Genital Warts in Men: HPV causes anogenital diseases in men. The most important benign pathology due to HPV is genital warts. Apart from that, HPV can cause anus, penis, and mouth-throat cancers in men. HPV type 16 is held responsible for these cancers that develop in men.
There are 22,000 HPV-related cancers annually in the USA, and 7000 of these are seen in men. In addition, 250,000 cases of genital warts (condyloma) caused by HPV types 6 and 11 are seen every year in sexually active men in the United States.
Genital warts detected in men are important in many aspects of public health and must be treated. The biggest problem we encounter in our country is that men do not recognize this disease, do not go to the doctor for a long time, do not have treatment, and consequently spread the disease. Below you can see genital warts in the mouth of the urethra.
Studies on HPV infection and its effects on men are new and our knowledge is still insufficient.
HPV and Genital Warts in Men
In the study conducted by Dunn et al., The prevalence of genital HPV (HPV types transmitted through sexual contact) in men was found to be 40%. Different rates were obtained in different groups in the study. For example, different groups such as students, soldiers, men in sexually transmitted disease clinics, spouses of women with CIN were examined. The frequency of HPV among these groups varies according to the type of the group but varies between 6% and 45%. The highest incidence of genital HPV was detected in men with a cervical cancer precursor lesion (CIN), with rates varying between 50-75%.
The prevalence of genital HPV in men does not change. Prevalence is the total number of new and old cases at a given point in time or over a period of time. For example, in 2013, how many people in Istanbul had genital warts (the total of old and new patients), that figure gives the prevalence of genital warts in Istanbul.
It is interesting that the prevalence of HPV infection in men does not change according to age, because of the frequency of HPV transmitted by sexual contact in women changes with age. It increases especially after the first contact (up to the age of 25-30), then decreases and then increases again in the perimenopausal period. However, the prevalence of HPV transmitted by sexual contact at all ages in men (the sum of old and new patients) is the same in age groups. For example, in a study conducted in Italy, 13-14% of women are sexually transmitted HPV after the first intercourse, then this rate decreases to 5% and below until the age of 39-40, and after the age of 40, it goes up to 8%. The rates in the world are similar to this. However, in the same study in men, the rates do not change according to age.
Interestingly, while the most common “high-risk” HPV is detected among HPVs transmitted by sexual contact in women, the rates of high and low-risk HPV types found in men are the same. This information actually supports the information about the HPV types that cause genital warts in men and these warts contain.
In 2013, Patel et al., In the study in which all the literature in English, Spanish, Italian, and German was scanned and the prevalence of genital warts in men and women was reported, the median value of genital wart incidence in men in European Continent was given as 195 / 100.000.
Incidence: The number of new cases or events occurring in a certain period of time (usually 1 year). For example, the new genital wart patient detected in 2013 gives the incidence of genital warts in 2013. Therefore, the rate above indicates that every hundred thousand people in Europe are seen in 195 cases of genital warts each year.
What is the course of the disease in men? Is The Virus Removed From The Body Or Is It Cleansed?
A very little researched issue in men is how HPV infection transmitted through sexual contact progresses. Limited studies have been related to heterosexual men.
In one study, 290 men were followed for 15.5 months and the prevalence of old + new HPV infection was found to be 52.8% during this period. New infection incidence is 42.3 / 1000 per month. Accordingly, the chance of contracting a new sexually transmitted HPV infection within 12 months is 29.2% !! 19% of this ratio includes high risk HPVs and 16% low risk HPVs. (Some patients carry both low and high risk HPV)
5.1% of men with each new infection get HPV type 16 and HPV type 18, and 3.4% get Type 6 and 11.
The time to clear the body from the virus is 5.9 months according to this study !! At the end of 12 months, HPV DNA is NOT available in 75% of men with the disease and cannot be detected. By the way, there is no difference in terms of high and 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)
In the same study, the rate of high and low risk HPV is the same. HPV tests on and around the penis root, glans penis and testicles are most often positive. However, it should be kept in mind that the study was conducted in a young male population with high potential for frequent change of partners.
How Does Contamination Happen?
The heterosexual transmission of HPV (female to male or male to female) still has dynamics under investigation, not clearly understood, and is still debated. However, the main reason is sexual contact.
Although there are many factors that affect the frequency of contamination, it is an important contagious factor to remove the hair just before the intercourse because it is practical !! When hairs are removed by methods such as hair removal creams and razors, some of the epithelial tissue is removed mechanically, which causes a large area to be infected with the virus at the time of contact with a woman with genital warts. Also, warts plucked during hair removal cause the virus to penetrate into the damaged epithelial tissue up to the bottom point we call the basal plate. In such cases, treatment is extremely difficult and the disease recurs. I will write these sentences over and over again in the treatment section because it is extremely important to understand.
The virus is also transmitted by oral and anal sex. In the context of frequent transmission, anal sex is most important. Because the formation of micro tears in the anal canal during intercourse is a common situation and it facilitates the transmission of the virus to the woman and the transmission to the man if there is bleeding.
Does Condom Reduce or Protect Contamination?
