HPV questions

[belowbad]

Dr. HHH,

As briefly as I can:

I met my girlfriend 7 months ago. A few months after we began having unprotected sex, I developed a wart just inside my urethral meatus. I got Condolox and the wart went away. After this, my girlfriend had a abnormal pap that found high-risk HPV. A colposcopy found CIN 1/2. She had cryotherapy and when she recovered, we resumed having sex, this time with condoms.

At the visit for the wart, I was screened for herpes and tested positive (IGG HSV-1 >5, HSV-2 3.24). I have never had cold sores, nor genital lesions other than the wart. I was retested by Western Blot, and am waiting for the results, which I understand are likely to confirm the IGG. My girlfriend has not yet been tested.

I followed up with a urologist. I am uncircumcised. The urologist looked at my foreskin, said it looked “unhealthy,” and recommended circumcision. He said that my foreskin could be infected with HPV and it placed me and my gf at additional risk. I got a second opinion. The second urologist said my foreskin appeared “normal” and he did not think circumcision was needed.

After a few weeks of using condoms, the wart returned in the same spot. This time it is being surgically excised. I have to wait several weeks for this procedure. My girlfriend does not show signs of warts, or herpes.

I have been struggling with depression brought on by this sequence of events. I feel awful.

My questions:
1. Should my girlfriend and I wait for the wart to be removed again before having sex? Is vaginal sex with condoms safe? Could the return of the wart impact her clearance following cryotherapy?
2. Is circumcision ever useful in clearing HPV? Could it have any health benefits for either myself or my girlfriend?
3. Why does my girlfriend have dysplasia and not warts?
4. I read a study that said HSV-2 can be a co-factor in dysplasia. Others disagree. Would having herpes affect the course of the HPV in either of us?

Thank you.

[belowbad]

Thank you in advance, and for your responses.

[H. Hunter Handsfield, M.D.]

Sorry, I missed that. It's an unusual result; usually the WB is definitive.  You can phone the University of Washington clinical laboratory and ask for clarification and advice.  I can't give detailed information on line, but I will email MedHelp and ask them to email you in turn, with the name and number of the lab supervisor.  She may recommend an additional test, but perhaps at little or no cost; or may be able to review your result and clarify it.

[belowbad]

Hello Dr.,

My Western Blot result was mention in the post above my last, albiet in passing. It is:

Positive for HSV-1
Indeterminate for HSV-2

Sorry for not stressing that.

[H. Hunter Handsfield, M.D.]

Option 1 is unlikely; probably you do have genital herpes due to HSV-2.  Options 2 and 3 probably are equally likely.  A low-positive result like yours could reflect recent infection, with a higher number expected at a later time.  But usually such results do not reflect recent infection.

As suggested above, the first step is for your apparently positive result to be confirmed.  If a Western blot test is negative, the issue will be resolved, i.e. a false positive initial HSV-2 test despite the relatively high ELISA value.  If the WB is positive, confirming that you have HSV-2, I then recommend your current partner be tested.  If she has a negative HSV-2 blood test, it will prove she was not the source of your infection.  If positive, however, it will not tell which of you infected the other; or whether both of you have chronic infections from previous partners.

Feel free to let me know your WB result, if you are tested, and your partner's HSV-2 results.  Until then I will have no further comments or advice.

[belowbad]

Dr. Handsfield, if you are able to comment on the HSV-2 test result, I would appreciate it. After considering it further, I believe that there are only three possibilities:

1. I do not have genital herpes.
2. I contracted genital herpes from my girlfriend sometime in the last 8 months and we both have asymptomatic infections.
3. I contracted genital herpes 10 months ago or more and have not fully seroconverted.

Of these, the third seems the most unpleasant, but the least likely.

Is there a possibility I'm missing? If you are able to comment once more, all my questions would be answered.

Many thanks.

[belowbad]

Thank you again for your comments.

I am not eager to be circumcised, and the lack of agreement over that issue is a little unnerving, but I do otherwise trust the first urologist and feel comfortable in his care.

Regarding the HPV test: Yes, my girlfriend's pap smear was specifically tested for HPV, and that test found a high-risk variety. What type was not specified -- one of 10 or so. The colposcopy followed this test.

My Western Blot result was returned positive for HSV-1 and indeterminate for HSV-2. I have also had a PCR blood test which returned negative for both. My doctor ordered this when I requested a test to confirm the original HSV-2 3.24 IGG result. I went through with it, but read later that it had no value, as I have never had a lesion that I consider consistent with herpes, either on my lips or genitals.

