something that you SHOULD SEEK TREATMENT FOR.

What causes these warts?

They are thought to be caused by the human papilloma virus (HPV) which is transmitted from person to person by direct contact. HPV is considered a sexually transmitted disease. You do not have to have anal intercourse to develop anal condyloma.

Do these warts always need to be removed?

Yes. If they are not removed, the warts usually grow larger and multiply. If left untreated, the warts may lead to an increased risk of cancer in the affected area.  This is similar to the risks of cervical cancer in women.

What treatments are available?

If warts are very small and are located only on the skin around the anus, they may be treated with a topical medication. They may also be treated by a physician by freezing the warts with liquid nitrogen. Warts may also be removed surgically. Surgery provides immediate results but must be performed using either a local anesthetic – such as novocaine – or a general or spinal anesthetic, depending on the number and exact location of warts being treated. Warts inside the anal canal usually are not suitable for treatment by medications, and in most cases need to be treated surgically.

Must I be hospitalized for surgical treatment?

No. Surgical treatment of anal warts is usually performed as outpatient surgery.

How much time will I lose from work after surgical treatment?

Most people are moderately uncomfortable for a few days after treatment, and pain medication may be prescribed. Depending on the extent of the disease, most people return to work the next day.

How long is treatment usually continued?

Follow-up visits are necessary at frequent intervals for several months after the last wart is observed to be certain that no new warts occur.

What can be done to avoid getting these warts again?

In some cases, warts may recur repeatedly after successful removal, since the virus that causes the warts often persists in a dormant state in body tissues. Discuss with you physician how often you should be evaluated for recurrent warts. Abstain from sexual contact with individuals who have anal (or genital) warts. Since many individuals may be unaware that they suffer from this condition, sexual abstinence, condom protection or limiting sexual contact to single partner will reduce your potential exposure to the contagious virus that causes these warts. As a precaution, sexual partners ought to be checked, even if they have no symptoms.

as a urologist i see a lot of patient with growths or bumps on the penis

some patients ask do I have cancer? do I need a biopsy? 

Most patients with a classic wart or HPV do not need a biopsy, patient who are uncircumcised or recurrent growths may consider a biopsy.

Freezing a wart with liquid nitrogen, cauterization, or topical treatments like aldara (imiquimod topical cream)

if you have a wart get to a doctor and have it treated.  A biopsy is not a  bad idea but no always necessary

thanks for all of stories and questions I hope this site can help you fight your personal war on warts. 

the wow team is committed to helping you with the most sensitive topics!

click find a physician for a team member physician in your area!

Penile warts are diagnosis that a trained doctor can make without a biopsy.  If patients have many warts or ones that look suspicious for other lesions like cancer I often biopsy a representative sample and freeze (with liquid nitrogen) or burn (electrocautery) or laser (C02 or YAG) the rest.  If a patient has warts on the foreskin and wants a circumcision I sent the tissue for biopsy. 

If your doctor didn’t send a biopsy and it didn’t come back that’s fine.  If it keeps coming back and there was never a biopsy ask your doctor to sent a piece to the lab or make sure they are convinced its not cancer.

I hope this post is helpful.  Go to our find a physician tab if you need an evaluation

Thanks,

Dr. A.

Treating penile warts presents several problems to the patient and to the treating physician.  The ideal treatment would be non-invasive, non disfiguring, quick, painless and it would eliminate the risk of any wart recurrence.

The ideal treatment does not exist.

Most treatments offer some sort of balance between expedience, invasiveness, and recurrence.  The correct treatment really depends on patient preferences, patient medical history, and the doctor’s experience.