Condom reduces the possibility of contamination, but since it covers only the root of the penis, the root of the penis is open to contact and transmission is possible. However, using condom is better than nothing, and most importantly, it protects against HIV, the AIDS virus. Therefore it should be used. Again, it is recommended to use for 6 months after treatment, especially for married couples. It is recommended to use it permanently for the other male group.
Does Circumcision Protect Against HPV?
Circumcision protects against both HPV and HIV virus. Although there are different opinions about circumcision, it has been shown in recent publications that circumcision protects against HPV virus. In the study of Banura et al., It was shown that the frequency of HIV and HPV virus transmission in circumcised men is lower than in uncircumcised men (Banura et al. Infectious Agents and Cancer 2013, 8:27)
Which HPV Types Cause Male Genital Warts? Or Which HPV Types Are Genital Warts Detected In Men?
As classical information, the types of genital HPV that cause genital warts can be listed as 6, 11, 42.44, 51, 53, 83. In different publications, 90% to 70% of all genital warts are caused by Type 6 and Type 11.
However, the question we gynecologists often ask ourselves: Why do we detect high grade (CIN II – III) cervical lesions in women with genital warts in her husband and lover? Is not it? Since these lesions are frequently seen in Type 6 and 11 causes of genital warts in women. Because the chance of Type 6 and 11 to cause CIN II and III is extremely low.
Studies have shown that warts in men (and indeed women) often contain more than one HPV type, and some of these HPV types are high-risk HPVs such as Types 16 and 18. The study of Gabriella Anic et al. Titled “HPV in Men Study” provided important data.
2487 men aged between 18-70 and WITHOUT genital warts were included in the study and were followed up between 2005 and 2009. By 2009, genital warts were detected in 120 patients. Looking at the HPV types that cause these warts, it was found that 45.5% of the patients were infected with more than one type, and 12.5% of them were HPV Type 16 and 18 positive.
The pictures you see below belong to 2 male patients whose partners I treated for cancer precursor lesions (CIN) in the cervix. As a result of typing, both patients had more than one HPV in warts and oncogenic, that is, high-risk HPV.
In the study conducted in Denmark by Kofoed et al. Published in 2013, only HPV Type 16 was found in genital warts in 2.7% of the cases. Although Type 6 and 11 were detected in 74% of the cases, more than one HPV type including high-risk HPV was found in 33% of men.
In conclusion, the gynecologist should know that genital warts may contain more than one HPV type and some of them may be oncogenic Type 16 or Type 18, and if he knows this, he should arrange his treatment by informing the patient and his wife in this direction, otherwise, he should direct the patient to a center where treatment can be performed.
How to Diagnose Genital Warts in Men? Which tests should be applied?
Of course, the diagnosis should be made visually and by watching. However, the presence of flat, flat condylomas in both men and women is certain. Therefore, in order to reduce the frequency of recurrence, a male patient should definitely have a periscope by applying 5% acetic acid to his penis. When viewed with large magnification, warts can be distinguished from the lesion that mimics genital warts (For example Molluscum contagiosum, herpes simplex, etc.)
Below you can see warts reacting with acetic acid on the penis surface in the patient who had a periscope.
Periscope makes the diagnosis better and thus the treatment is effective. Nicolau et al. Clearly demonstrated this in their study (Sao Paulo Med J. 1997 Jan-Feb; 115: 1330-1335)
Apart from the periscope, if the male patient has anal condyloma or is homosexual, an anal smear should be taken. The person does not need to be homosexual in order to develop anal condyloma and genital warts. In a way that we still do not understand the reasons very clearly, women also have condylomas around the anus without anal sex.
The Effect of Genital Warts on Sperm and Male Reproductive Health
Human Papilloma Virus (HPV) has more than 200 varieties, there are nearly 40 types that show symptoms in the form of warts in the genital area in men and women. The most common types are HPV 6 and 11. Types 16 and 18 have a high risk of cancer in the cervix, penis, and anal area. Frequently, the risk of transmission is high between the ages of 15-24 and since it is a sexually transmitted disease, polygamy increases the risk of transmission. In a study conducted in the USA, it was reported that approximately 80 million people have active infections (Oshman LD, et al. JAMA, 2019). Accordingly, couples who have problems with having children are very likely to have or be exposed to HPV infection.
Many studies have been conducted on the effect of HPV infection on reproductive health. While a limited study has shown that HPV infection has an effect on female infertility, many studies have shown that it causes infertility problems in HPV-infected men compared with control groups (Foresta C et al. Andrology, 2015). It is known that sperm count, motility, and shape in men are affected by many environmental factors, infections, habits, and living conditions. In the June 2020 issue of the journal Fertility and Sterility, Weinberg M et al. The effect of HPV in semen on semen parameters and in vitro fertilization results was investigated with his systematic examination and meta-analysis study. In this study, the authors investigated the effect of HPV on sperm quality in semen samples of more than 3700 men in 16 studies. It has been demonstrated in meta-analyzes that HPV infection reduces sperm count (-4.6 million / ml), motility (11.7%), and morphology (2.4%). In this article, it has been reported that the effect of HPV on pregnancy rates was not shown in the literature, but the risk of miscarriage increased in many studies. The authors stated that HPV infection is more common in oligospermia men with sperm counts below 15 million / ml, but the relation of this decrease with HPV infection cannot be demonstrated. Likewise, it has been reported that sperm motility is more affected by HPV infection in men with movement problems compared to those without. When the results of IVF are examined, it is understood that the adverse effects of HPV have increased from the meta-analysis results of 4 studies.
