Genital warts, or condyloma, are caused by a group of viruses called human papilloma virus (HPV). There are over 46 different types of HPV.

Warts are transmitted sexually, in fact, HPV and herpes are the two most common forms of sexually transmitted disease. A study revealed over 964,000 cases of HPV diagnosed in 1981, and this does not include health clinics, hospitals, or military bases. From 1966 to 1981, there was a 459% increase in the incidence of warts.

A recent report indicated that in 1987 there were over one million new cases of condyloma diagnosed.

Warts may appear as early as two to three months after contact, or remain undetectable for as long as years. In the male, they can appear on the penile shaft, perineum, perianal area, or in the urethra (urinary tract). In the female, they can be on entrance to the vagina, on the perineum, or on the cervix. They may cause itching, irritation, or bleeding; but most frequently they produce no symptoms. Warts on the outside genital area may be firm, raised, and dark pink or red. Often one or two warts may be present, or they may be in a cluster that looks like tiny cauliflowers. The appearance of warts can vary.

Over the past few years, medical research has revealed that HPV, type 16, 18, and 31, have been associated with cancer of the cervix in the female. Fortunately, cervical cancer can be caught in an early stage when the Pap test reveals pre-malignant or early cancerous changes. Once again, this has been associated with certain types of the HPV. Unfortunately, it has also been discovered recently that HPV 16-18-31 will produce warts that very frequently are invisible to the naked eye in both the male or female.

It is very rare for the HPV to cause cancer in the male; however, there are some recent studies that do show some correlation between the very rare carcinoma of the penis and HPV. Certainly, the main person at risk in this situation is the female partner. Therefore, not infrequently, a male is referred to the urologist because an abnormal Pap test result was obtained on the female. Physical examination of the male genitalia will detect some of the genital warts. However, in order to help try to detect the nonvisible ones, a very mild acetic acid solution (half strength vinegar) is applied to the penis and allowed to dry for five minutes. A microscope is then used to detect some of the nonvisible lesions.

Treatment of warts is a very frustrating problem. Not only may some of the warts remain dormant for a long period of time, but the treatment alternatives available to the male are frequently not successful, are associated with some side effects, and have a high recurrence rate.

Because of the potential for warts to be present inside the urethra, or urinary canal, a urine specimen (urine cytology) can be obtained and sent off to the lab for microscopic examination of virus containing cells. A swab of the urethral entrance is also taken to check for HPV virus. In addition, if necessary, a small flexible telescope (cystoscope) may be passed into the urethra to visibly inspect for warts.



Treatment alternatives include:

1. Trichloroacetic acid. A weak acid that is placed on the warts to kill them. This has been associated with minimal side effects. There can be some breakdown of the skin and secondary infection if proper hygiene is not followed. With the use of trichloroacetic acid, as with the other treatment modalities, Neosporin ointment (available at the local pharmacy) should be applied to the treated areas three times a day.

2. Podophyllin. Podophyllin is a substance that, when applied to the skin, will arrest cell division in the virus. Although very inexpensive, the success rate is not high. Potential side effects include skin breakdown, and the medicine must be washed off within three to four hours of application.

3. 5-FU (Efudex). A strong cream, which when applied to the warts will kill the viral cells. It has a higher success rate than Podophyllin, but also a higher incidence of skin breakdown. It can be injected into the urethral canal with a 90% response rate. However, there is an associated risk of burning with urination and irritation to the opening of the penis with its use. Any contact with the scrotum can cause significant breakdown of the skin and should be avoided.

4. Laser therapy. This is an outpatient procedure in which the warts are anesthetized with Xylocaine, and the wart with the surrounding area is burned with the laser. There is almost no discomfort associated with the therapy. It does require a visit to the operating room of a hospital.

5. Interferon. Injection of warts with a new medication that has had reasonably good success in cancer patients. Unfortunately, significant side effects can occur throughout the entire body.

A recent study has revealed that recurrences can be high if not dealt with properly. This was felt to be secondary to re-infection from the urethral canal as well as undetectable warts that subsequently developed.

We, therefore, are dealing with a problem that carries a high risk for the female partner. Unfortunately, the ability to diagnose warts in the male is not good, the treatment alternatives have a low success rate, complications can occur, and recurrence is possible.

Recognizing the difficulty previously mentioned, I have recommended and implemented the following diagnostic and treatment program.

1. Treating all visible condyloma with combination trichloroacetic acid-Podophyllin regimen. Weekly follow-up visits are recommended until eradicationhas been completed..

2. Use, of a microscope to diagnose and screen for nonvisible condyloma on all patients whose partners have severe dysplasia or CIS by Pap tests.

3. Offering all patients with grossly visible warts or partners of patients with less than severe dysplasia microscopic examination as well.

4. Treating all microscopic lesions with combination trichloroacetic acid-Podophyllin on a weekly basis until there is no further evidence of condyloma.

5. Utilize urine cytology, urethral Pap tests, and flexible cystoscopy (flexible telescope) on all patients with grossly visible warts, microscopically positive condyloma, or partners of patients with severely abnormal Pap tests. Offer all patients of partners with less than severely abnormal Pap tests the same diagnostic modalities.

6. Treat all severely abnormal Pap test partners or urine cytology positive patients with self intra-urethral instillation of 5% Efudex cream five times a day for a week. Cauterize all cystoscopically visible urethral warts in the operating room under general anesthetic. Because of the possibility that the urethra screening test could be negative and condyloma still be present, the preventative instillation of 5% Efudex cream must be offered to all patients with partners with severely abnormal Pap tests. CAUTION MUST BE TAKEN TO ENSURE THERE IS NO CONTACT OF THE EFUDEX WITH THE SCROTAL SKIN.

7. Periodic follow-up examination at least every other month are necessary for all patients once condyloma have either been eradicated or to ensure that development does not occur following the initial evaluation. The follow-up visits would include microscopic examination, urine cytology, and urethral Pap tests. Cystoscope would be used only on previously urethral positive patients. In the meantime, condoms should be utilized for at least four to six months following exposure or evidence of the condyloma.

Both the male and female can feel frustrated or depressed about the problem that they have obtained. However, there is a potential for cure, and patience is necessary. Some things that can be done to reduce the risks of getting genital warts in the future (one can become re-infected) are limiting the sex partners to those you know and trust. Additionally, a condom should be worn by males during intercourse and does provide some protection.

In conclusion, since you have found out that you have genital warts or have been exposed to them, remember, this is one of the most common sexually transmitted diseases in the United States today, and you are not alone. Patience and perseverance is the key to coping with warts. While the male is at low risk for serious problems, unfortunately, the female is not. The male partner must feel a strong sense of obligation towards all his female partners in this situation. All female contacts need to be informed of the potential exposure to genital warts and be urged to obtain a Pap test from their local physician.

If you can either obtain a copy of your partner's Pap test or have her physician mail the office a copy, this will be beneficial in recommending the diagnostic and treatment program for the male partner/contact.

FRED CREUTZMANN, M.D. CARROLLTON - 972-394-7277 or www.DrCmd.com