Andrew Siegel MD 10/5/19
HPV (human papilloma virus) is an important public health issue that not only may cause warts, but also may be responsible for a host of different cancers in both genders. Currently available prophylactic vaccination has the potential for eradicating both warts and cancers that are related to the virus.
Human papilloma virus (HPV) is the name given to a heterogenous group of viruses that are transmitted by skin-to-skin or mucosa-to-mucosa contact of the genitals, anus and the oro-pharynx, entering the body via skin or mucosal trauma, and not through an exchange of bodily fluids. H–> human; P–> papilloma = wart like growth; V–> virus. Certain types cause common and plantar warts, others cause genital, perineal and anal warts (ano-genital warts), and yet other types can cause a variety of cancers.
HPV is the most common sexually transmitted infection in the United States, prevalent in about 45% of adult men and 40% of adult women. An estimated 80% of sexually active people contract HPV at some point in their lives with about 15 million new infections annually in the USA. 80 million or so people are thought to have an active HPV infection at any given time. When symptomatic, HPV is characterized by genital warts (condyloma) in the anogenital regions. Aside from infecting the genital and anal areas, the mouth, throat, and even the respiratory tract are potential sites of infection. HPV has been associated as a causal agent for cervical, penile, vaginal, vulvar, anal, and oral-pharyngeal cancers.
Types of HPV Infections
Infections can be characterized as latent, sub-clinical or clinical. Latent infections are the most common type: asymptomatic, transient, self-limited, unrecognized and detectable only by tests for viral DNA, but transmissible to sexual partners. Latent HPV infections are often neutralized or made dormant by the immune system for significant periods of time, only to be later unknowingly transmitted to another sexual partner, including a spouse.
The uncertainty over “who” is responsible for transmission of the HPV and “when” the infection occurred can be a source of great anxiety for a couple when one partner becomes aware that they are infected. It is extremely difficult to source the origin of any HPV infection since the virus can remain dormant for years. The HPV diagnosed today could have been acquired from one’s current sexual partner or any previous one. Pointing fingers is pointless!
Sub-clinical infections are identified only after careful inspection of the ano-genital regions of the body following the application of acetic acid, which causes the lesions to appear white.
Clinical infections cause visibly apparent wart-like lesions of the ano-genital area, known as condyloma, the vast majority of which are caused by HPV-6 and HPV-11. These viral types have also been associated with conjunctival, nasal, oral, and laryngeal warts. These are not the types that cause cancer. Ano-genital warts are typically flat, raised, or stalk-like often reddish-brown growths on the genitals, particularly under the foreskin of the uncircumcised penis, on the shaft of the circumcised penis and on the vulva. They can also occur in the groin, pubic region, scrotum, perineum, urethra, vagina, cervix and anus. They are usually asymptomatic, but can occasionally be itchy or painful depending upon their size and location. In men, these are usually obvious since they typically occur externally on the skin of the penis, pubic area, scrotum, perineum and anal regions. On occasion they can occur within the urethra, the channel that conducts urine through the penis. When left untreated, they can enlarge significantly into cauliflower-like, variable size lesions. In females, they are obvious when on the vulva, but they can also occur in a hidden nook and cranny of the vagina or within the cervix, which can make identification challenging.
The diagnosis of ano-genital warts is often obvious by visual inspection and can be confirmed by biopsy. If left untreated, warts can remain stable, increase in size and number, and sometimes regress and resolve.
Treatment of Ano-genital Warts
The intent of treatment is to remove all visible warts and is guided by wart size, number, and location, patient preference, cost, convenience, side effects, and physician preference. There are treatments that patients can apply and those that physicians can administer.
Patient applied treatments:
- Aldara (Imiquimod) 3.75% or 5% cream: topical immune enhancer; 5% applied once at bedtime, three times weekly for up to 16 weeks or 3.75% applied at bedtime every night
- Condylox (Podofilox) 0.5% solution or gel: anti-mitotic drug that is applied twice daily for 3 days followed by 4 days of rest; this can be repeated for up to 4 cycles
- Veregen (Sinecatechins) 15% ointment: green tea extract applied three times daily for up to 16 weeks
Physician administered treatments:
- Cryotherapy with liquid nitrogen or cryoprobe: destroys warts by freezing causing frostbite
- Surgical removal by excision, laser or electrosurgery
- TCA (Trichoroacetic acid) or BCA (bichloroacetic acid): caustic agents that destroy warts by chemically coagulating proteins; can be repeated weekly as necessary
It is important to know that treatment does not eradicate the HPV virus itself. Even after treatment, HPV can remain present and still be transmitted to partners. It is not uncommon for genital warts to recur after treatment, especially in the first few months. Sexual activity should be avoided until after treatment. Although condoms lower the chances of transmitting genital warts, they are not infallible because HPV can infect areas that are not covered by a condom.
HPV-induced Cancers
Certain types of HPV (oncogenic types) can give rise to cancer of the vulva, vagina, cervix, penis, anus and oropharynx. HPV-16 and HPV-18 are the types that most commonly cause cancer. HPV is estimated to be responsible for 7-8% of all human malignancies. HPV is associated with 96% of cervical cancers, 93% of anal cancers, 64% of vaginal cancers, 51% of vulvar cancers, 36% of penile cancers, and 63% of oro-pharyngeal cancers.
