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
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
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
dyloma 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
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
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
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
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
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 s
everely 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.
Please call us for more information at 303-724-2712.