Treatment options include:

• Imiquimod: This is a form of immunotherapy.  Is not invasive and non-disfiguring but requires 16 weeks of therapy.  Dermatologists seem to like to use it, but urologists like Dr Schoor, who have had extensive experience with imiquimod, have not found it useful for his male wart patients.
• Podophylin: This is another form of immunotherapy.  Like imiquimod, it is non-invasive and non-scar producing.  Podophylin takes approximately 4 weeks to work and is very effective on penile condylomas.  Recurrence rates are low with this approach.
• Cryo therapy: This means freezing off the warts, usually with liquid nitrogen.  This is a great treatment that effectively gets rid of the lesions without scar formation or marks and has very low recurrence rates.  It is painful and requires at least 3 to 4 applications over a 6 to 8 week period.  Dermatologists like this form of treatment for their patients.  Urologists don’t too so much of it, however.
• Cautery: Effective though invasive and scar producing.  It does require that the doctor give a local aneshtetic prior to the procedure.  Recurrence rates are higher than for the other treatments, but the results are immediate.  Perhaps the worst aspect of this approach is that the cautery smoke may contain vaprized though live viral particles that can be inhaled by patient and staff alike.  To prevent this occurrence, special masks may be worn.
• Excision: 100% effective but 50% or greater recurrence risks when used alone.  It does leave a scar but the result is immediate, which most men want.  Another advantage is that it allows for pathologic confirmation of the lesion, which on rare occasion can be a penile veru
  

  Using crythherapy to treat disease

  cous cancer.  Recurrence risks can be minimized by cauterizing or freezing the base after the excision or by having the patient apply podophylin or imiquimod after the wart has been removed.

• Laser therapy: This procedure is done in the OR with a CO2 laser.  It is very effective over the short and long term, non-scar forming, and immediate.  It is very expensive and best reserved for patients with extensive disease, such as in the immunoscompromised population.

We hope readers find this useful.

My wart schpeel
I see a fair number patient consults for “rule-out HPV” or “rule-out warts.”  The typical scenario is the following:

A woman goes to her gynecologist for a routine Pap smear and is told that the results came back positive for HPV.  She is then told by her doctor to have her male partner “checked-out.”
What does all that mean and what really happened at that patient’s doctor visit?

In a nutshell, the American College of Ob-Gyn recommends that women get periodic Par smears since Pap smears can detect cervical cancer early, and this saves lives.  Pap smears can also detect other disorders such as yeast infections and HPV infections.  HPV is the virus that causes genital warts.  On a Pap smear, the HPV virus produces cells with a characteristic look that most medical students would easily recognize.  That finding is called a Koilocyte.  When a Pap test shows Koilocytes, it indicates that the woman has been exposed to the HPV virus.

So what?

HPV is what is known as a ubiquitous virus.  This means that everyone—and their mothers—has been exposed to it at some point in their lives.  Most people just don’t know it.  The HPV virus family has many strains—more than 400.  Some strains cause genital warts.  Some strains cause Pap smear changes on women.  Some strains cause penile cancer while other strains cause cervical cancer.  Some strains cause warts on the ankles of young children.  And still, some strains don’t do anything that we can detect or that cause problems.

Here is the real interesting part about the HPV virus.  It exhibits a characteristic called tropism.
TROPISM

Tropism is a feature of many viruses.  It means that a specific virus can only attack and cause damage to a specific target, such as a cell in the cervix or on the ankle or a blood cell.  HIV has tropism for CD-4 blood cells.  HPV has tropism also.  Some strains will only cause problems on the ankle while other strains will only cause penile warts.  Other strains will only cause Koilocyte changes on a Pap smear while a different strain will cause cervical cancer.

Clinically this means that when a woman has a positive Pap test, it does not mean that the man necessarily infected her with the virus or that the man has a penile wart.  It does not mean that he did not do so either.  It just means that the virus strain that caused the Pap findings may not be the same strain that would cause a penile wart on the man.  It also means that the man should be evaluated for the presence of any lesions or warts on his penis.

Does that mean that you will always need to use a condom.  I tell my patients that there are many good and important reasons to use condoms, especially with new or not well known partners, but that HPV prevention is among the least important of those reasons.  Condoms can help prevent the transmission of HPV virus but not necessarily.  HPV can be transmitted in semen, but also is other body fluids.  The best way to prevent transmission of HPV is abstinence or to keep the number of sexual partners to a minimum.  Barring those 2 strategies, HPV infection will definitely occur.  Whether you develop problems from HPV depends on your own immune system and the viral strain with which you have been infected.