Questions and Answers about Human Papilloma Virus
WHAT IS HPV?
HPV is a very common virus which can cause a broad spectrum of illness from asymptomatic skin and mucous membranes, to anal or cervical dysplasia, and at worst, to full blown anal or cervical cancer.
There are dozens of identified strains of HPV, some of which are commonly associated with warts (Types 6 and 11), however many people can harbor the virus without ever having a single wart. Some of the strains (Types 16 and 18) can reside in the anus and cervix and cause varying degrees of inflammation broadly characterized as dysplasia. Severe or highgrade dysplasia (HSIL) is strongly associated with the development of anal and cervical cancer, especially in men and women living with HIV/AIDS.
WHO HAS HPV?
The true prevalence of HPV is impossible to know because there is no single test that can rule it in. In addition, most people may be infected for decades before they manifest any symptoms or other changes. It is estimated that up to 60% of sexually active adults have HPV. It is also estimated that close to 100% of gay and bisexual men (MSM), and up to 85% of HIV+ women will have HPV. As many as 40% of people with HPV assume that they are not infected.
HOW DO YOU GET IT?
HPV is passed by skin-to-skin contact. Virus particles may be shed in the skin even in the absence of visible warts or any mucosal contact. HPV may be present on the thighs, scrotum, penis, anus, buttocks, vagina, cervix and labia. Condoms only cover the penis so although they may reduce the risk of transmission, they unfortunately do not reliably prevent the transmission. HPV can also be present in the mouth and lips.
HOW DO I KNOW IF I HAVE IT?
All high risk individuals including gay men, women who either engage in anal sex, or have had a history of abnormal cervical pap smears, all adults who have had genital warts and/or HIV/AIDS should undergo rectal examination (visual inspection and digital exam) and request an anal pap smear every year. These two methods together provide the most sensitive and cost-effective screening method available. The rectal examination will provide visual and tactile evaluation of the anus and anal canal, while the pap smear will evaluate for subtle pre-cancerous changes within the lining of the anal canal.
Obviously if you have any external wart, you probably have it, but HPV may take many forms from the stereotypical cauliflower crotch to flat shiny lesions, to small ulcers, to normal appearing skin with underlying changes.
SO I HAVE HPV; WHAT NOW?
Most people will understandably want any and all warts removed. Although the presence of warts is generally harmless, the removal or eradication of all visible warts is warranted for a number of reasons. Firstly, visible warts are more likely to shed and infect others.
Secondly, while the majority of anal cancers arise from non-wart forming strains of HPV, there can occasionally be small deposits of precancerous cells arising in a large wart. Lastly, cosmesis and the presence of warts can have significant effects on self-esteem and selfimage that should not be underestimated.
For those with abnormal pap smears but no obvious lesion on exam, a more sensitive procedure called high-resolution anoscopy (HRA) may be offered in order to root out any areas of abnormal or pre-cancerous cells.
HOW CAN I GET RID OF MY WARTS?
In the presence of warts, often your physician will want to biopsy one or more of the warts to evaluate the cancer potential. Once this is done, a number of remedies exist for home treatments, in-office procedures and occasionally, outpatient surgical treatment.
There are a few topical medications including imiquod, podophyllin and 5-fluorouracil which are occasionally used. These can be applied at home but are limited in their use by local skin toxicity, high recurrence rates and the inability to use them on internal anal lesions. In-office treatments include eradication by the use of liquid nitrogen to freeze, acid to burn, infrared coagulation to ablate or a number of other destructive techniques.
These are limited by patient discomfort (local anesthetic may be used) and a smaller but still significant recurrence rate. Finally, for eradication of extensive lesions, or in cases of extensively nervous patients, outpatient surgery with conscious sedation may be warranted to help ensure total destruction of all lesions with a combination of techniques.
HOW CAN I KEEP THEM FROM COMING BACK?
Unfortunately, you will never be virus free. As is the case with many viruses, it may go into a sleeping latency phase in which there is no external site of disease. Continuing annual surveillance with rectal exams and pap smears would appear to offer the best protection especially in cases of older individuals and in those who have HIV for decades. There is a clear connection between the amount of time you are infected with HPV and the subsequent development of anal cancer.
WHAT ABOUT THE HPV VACCINE?
The HPV vaccine, Gardasil® is currently approved for young women and just this past year young men up to the age of 26. It protects against the two most common wart forming and two most common cancer causing strains of the virus. Although the strain-typing of your HPV is approved in women, it is not yet approved for men.
It would follow that even men with warts would benefit from the vaccine as they may not have the cancer forming strains yet and although it may not prevent warts, it may keep you from picking up the high-risk subtypes. There is no indication for those individuals over 26, however there is some evidence to suggest that vaccination of older individuals at high risk may still be beneficial and you should ask your physician if you think that Gardasil® may be right for you.