What IS HPV?

Human papillomavirus (HPV) is the most common sexually transmitted infection among humans today. About 20 million Americans are currently infected, and about 5.5 million people become newly infected each year. HPV is comprised of more than 100 different variations of HPV, with more than 40 of these variations affecting the human population.

Infectious Life and Transmission:

Double stranded Human Papilloma Virus enters the skin and passes its DNA to the proliferative layer of the skin genome and as a result, undesirable proliferations will occur which appear as warts. Inoculation without manifestation of warts may take from a week to 18 months or more. It means you may have been infected with HPV but won't develop a visible wart until a much later time. This is the reason why we ask our patients to return to the clinic for a re-evaluation after 6 months and 2 years to make sure that they don't have a new wart. Some individuals are naturally resistant to HPV viruses and don't become infected as easily as others. HPV warts are a contagious infection and spread easier by manipulation such as scratching or shaving.

What Are Genital Warts ?

Visible genital warts usually are caused by HPV. HPV is a virus and the warts is the outcome, however, remember that not every growth in the genital area is a genital warts caused by HPV.

It must be diagnosed by your medical doctor only. HPV is very common in sexually active men and women and can sometimes have serious health consequences. About 20 million Americans are currently infected, and about 5.5 million people become newly infected each year.

The virus can infect the genital skin and the linings of the vagina, cervix, rectum, and urethra. They come in different shapes and color.  Typically they present like cauliflower growth scattered around randomly, however, it comes in different look that could mimic other skin presentation. For Example: they could look like mole , skin tag, cyst, keratosis, etc.

They come in different shape such as raised, flat, big and small. Many patient have these growth for months and years and they might not even know it. This become alarming when patients see multiple lesion and start thinking that they are facing ongoing and spreading disease before seeking medical attention. Many lesion occur in male or female genital that could be easily mistaken by genital warts. I have seen many patients in the past that getting  treated for genital warts with significant scar associated with various type of the treatment that had no HPV warts to begin with.

If patient gets labeled with HPV warts then he/she will carry the diagnosis from one doctor to another and all will follow the path of continuity of the care till and experience physician evaluate the patient along this path to change the diagnosis and obviously treatment course. In other words, not every growth is genital warts by HPV.

Location of Warts:

This affects both females and males. In addition to the scrotum, the penis, vulva, perineum, and perianal skin, genital warts can also occur on the cervix, vagina, urethra, anus, and mouth. Intra-anal warts are seen predominantly in patients who have had receptive anal intercourse; Anoscopy or anal pap smears might be needed for these patients. These warts are distinct from perianal warts, which can occur in both men and women who have never had anal sex. We diagnose and treat most of those external wart.

Human papilloma virus has tissue affinity. It means that each HPV like to infect certain part of the body and not others.

At many instances, wart started in one part of the body and will extend to other part. For Example, sexual intercourse may infect you and you get genital warts, then you infect yourself and waarts will extend to different area such as scrotal, anal or pubic area. Treating physician must examine the patient carefully of not missing any warts which may contribute to further infection.

During your visit we will fully examine you with different diagnostic tools such as filtered light, Microscope or  Macroscope to make sure we are not missing any warts at time of the treatment.

Physician must have an important goal at the time of the treatment and that would be that there will be no warts left when patient leave the clinic. Area of the infection has its own characteristic. That is important element because the technical approach might be different. Pubic skin is thicker, Scrotum is thinner. Penile skin is keratinized while anal skin is mucosal.

Using protection such as condom will somewhat protect the area in which has been exposed in sexual contact, However, there is no condom coverage on scrotum, pubic, anal, gron, medial legs perineum or anal area.

In many instances I see the condom user patient get genital warts just above condom coverage ring so I could assume that patient usually use protection, but of course no condom would cover all part of sexual organ.

Diagnosis:

Not every growth on the genitalia is a genital wart by HPV. It must be diagnosed by an experienced medical doctor. We provide a diagnostic service after initial consultation and evaluation. Diagnosis could be confirmed by a biopsy as well, the physician may decide for biopsy, for example, if the size of the warts are big and bleeding or pigmented.

Acetic acid application (vinegar test) is not sensitive and not a reliable test. Physician experience is a major factor in diagnosing warts early and treating them immediately for more successful outcome. There is no blood test for HPV or genital warts, so we can not tell the overall status of an individual's HPV. The virus does not circulate in blood and that is why we do not do blood test for the diagnosis. There is limited testing for females consisting of an element of typing for the cervix but not for men. If the HPV causes visible genital skin growth, then the doctor examination is the most important factor.