As a result, debate arises about potential preventive or therapeutic methods based on the effects of HPV infection on sperm parameters. In this case, 2 doses of HPV vaccination come into question for protection from HPV infection (or, in the light of new findings, for potential treatment). The HPV vaccine is currently recommended between the ages of 11-26 in vaccine administration protocols. As of August 2019, it is seen that the US Center for Disease Prevention and Control has changed its HPV vaccine recommendations for adults. In the recommendation, it is suggested that adults in the age range of 27-45 can be decided by interviewing patients. Once the infection has started, new evidence suggests that the vaccine may have a potential effect in transmitting the disease. In addition, according to new information, it is thought that the HPV vaccine has positive effects on reproductive health. Garolla et al. In a study conducted on 151 couples with HPV infection in semen, they compared the results of 79 couples who accepted the vaccine and 72 who did not. After 1 year, the rate of HPV in semen decreased from 100% to 70% in those who were not vaccinated and decreased from 100% to 10% in those who were vaccinated. A more interesting finding is that while a pregnancy rate of 15.3% was observed in those who were not vaccinated naturally, the pregnancy rate in couples who were vaccinated showed a statistically significant increase of 38.9%. It has been observed that the semen of men in all pregnancies do not have an HPV infection. This study needs to be supported by new studies in the future in terms of the effect of the HPV vaccine on sperm parameters and revealing its potential to increase the possibility of pregnancy.
Genital Warts Treatment in Men
1 . Patient education and care of the genital area:
The patient must learn to examine himself and inform his doctor in case of recurrence of warts. At least 3 months but ideally 6 months should not shave !! As I have detailed above, whichever method is used, the removal of hair from the genital area damages the surface epithelium and facilitates and increases both transmission and recurrence. When the hair grows, it is sufficient to cut it with scissors without bleeding. The man must use a condom. This period is at least 6 months for monogamous individuals. The issue of vaccination of males is detailed below.
2. Basic points in the choice of treatment:
Patient’s request and previous experiences: If the patient is a patient who has been treated many times before, has used medical treatments but failed, one of the surgical methods can be chosen.
- Medical facilities: In the center where the patient applies, destructive surgical methods may not be available. Or the patient has another systemic disease.
- The experience of the clinician and the doctor: In today’s concept, it is thought that the treatment and follow-up routines of each clinic and the doctor are more important in obtaining the best results.
- Podophyllin: It is a herbal-based antimitotic drug. Patients should be very careful when using it because it is toxic to normal skin. It is difficult to use. It should not touch the surrounding tissue too much. The area of the condyloma to be treated should not exceed 10 cm2 and the amount of Podophyll used daily should not exceed 0.5 ml.
- Imiquimod (5% and 3.75%): It is an «imidazoquinoline» group molecule with immunomodulatory, antiviral, and antiproliferative properties. It particularly affects interferon levels. Clinical studies have shown that it provides a full cure in 40–77% of patients with genital warts. This is also toxic to normal skin. Redness, burning, itching are common during treatment. But the most important side effect is that it causes discoloration of the skin similar to vitiligo. After its application, the recurrence rate of warts is between 9 – 23% in different publications. It should be used 3 times a week, a maximum of 12 – 16 weeks. If it does not exceed 12 weeks of use, it may cause an increase in the frequency of warts (because it destroys E2).
- Sinekatekin (in 15% oil): Green tea extract. It is 50 -60% effective thanks to 8 different extracts. It has been approved by the FDA in the USA.
- Acetic Acid (Tri – Bi): Its application in a male patient is controversial, is it necessary, question mark.
4. Surgical Treatment:
The important thing is which method the surgeon has adopted. Laser coagulation is expensive and not common. It is unnecessary for glans, too. Cosmetic results are the same
Important point: In terms of preventing recurrence, the patient should pay attention to protective measures. General anesthesia is unnecessary. Extensive lesions can be eliminated with local anesthesia. General anesthesia can be applied in selected and very common cases, anal condylomas.
- A. Cryocooter: Destruction of lesions by freezing. The results obtained with the application of some sprays are not always pleasant. Especially if the lesions are widespread and large. The problem is using the same tips when using a normal cryocooler. It takes a long time to change according to the lesion. When the same tip is used, it either falls short or destructs in a wide area.
- B. Electrocauterization. It is my choice. With local anesthesia, widespread lesions can be treated effectively, without leaving any scar at once. General anesthesia is applied if the lesions are widespread and there are anal diffuse warts. HAs do not need to be out of power, often all lesions heal within 20 days.
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