HPV gives rise to abnormal cell changes of the cervix (dysplasia) that can ultimately lead to cervical cancer. Cervical cancer is completely preventable if precancerous cell changes are identified and treated early, before cervical cancer develops. Diagnostic regimens use cervical Pap smears, HPV DNA testing, and colposcopy (visual inspection of the vagina with magnification). Cervical cancer has been the most studied of all the varieties of cancer that HPV can cause and was the first cancer in females to be identified as being caused exclusively by a viral infection. The association between HPV and cervical cancer was proven by a German researcher, Harald zur Hausen, who was awarded a Nobel Prize in Medicine for his work. He ultimately cloned HPV-16 and HPV-18 viral subtypes from patients with cervical cancer.
Oro-pharyngeal cancers include cancers of the tonsils, base of tongue and the back of the throat. The survival rate of these HPV-related head and neck cancers is much better than for that of tobacco-related head and neck squamous cell cancers that are not HPV-related. The last few years have witnessed an alarming increasing incidence of HPV-related oro-pharyngeal cancers, particularly in men.
HPV Testing
HPV genotype testing via 3 commercially available kits can be done at the time of a Pap smear in females. Although HPV genotype testing via swabbing obvious lesions can be done in males, it is not FDA-approved for use in men as it is for women. Anal cytology (examination of cells from the anus and rectum) and anoscopy (a visual inspection of the anal canal and rectum with a small scope) can be done in men suspicious of harboring anal HPV.
HPV Vaccination
The HPV vaccine was developed in Australia at the University of Queensland by Ian Frazer and Jian Zhou. In 2006, Gardasil–the first HPV preventive vaccine– was marketed by Merck. It was not until 2014 that the FDA approved it in the USA.
Prophylactic HPV vaccination is a potent tool to prevent HPV-related cancers and ano-genital warts. In Australia, due to the effectiveness of vaccination and screening, cervical cancer mortality is almost zero. It is important to know that the vaccine does NOT treat existing HPV or genital warts.
There are three formulations available:
HPV 16/18 Cervarix (Glaxo/Smith/Kline)
HPV 6/11/16/18 Gardasil/Silgard (Merck/Sanofi Pasteur)
HPV 6/11/16/18/31/33/45/52/58 Gardasil 9 (Merck)–the only formulation available in the United States; it protects against nine HPV types including the types most commonly associated with ano-genital warts and cancer.
All boys and girls age 11-12 are recommended to receive the HPV vaccines prior to the onset of sexual activity. A two-dose schedule is recommended for those initiating the vaccination prior to their 15th birthday, whereas a three-dose schedule is recommended for those receiving the vaccination after their 15th birthday. The vaccines protect against HPV for at least 6 years. The Gardasil 9 vaccine is FDA-approved in females for the prevention of cervical, vulvar, vaginal, and anal cancers caused by HPV types 16, 18, 31, 33, 45, 52, and 58; precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58; and genital warts caused by HPV types 6 and 11. The same vaccine is FDA-approved in males for the prevention of anal cancer caused by HPV Types 16, 18, 31, 33, 45, 52, and 58; precancerous or dysplastic lesions caused by HPV Types 6, 11, 16, 18, 31, 33, 45, 52, and 58; and genital warts caused by HPV Types 6 and 11.
The vaccine was originally approved for ages 9-26, but in October 2018 the FDA expanded the indication of the vaccine for adults up to 45 years of age. This age extension should effectively prevent more than 90% of HPV-related cancers.
On point NY Times article by Jan Hoffman (9/23/19): How anti-vaccine sentiment took hold in the United States.
Bottom Line: HIV (human immunodeficiency virus) put a new perspective on both HPV (human papilloma virus) and HSV (herpes simplex virus) in terms of the gravity of sexually transmitted infections; however, HPV remains a potentially dangerous infection because of the possibility of viral-induced cancer that is increasingly prevalent. The availability of the HPV vaccination truly represents a major public health coup, a triumph that will wipe out the potential for many cancers as well as warts. Sadly, there is not much drama nor appreciation for the prevention of diseases one will never get (as opposed to the drama and appreciation when diseases occur and are cured). Zimmerman’s law is that nobody notices when things go right, but it is important to recognize and be grateful for progress in vaccinations and other public health measures.
Wishing you the best of health,
A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”: www.HealthDoc13.WordPress.com
Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States. Dr. Siegel is the author of Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. The first section of the book provides abundant information on the prostate and prostate cancer, while the second and third sections address male urinary and sexual concerns, respectively.
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: anal cancer, Andrew Siegel MD, ano-genital warts, cervical cancer, condyloma, HPV, human papilloma virus, oro-pharyngeal cancer, penile cancer, vaginal cancer, vulval cancer
Our Greatest Wealth Is Health 
October 13, 2019 at 6:50 AM |
Thank you for this updated and on point info Dr Siegel