The Diagnosis and Treatment of Condyloma in the Male
There is no longer any question concerning the association between some condyloma, or genital warts as they are more familiarly called, and cancer of the reproductive tract in women as well as in men. Condyloma are caused by the human papilloma virus (HPV). The link between HPV and cervical carcinoma in situ has been very well known for years. A large number of people have HPV infection invisible to the naked eye but which can be clearly seen after the application of acetic acid and examination with magnification.
While urologists do not routinely diagnose or treat condyloma in females (such treatment is generally provided by gynecologists), the do participate in the evaluation and management of male partners of effected women.
Cause of Condyloma
Although genital warts are caused by human papilloma virus (HPV), many more people are infected with the virus than have warts. While HPV infections are not reportable as a sexually transmitted disease (STD), there is no question that they are indeed sexually transmitted.
HPV is a papillomavirus containing double-stranded DNA. It is the same shape as the herpesvirus. It does not appear to be blood-borne. Because some condyloma spontaneously disappear, as do some common body warts, it is clear that a large role in the infection is played by the individual patient’s cell-mediated immunity.
About 30$ of women who have HPV of the cervix, as diagnosed by Pap smear, go on to develop cervical dysplasia. It is clear that some forms of dysplasia and cervical cancer are caused by HPV.
Recently, researchers have been typing HPV; there are now over 45 known HPV types. Of these, HPV type 6 and type 11 involve the genitals in about 10% to 15% of cases. HPV types 16, 18, 31 and others are found mainly in cervical, vaginal and vulvar carcinoma.
Diagnosis of Condyloma
The clinical appearance of condyloma is well known: They usually begin as soft, moist, pink or red swellings that grow fairly rapidly and become pedunculated, i.e. stalked. They usually occur on warm, moist surfaces, including the thighs and lower abdomen as well as the anogenital surfaces. Common sites in the male also include the area under the foreskin in uncircumcised men and the underside of the penile shaft.
Condyloma and carcinoma may resemble each other; hence, biopsy is necessary to make the proper diagnosis.
Subclinical condyloma cannot be seen with the naked eye. This type of lesion is as infective as the papillary type and has the same potential for transmission. It may also be a precursor of carcinoma in men as well as women. Thus, it is important to diagnose these lesions as well. It is no longer appropriate to consider macroscopic or microscopic condyloma as a minor health problem. The incidence of subclinical disease in male consort of women with condyloma is high. In one group of 51 men studies, 95% were found to have condyloma; 90% had subclinical disease.
Identification of subclinical condyloma is made by soaking the suspected area with acetic acid solution, allowing the area to dry and then inspecting it with a good light and magnification. Acetic acid caused subclinical condyloma to turn a shade of white (acetowhite areas).
It’s important to keep in mind that some disease entities give a false positive appearance. These include fungal infections and those areas of the genitals exposed to constant friction. A small biopsy of the lesion will confirm the presence of HPV.
Additionally, because HPV DNA has been found in ejaculate and urine, and clinical and subclinical HPV has been found in the male urethra, a Pap smear from the urethra and collection of a urine sample may be taken. Patients with condyloma on the external genitalia and especially those who complain of hematuria or urinary obstructive symptoms may have condyloma in the urethra. These patients may require cystoscopy to rule out that possibility. Once the acetowhite areas on mucosa or keratinized skin are identified, other representative areas at least should be biopsied.
A histologic report that indicates either “dysplasia” or “koilocytotic changes”, or “atypical mitotic changes”, suggests the need for therapy. A new type of diagnostic procedure will involve staining for specific viral DNA using a special DNA-probe technique.
Treatment of Condyloma
Cure rates for condyloma, especially subclinical condyloma, are notoriously low. Treatment efficacy for standard therapies range from 20% to 90% in the immediate treatment period. After 3 months, however, many patients have recurring condyloma in the same area.
The consensus is that patients with visible condyloma should have them removed. Those males with subclinical condyloma may be candidates for laser ablation of suspicious subclinical areas if the virus has been typed as 16 or 18, or in the absence of typing there is histologic evidence of dysplasia and/or atypical mitotic changes upon cervical examination of their female partners.
There is a consensus that podophyllum, while it has eradicated exophytic (grossly visible) warts in the past, is probably outmoded. It is an unstable substance, its strength varies from bottle to bottle, and some patients are overly sensitive to it. Furthermore, it cannot be used during pregnancy. Eighty five percent trichloroacetic acid is used as a substitute for podophyllum. It is reasonable to treat lesions on the keratinized part of the skin once or twice with chemical agents. In general, however, such lesions are refractory to caustic agents and physical destruction is necessary. 5-Fluorouracil (5-FU) has also been used to treat warts.
Laser Treatment of Condyloma in Men
When there are extensive exophytic lesions, when the danger of scarring from conventional methods of treatment is high, or when there are refractory lesions – where success seems to depend on not only destroying the lesion, but also destroying a margin of subclinical or latent infection – laser becomes the treatment of choice.
Laser therapy is the most practical, innovative treatment modality to come along in the last five years. Carefully applied, CO2 or YAG laser therapy directed to a field of treatment rather than a single spot can yield cure rates up to 95% for grossly visible lesions. 5-Fluorouracil has also been used successfully in the urethra as has the laser. In treating the shaft of the penis for subclinical diseases, laser ablation is followed by a course of 5-FU cream. Although there may be local discomfort as a result of inflammation caused by the ointment, healing takes place in four to six weeks.
Interferon: Except in severely immunocompromised patients, there is no role yet for interferon in the everyday treatment of condyloma. First, interferon has not been approved for this indication; second, it is very expensive; and third, there are severe side effects associated with its long-term use. Finally, the condyloma tend to recur as soon as the interferon is stopped. In the future, oral low-dose forms of interferon may become available, giving it a role in the management of condyloma.
At the forefront of therapy is the use of CO2 laser in patients with a large number of exophytic and subclinical condyloma. The involved areas are washed with clear soap and allowed to dry. A 5% acetic acid solution is then liberally applied to the penile shaft, scrotum and inter thighs. These areas are then allowed to dry for three minutes.
The involved areas are injected with local anesthetic. After careful inspection with magnification, each lesion is vaporized with the CO2 laser as is a small area around each treated point. All visible condyloma on the penile shaft are treated.
When laser treatment of the penis is completed, healing takes about a week. Simple burn cream application is recommended if necessary. After healing has occurred, 5_FU cream is applied if indicated. Patients can put the penis outside of a scrotal supporter through a hole made in it. This protects the scrotum from the 5-FU cream. Patients are instructed to wash the penis and remove the supporter the morning after each 5-FU treatment.
Patients may resume intercourse, at will, but should use condoms for six months. This six-month waiting period will allow observation for recurrence and prevent reinfection of the female partner if elimination of the HPV infection has not been achieved. Follow-up examination is in three months. If additional condyloma are found, the laser and 5-FU treatments are repeated. If there are additional condyloma, patients are asked to return again in six months for a checkup.
Although urologists can cure grossly visible lesions in 95% of cases, the subclinical cases of condyloma virus are much more resistant to therapy and may require multiple treatments.
Except in severely immunocompromised patients, there is no role yet for interferon in the everyday treatment of condyloma. First, interferon has not been approved for this indication; second, it is very expensive; and third, there are severe side effects associated with its long-term use. Finally, the condyloma tend to recur as soon as the interferon is stopped. In the future, oral low-dose forms of interferon may become available, giving it a role in the management of condyloma.