Pap Smear and HPV Test:

HPV test and pap smears are primarily for evaluation of cervix such as detection of cervical cancer or any abnormality. This would not tell you if you have external genital, anal or perianal warts or not. For example, you could have a HPV wart on your labia majora of the vagina, anal or perianal warts and yet have a normal pap smear with no HPV. However, if you are diagnosed with external genital warts then we always recommend you to get a pap smear to make sure that you do not have anything internally. If your doctor gets suspicious of genital anal warts which are spreading then he/she would consider treatment as this could be extended internally (vaginal, anal, urethral) with possible later complication. On the other hand there is a possibility that your warts go away on their own, but you must consult with your MD. In conclusion the following are real possibilities :

1) You have Anal, perianal or genital warts and you have normal pap smear with Negative HPV DNA Test

2) You have Anal, perianal or genital warts and you have abnormal pap smear results with Negative or Positive HPV DNA Test

3) You have no Anal, no perianal and no genital warts and you have abnormal pap smear results with Negative or positive HPV DNA Test

Protection:

Although condom use is a must for those infected with HPV, it unfortunately does not provide full protection from genital warts. A condom provides protection only for the area it covers (above the base of the penis), leaving other areas such as the pubic area and scrotum susceptible to infection. Many male patients develop genital warts in the unprotected areas and the disease then spreads to the penile shaft. Likewise, women can be infected with HPV through a male with warts on the genital areas not covered by a condom. Even so, while the CDC reports that scientific evidence suggests the effect of condoms in preventing HPV infection is unknown, condom use has been associated with lower rates of HPV-associated diseases including gential warts and cervical cancer. This evidence is not sufficient enough to deem condoms a primary prevention strategy for HPV, but the indication that condom usage may reduce cervical cancer risk is certainly worth considering.

Genital Warts Psychology:

Many patients with genital warts struggle with anxiety, depression, or a feeling of guilt or uncleanliness. Most obsess about their genital warts for weeks, months, or even years as repetitive treatment proves to be a failure. Some fear their sexual partners will question them about their visible genital warts. Their obsession with overcoming this challenging battle may even drive them to try alternative, and often injurious, methods of treatment. Use of self-manipulation and destruction with sharp objects, freezing, home remedies, creams bought on the Internet, and various acid, tea tree oil, and silver compound applications is very common.

As genital warts increase in intensity, size, and number, the feeling of failure continues to impact the patient’s psychological state. For this reason, removing the visible warts not only improves the patient’s physical state; it also improves the emotional state.

Treatment:

Life is filled with beauty and darkness. We fight to win, sometimes victoriously and other times not, but the point is that we get up and fight again, learn a lifetime experience and put it behind us. However, as humans we tend to stop fighting if there is no chance of winning. To win, it is necessary to have the right tools and preparation, including strength and knowledge of the enemy's behavior. Genital warts are the product of a virus that works from within the body’s cells; to battle it, the immune system must be as strong as possible. Worry or depression can weaken the immune system, which is one of the reasons why it is so important for patients to be educated about their condition; the more that is known, the better the chance to fight it

With regard to genital warts, each wart must be approached differently. There is no quick and easy treatment such as a pill that will eliminate them. Each wart must be examined individually and its features evaluated; how big it is, its thickness, its location, the color, whether it was previously treated, if it is associated with scarring, the rapidness of its growth, and the length of time it has been present must all be taken into consideration. One method of treatment does not fit all warts so it would not be appropriate for a treating clinician to treat all warts with liquid nitrogen without regard to the wart’s individual characteristics. Likewise, FDA-approved creams would not be the most optimal treatment for prominent warts and non-FDA-approved creams would never be recommended due to serious damage, and exacerbation of infection. Our approach for the treatment might be different from person to person which depend on location, size and quantity of warts but our ultimate goal of genital warts treatment is a

"One Time Treatment for Each individual Wart"  

This is a significant accomplishment in my practice due to the fact that there is a very high relapse rate of genital warts regrowth after removal by any method. You may know this already if you underwent previous treatment. We may have no control over new growths of genital warts in other areas, but our goal is to keep the population of genital warts at zero percent for a certain period of time. If there are no "parental warts," then there is more of a chance that “offspring warts” will not develop. We can provide surgical destruction for what lesions we can see, but this is not possible with what we cannot see, so we map the skin and evaluate it thoroughly. I look at the area with a microscope, ensure that all warts are removed, and then hope for the best as far as new growths. I have frequently seen patients with multiple treatments of their warts who have had significant relapse rates. My main objective is to treat genital warts with no relapses on the same wart at the treatment site. Although there is no 100% guaranteed with any type of surgery, the first shot at treatment should be the best one. The tools of treatment are only as good as the treating physician’s talent and skill.