Genital Warts misdiagnosis??

Hello,

I recently found a few small bumps in my pubic area, underneath my pubic hair.  Some were clustered together in groups of two, some were singular.  They were flesh colored, painless, and smaller than a sebaceous cyst.  My family medicine practitioner examined me and felt that they could be genital warts.  To be sure, he biopsied one of them, and sent it off to the lab.

My results: "The skin biopsy from the pubic area shows a squamous epithelial hyperplasia with mild hyperkeratosis and focal increased granulosis.  Definitive HPV effect is not identified in the biopsy.  A condyloma cannot be entirely excluded; however, definitive features are not identified.  Correlate clinically."

My doc reviewed the results with me, and told me that I likely had GW, and he performed cryo on the area.  Naturally, I was pretty devastated.

I discussed the lab results with another, more experienced practitioner, and he told me that he felt the bumps were likely not GW.  I don't know what to think now.

I still have two small bumps in the same general area that need to be treated.  I believe the first doc missed one when he cryo'd me, and the other bump looks to be new. The spot that was missed appears to have grown and divided into two small adjacent bumps.

My questions:

1) What does the pathology report show?  Isn't the reason for having the lab work done to obtain a definitive diagnosis?

2) If not GW, what are these bumps?  Are there other similar skin conditions that could've been the source of a misdiagnosis?

3) If this is GW, am I going to have to disclose this to future partners if I don't have any visible lesions after treatment?

4) Should I have a path report performed on the one bump that's appeared to have grown?

My life hasn't been the same since all of this happened.  I'm not having sex any more, and feel lost, confused, and in need of some resources to help me cope if I do indeed have GW.  I've tried ashastd's forum, but it hasn't helped much.

Thank you.

[Edward W Hook, MD]

Welcome to the Forum and my apologies for having missed your earlier question.  I will do my best to answer your questions.  Your situation is a bit challenging because we typically hope that biopsies will be definitive.  Yours showed the growth of cells that we tend to correlate with HPV but was not definitive. I suspect there are other dermatological processes which might cause lesions such as these but you would have to ask a dermatologist to be sure.  Going against warts is their location.  The pubic area is an unusual place for warts but a typical location for other processes such as skin tags.  Thus it is difficult to say with any certainty was this a wart or not.  Importantly for you however, what this is not is anything dangerous or problematic. Lesions of this sort can readily be treated with freezing as you were with good results (i.e. the lesions go away).

But, what if the lesions were warts?  This is by no means the end of the world.  For better or worse, at present HPV is a "fact of life" and most people have it or will have it at some point in the future.  Despite this fact, only a tiny minority of persons with HPV get the consequences of infection (primarily women and primarily cancer and pre-cancerous lesions).  HPV is the most commonly acquired STD.  Over 85% of sexually active women will have HPV infection at some time in their lives.  The figure for men is less well studied but similar.   In some HPV will cause genital warts, in others it will not cause warts but may lead to changes in PAP smears.  In nearly everyone who gets HPV, warts or otherwise, the infections will resolve by themselves without therapy in 8-24 months.  In a very small minority of women, HPV infection can persist and lead to the pre-cancerous lesions that PAP smears detect and which can then be treated.  For men there is far less risk of any sort.  IN both sexes, treatment with cryo accelerates the resolution process.  With this as background, let's address your questions

1.  See above. Sometimes a single biopsy is not sufficient to get a diagnosis and a second biopsy needs to be performed if the answer is of important.  In your case the answer is not medically important but if it is important to you, perhaps you can have a second lesion tested.
2.  There are conditions that can do this but rather than ask me, I would ask a dermatologist.  Perhaps Dr. Rockoff on the Dermatology Forum can help.  My guess is that he will tell you that it more likely than not that this is probably a wart but that is only a guess.
3.  I see no reason for disclosure.  The topic of disclosure has been discussed many times on this Forum and the question is how important is it to disclose when the disease is so common and a person really cannot tell where it came from.  
4.  If Dr. Rockoff can't help. It is up to you.  It really is not medically terribly important.

I realize you wrote asking for a definitive statement and I have not been able to be precise.  Sorry about that.  AT the same time, I again raise the issue of whether the most important fact for you is that this was not something serious.  I think you do have that answer.  EWH

[Max967]

p.s. - I forgot to add that I am a 31 y.o. male.

Thanks!

[Max967]

Doctor,

Thank you for your reply.  I appreciate your candor, and I understand that my situation presents certain limitations with respect to a definitive diagnosis.

You are now the third medical professional who has advised me that, regardless of what the condition is, (warts or not) there is no need for disclosure as long as it's been resolved.  (The two docs that physically examined me both told me that there was no need for disclosure once my skin doesn't show lesions.)

With that in mind, I am just going to have to rely upon the medical advice, and put the thoughts of guilt and "what if's" out of my head.  (Easier said than done, as my nightmare scenario is having a future partner develop warts after having sex with me...)

I don't know why this is such a difficult thing for me to deal with.  Part of it is the feeling that I should've been more responsible, and had sex only with people who I knew well, and with whom I had a discussion with regarding past sexual history prior to engaging in sex.  I suppose I was just "being a guy" though -- I just wore condoms, and figured everything would be OK.

The other problem is that HPV -- as common as it is -- is typically asymptomatic.  Thus, the people who show visible symptoms of infection are left feeling singled out, and have a hard time dealing with their diagnosis.  For me, the process of acceptance and moving forward has been especially difficult, since my diagnosis was uncertain.

All of that being said, I'm going to work hard to accept my possible infection as "normal", and to move forward and to put all of this behind me once I'm cleared of symptoms.  As you pointed out, the important thing is that my health is not at risk, and the consensus seems to be that, if I'm lesion free, neither is the health of my potential future partners.

Thanks again,

Max



  

[Edward W Hook, MD]

Thanks for you note.  I appreciate your lingering concerns and can tell you that they are not unique by any means.  I wish you all possible succss in moving forward.  As you point out, there is no reason not to.  EWH