Anal warts and related questions

[atloss]

Dear Dr. Handsfield:
   I'm a 31yo gay man with a same-sex partner of 5 years. No HIV and other STDs. In Feb, my primary suggested anal pap smear. The result came back positive. I've had these internal bumps since late 2005 which I thought were hemorrhages. I only came to feel an external tag in Feb and again didn't pay much attention to it until the result came back positive. He referred me to a specialist. She examined me to confirm that I do have anal warts. She removed the external one(<0.5cm) and told me that if this is the only one I have since Jan, I probably won't have more external ones.  My questions are:
  1. I got my biopsy report today. The specialist said she'll need to have a noted pathologist to determine the exact grading. Simply, she said I am in between low and high grades strips. I forgot to ask her how common/uncommon is this?
  2. The size of the internal wart removed is roughly 0.6cm. The internal ones haven't given me any trouble so far. I scheduled a late surgery in Sep for I'd like to get a second opinion most certainly yours.  
  3. My partner and I are both monogamous and don't use protection. No doubt he's infected, too. Top or Bottom, should we have sex only after the internal warts are removed (if surgery indeed is recommended). From what we've read here, there's no reason to change our sexual practices. Did I misunderstand you?
   We feel lucky to have a very knowledgeable doctor like you to educate us. Thank you so much.

[H. Hunter Handsfield, M.D.]

Unfortunately, you are asking questions that are pretty much beyond my expertise.  In my STD clinic, we do not do anal paps, and we refer patients with suspected anal cancer or pre-cancerous lesions to specialists.  So I have little direct experience with your questions, and can reply tsome of them only in general terms.

1) The main thing probably is to be sure that the biopsy does not show actual cancer.  If not, most likely you have no worries.  However, your provider probably will want to reexamine you (and perhaps repeat a biopsy?) from time to time in the future.

2) I agree that most likely you won't have further external warts, but that's definitely not a guarantee.  You don't say what the surgery is for--to remove the possibly pre-cancerous anal tissue?  Or the internal warts?  We normally do not recommend treatment of internal rectal warts in my STD clinic, but opinions on this vary widely.

3) I agree your partner almost certainly is infected with your HPV strain (or has been infected by it and now is immune), and that there is no point in modifying your sexual practices at this time.

My main advice is that you follow your own provider's recommendations--or, if uncertain about it all, ask for referral for a second opinion.  My online advice doesn't count.  Sorry I can't be of greater help.  

Good luck--  HHH, MD

[atloss]

Thank you doctor for always been prompt and to the point.

The one external wart was removed to reduce my anxiety level. The specialist said she thinks the external one is most likely low grade, but it was still sent to the lab. The September surgery is scheduled to remove internal warts. Meanwhile, we're just waiting for the follow up addendum to current pathology report: "Anal Intraepithelial Neopplasia with Features of Condyloma, Grade I-II, Strips of." She described my case as a "hedge" and is wainting for a gynecologic pathologist to review my case. She did tell me that from her experience with HPV cases, she does not think they are pre-cancerous, but still want to make sure.

Her response was rather neutral when it comes to removing rectal warts. She did not urge me to have the surgery done or otherwise. I know if the internal ones haven't gone away by now after more than 1 year, they probably won't go away on their own. Perhaps it is too early to think about the next steps since we don't know the review result, but my understanding is:  AIN III-type lesions that are not treated or removed may develop into invasive cancer, but surgical removal does not actually treat or get rid of HPV. Am I mistaken? But if a person never have warts, or after having warts removed and showing no further symptoms or signs of recurrence, can we say he or she can consider themselves safe albeit never really without HPV?

It's hard to say either I am infected with his HPV strain or he mine. I have very limited protected sexual encoutners with men before I met him, and he was far more sexually active than me. We think it is possibly because my immune system is more suppressed due to stress than his that I developed symptoms. But after reading your answers to many other questions, we really learned that we don't need to worry about the ping-pong effect. You are absolutely right that HPV is extremely anxiety-inducing.

I am sorry if this is not the place to ask, but since I will in fact spend 2 months in Seattle this summer, will you be able to refer me to a specialist in the area to get a second opinion or if needs be another biopsy?

Thank you.