Lumps And Bumps On The Genitals
In sexual health practice, lumps and bumps in the genital area are very commonly seen. There are four main causes of such lumps; genital warts, molluscum contagiosum, Fordyce spots and pearly penile papules in men.
The human papillomavirus (HPV) is a virus that infects the epithelial (skin or mucosal) cells. There are many types of the virus which are numbered in order of their discovery. The majority of types cause no symptoms; some cause warts (verrucae) while others can, in a minority of cases lead to cancer. Warts which appear in the genital region, penis, vulval, vaginal or anal are termed genital warts.
HPV is believed to be the commonest sexually transmitted infection in the developed world and many sexually active men and women will be infected with the virus at some time in their lives. More than 30 to 40 types of HPV are transmitted through sexual contact. Ninety percent of genital warts are caused by HPV types 6 or 11. These are very common and highly infectious. Penetrative sex is not required and skin-to-skin genital (e.g. penile-vulval) contact is a recognised mode of transmission. Not everyone who is infected with the virus develops warts and the HPV genotype 6 and 11 that cause genital warts tend to run a benign self-limiting course.
It has been estimated that HPV causes almost 100% of cancer of the cervix, 90% of anal cancer and 40% of cancers of the external genitalia (vulva, vagina and penis). HPV can also cause cancer of the mouth and throat. HPV infection of the cervix usually clears after a few months but persistent infection beyond 12 months, as occurs in 5-10% of women, is associated with changes in the cells of the cervix. These changes can progress to cancer, a process which usually takes 15-20 years. Cervical cancer is rare in women under 30 years of age. Factors believed to contribute to the progression to cervical cancer include immune suppression, as in advanced HIV infection, cigarette smoking, long-term uninterrupted use of hormonal contraceptives and co-infection with Chlamydia trachomatis or Herpes simplex. 70% of cervical cancer is caused by the high-risk HPV genotypes 16 and 18.
Genital warts type 6 and 11 are diagnosed by inspection. The warts can be flat or on a stalk and are ‘cauliflower like’. Cancer causing warts can be identified on cervical screening or in anal screening where appropriate. Warts can often be mixed up with molluscum contagiosum and pearly penile papules.
Warts are treated by several methods, freezing with liquid nitrogen, surgical removal , laser removal and topical treatments available on prescription. In Harold’s Cross surgery, we specialise in the radio-surgical removal of genital warts. This is done under local anesthetic with instantaneous results. The warts are gone when you leave the surgery. The focused radiosurgical probe means no collateral tissue damage and no bleeding. The recovery time is days (10-14) and heals with none or minimal scarring. Genital warts may recur but usually do not. If they recur, retreatment is recommended. Condoms offer some protection from genital wart infection but not always. The warts may be on areas not covered by condoms.
Vaccines have been developed to protect against HPV 6 and 11, the common cause of visible genital warts and against the oncogenic (cancer causing) forms of the wart virus. They do not contain any live biological products so they are non-infectious and prevent 70% of oncogenic viral infection. The vaccines are given as a series of three intramuscular injections over a six-month period to 16-26 year old females and 9-15 year old children and adolescents. Vaccination is also offered to men who have sex with men. Vaccination prevents HPV infection but does not treat existing infection so for maximal efficacy, it should be given before infection occurs, before first sexual activity. Women infected with one or more HPV genotypes targeted by the vaccine have been protected from clinical disease caused by infection with the remaining genotypes in the vaccine. As infection with other genotypes, not protected by current vaccines can occur, vaccination is not a substitute for cervical smear testing. HPV vaccination is also effective in males, proving protection against genital warts and potentially pre-cancerous lesions caused by some HPV genotypes. Vaccination is expected to offer some protection against penile cancer and anal cancer in men who have sex with men, particularly those co-infected with HIV.
Molluscum contagiosum is an infection of the skin caused by poxvirus. It is a common disease and has a higher incidence in children, those who are sexually active and those who are immunocompromised (advanced HIV disease of on immunosuppressive medications).
The rash consists of crops of pearly dome-shaped bumps from 1 to 5 millimetres in diameter with a depression in the centre. It can affect any area of the skin but is most common on the trunk and limbs. It is generally not painful but may occasionally be itchy. Bacterial infections may occur at the site of the rash (impetigo). The virus is spread through skin to skin contact and from scratching the bumps then touching normal skin. Handling objects such as towels can also spread the virus which may be picked up in swimming pool changing areas.
Molluscum contagiosum is diagnosed clinically by the appearance of the rash. It may be mistaken for genital warts. Most cases of molluscum contagiosum are ‘self-limiting’, the rash goes away without treatment in 2-3 months. It is recommended that genital molluscum contagiosum be treated to limit spread. Treatment is also recommended if there is bleeding, bacterial infection or itch. Similarly, embarrassment is a treatment indication as is limiting scar formation. Methods of treatment include enucleation (removing of the centre) of the lump, with a sterile needle, freezing with liquid nitrogen and/or application of prescribed preparations. At Harold’s Cross Surgery, we use radiosurgical removal. As with genital warts, unlike liquid nitrogen application, targeted removal of the molluscum is achieved with minimal collateral skin damage. Following successful treatment of the molluscum contagiosum, the virus does not persist in the body (unlike herpes). The person has no permanent immunity to the virus so re-infection may occur.
It is very difficult to prevent the sexual spread of molluscum contagiosum apart from abstinence while the lesions are present. Once gone, the person is non-infectious. Condom use does not offer much protection as the rash is usually in the groin or pubic area not covered by the condom.
Fordyce spots are small yellowish red or white spots on the head or shaft of the penis or the labia. They are sebaceous glands (tiny glands found near the surface of your skin) without hair follicles. They can also appear on the inside of the cheeks or on the lips, and are present in 80-95% of adults. They appear as small, painless, raised bumps 1 to 3 mm in diameter. They are not associated with any disease or illness, nor are they infectious but rather they represent a natural occurrence on the body. No treatment is required, unless the individual has cosmetic concerns. Persons with this condition sometimes consult a Sexual Health Specialist believing they may have a sexually transmitted disease, commonly genital warts.
Should treatment be indicated, we a Harold’s cross surgery specialise in the radiosurgical removal of Fordyce spots.