HPV Confused and Worried ???

[Please Help Me - Really Depressed]

Hello Doctor,

Over the past few months I’ve become interested in learning about HPV after being diagnosed with anal warts. I’ve probably read every known website about it, including cdc.ca, Dr. Klausner’s website SFCC, American social health website, thebody.com etc and of course your replies to questions in regards to HPV all highly great accurate sources of information.

My main concern is about visible genital warts, caused by low risk types 6 and 11. Whether they are on the penis, vagina, or anus they are still considered low-risk and same goes for if they are internal or external to the genital being affected.

In the big picture about all this, you clearly mention which is very relieving to hear that no one should lose a minute of sleep over HPV especially men whether it causes warts on any genital or abnormal pap spears, where women should just have regular pap smears)

1. Is it true that warts really are just a nuisance or psychological effecting when it comes to posing a risk to someone’s health?

2. Some sites say that warts left untreated will lead to genital cancer, (especially persistent internal warts? If this is the case why does it matter if they are internal or external such as in the anus? I was told about this being the case about anal warts from an American social health STD hotline rep after mentioning to him I still have a few internal warts left, although he agreed with me that this is not true and it’s a different strain that is needed to result in genital cancer which is the high risk type but he said that’s not the case with anal warts and I should have them removed? After telling him how does that guarantee that tissues around it aren’t he didn’t have any answers? Again if true why so please?

Please see these 2 quotes from Dr. Klausner’s website…

“Internal warts are not easy to treat and in general if they are not bothering you it’s generally best to just leave them be. Often they will subside on their own as your immune system clears them.”

“Most doctors in this field do not recommend treatment for small internal warts unless they are causing bleeding, pain or obstruction. Most of these warts go away over time on their own and there is no need to treat them.”

These quotes along with your replies and my highly experienced colon rectal surgeon’s response trained at the mayo clinic – that it doesn’t cause cancer are very relieving. But the quote below isn’t,

“That said, men with anal warts do have an increased risk of anal cancer, so you should talk to your provider -- primary care doctor, internist, family practitioner, GP or the like -- about an anal pap smear. While not all experts recommend routine anal pap smears, some do.”

3. Do you recommend that warts be biopsied or typed just to be safe, or can they be easily distinguished by

[H. Hunter Handsfield, M.D.]

Although the research isn't definitive, it is likely that people with genital warts have a somewhat increased risk of anogenital cancers.  This can occur because HPV-6 and 11 probably can sometimes cause cancer (they are called "low risk" HPV types, not "zero risk"); and people with warts might, on average, have a higher risk of also being infected with a high risk type.  I agree with the statements you attribute to Dr. Klausner; there is no conflict between them and the quote from an earlier thread on this forum.  The overall risk of anal or genital cancers is very low in people with warts; and in any case, if diagnosed and treated early (within a few years of onset), almost all such cancers are easily treated and cured.

To your specific questions:

1) The distinction between a "nuisance" and a serious health problem is subjective; each infected person probably has his or her own opinion.  The medical and public health consensus is that warts are more an inconvenience than a serious health threat.

2) There are no guarantees, just probabilities.  Those probabilities indicate that most people with genital or anal warts shouldn't much worry about it, but follow their providers' advice about symptoms to look for and possible future re-examination.  And they should put the risk into a realistic perspective.  We're talking lightning-strike range of probabilities; the chance of cancer is far less than the chance of dying on any particular day due to an accident or unexpected illness.

3) Routine genital warts do not require biopsy.  Criteria for biopsy include certain appearances and, mostly, failure to respond to routine treatment.

Bottom line:  The risks are low, generally not worth losing sleep about.  The more you look for potential conflicts in recommendations online, the more you will find.  Given the extensive online research you apparently have done, my suggestion is that it is time to stop, go on with life, and follow your provider's advice.

Good luck--  HHH, MD

[Please Help Me - Really Depressed]

Sorry i forgot to include the rest of my questions.

4. Any reason as to why if one leaves the warts untreated that the external ones go away before the internal ones do?

5. Lastly the question is if the warts whether they are internal or external are not bothersome, does it really make a difference if they ever go away when it comes to health risks such as cancer? When I ask this I am speaking for most individuals that are not HIV positive or engaging in anal sex, whether they are male or female, or does that even matter? I think this is the main question that will put my mind at ease, and stop worry about all this regardless of whose right and who’s wrong about HPV related cancer.

Again Doctor I hope this isn’t a waste of your time, but perhaps a response to this would greatly help lots of people when it comes to dealing with confusion and the psychological burden from HPV including me. I know I have become abnormally obsessed and confused after reading different opinions from STD experts.

Many many thanks for your input.

[H. Hunter Handsfield, M.D.]

4) I'm not sure it is true that "if one leaves the warts untreated that the external ones go away before the internal ones do".  As far as I know, either internal or external warts may clear up before the other does.

5) I do not know whether the risk of cancer is any higher in people in whom warts persist versus those in whom they resolve.  It makes sense, but I am unaware of any data one way or the other.  In any case, almost all warts do clear up and the risk of cancer is too low to worry about.

You might indeed have found both right and wrong information about HPV and cancer, but you don't cite any of it.  Your questions suggest you have found pretty consistent information and advice.

Thanks for the thanks about the forum--   HHH, MD

[gettogether]

I have been diagnosed with the same thing, internal anal warts. However, I don't have and have never had external anal warts.  The nurse practitioner who examined me said they have to be removed no question. I advised her that I had read and researched online as well and that most of the time they go away on their own. And she said no they don't and that they must be removed, because they could become cancerous or they could get bigger. This is contridicatory to what has been stated on here and in previous posts.  Comments?

[H. Hunter Handsfield, M.D.]

Like your NP, some experts believe internal warts should always be removed.  It is a matter of judgment and there are no definitive data, so nobody can say for sure your NP is wrong.  However, the majority opinion is against her.  And although some NPs may be legitimate experts on anorectal warts, most are not.  You should get a second opinion.

No prolonged discussion, please; this is something of a thread jump.

HHH, MD

[HHH,MD]

I deleted your inappropriate new thread.  Isimply cannot second guess a direct examination by an experienced colorectal surgeon. If he says you're normal, you're normal.  I fully understand why he got mad at you--so am I. Follow his advice, both about medical follow-up (if any) and to "stop looking for things and move on with life".

HHH, MD