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 – Genital Warts
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. At Harold’s Cross surgery, we specialise in the radio-surgical removal of genital warts. This is done under local anesthetic with instantaneous results. The focussed radio surgical probe means no collateral tissue damage and no bleeding. The recovery time is days and heals with no 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. Warts may be on areas not covered by the 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 to 26 year-old females and 9 to 15 year-old children and adolescents. 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.