My GP said that the indeterminate Western Blot could mean I am still developing antibodies because my girlfriend exposed me. I'm certain this is possible, but without going into detail, given our sexual histories and history of testing, it is far, far, more likely that I had it prior to the relationship. So, I feel like I'm at a dead end as far as testing for HSV is concerned. For now, my girlfriend and I plan to continue with condoms until she has a clear Pap smear, so perhaps I will get another IGG test before she goes to the gyno again in a little over two months.

This conversation has been very helpful already and I welcome your further comments. I have been mentally replaying your suggestion of these problems will become a "distant inconvenience". I very much look forward to that day. My mental state has improved somewhat, although the facts remain unchanged.

[H. Hunter Handsfield, M.D.]

Thanks for the greater detail about the urologists' advice.  Sounds like they are up to speed, and I agree that urethroscopy makes sense and can best be done as a single procedure when the visible wart is excised.

Once an HPV infection is established for a couple of months, it is likely that the infected person is immune, or at least highly resistant, to new infection with the same type.  I don't see why the status of dysplasia or its treatment would have any effect, although I doubt this specific issue has been studied.

Some gynecologists may assume a high risk type, and so inform the patient, based only on the dysplasia itself, without actually having a positive test result for HPV or a test to determine high versus low risk.  If your partner had a specific lab test reporting a high risk HPV type, that information probably is accurate.  If so, most likely it is a different strain than the one causing your wart.  However, I cannot say how commonly the high risk types themselves cause overt warts; I'm sure it can happen, but not often.

Dysplasia and pap smear terminologies can be confusing, even to professionals and especially to medically untrained patients.  The "Bethesda" classification of high and low risk intraepithelial lesions (HSIL, LSIL) applies strictly to pap smear results.  The cervical intraepithelial neoplasia terminology (CIN) is strictly for biopsy results.  Many LSIL paps end up with apparently higher grade lesions on biopsy, even CIN 3 and very frequently CIN 1 or 2.  Likewise, many HSIL paps turn out to have low grade changes on biopsy, e.g. CIN 1.  Also, "progression" from one stage to another is not smooth.  The very first abnormality can be CIN 3 or HSIL; and lesions can go back and forth between stages.  For these reasons, your partner's CIN 1/2 result does not imply her lesion has "progressed" since initially detected.  Probably it has not.  The large majority of CIN 1/2 dysplasias eventually clear up entirely, even without treatment; that result is not particularly high risk for development of cancer.  Of course she should follow her gyn's advice on follow-up and/or further treatment, but all things considered this is not likely to ever be a serious health problem for her (or for you).

Finally, going back to your HSV test results:  in my initial reply, I failed to comment directly on it except to reassure you about any relation to HPV or progression of HPV infections.  Your numerical result for HSV-2 (OD ratio 3.24) is strong evidence you have HSV-2, but as you already seem to know, the test is not 100% reliable unless the result is 3.5 or higher.  I would expect the Western blot result to be positive; but I would be happy to comment further when you have the result.  If positive, your partner should have an HSV blood test somewhere along the line.

[belowbad]

Thank you for your reply. It is tremendously reassuring, and, if you can't tell by my post, I've read and relied extensively on the information found on this site.

Both urologists agreed that excision of the wart was a proactive step, and likely to be more effective than further topical treatments because meatal warts are more difficult to treat topically (though I was warned that it could still recur either way.) There are no deeper warts immediately visible, but I was told that excision would also allow for urethroscopy and biopsy of the wart, both of which would also be beneficial. I welcome your comment.

If you can bear them, I have a few follow-up questions:
"1) You and your gf are sharing at least one HPV infection, and have been doing so for several months.  At this point, there is no reason for you not to continue sex, and I see no need for condoms.  Having sex has nothing to do with the fact that your wart recurred after the initial treatment."

Q: What about reinfection following treatment for dysplasia? I understand that once you've cleared an HPV infection, you cannot reacquire the same type. But what about during the period immediately following treatment?

"3) As noted above, you and she may be sharing more than one HPV infection.  Or her "high risk" infection was misdiagnosed.  Or your wart, atypically, is due to the same high risk strain she has."

Q: So high-risk HPV could be wrongly identified, or present but not responsible for the dysplasia? I thought that low-risk HPV did not cause dysplasia that progress past LSIL, whereas my girlfriend's diagnosis of CIN 1/2 seems to indicate some progression.

Q: How often do high-risk varieties of HPV cause fleshy raised warts?

Thank you again, very much.

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  I understand your concerns.  However, you should look at your HPV infection as an inconvenience, not a serious health risk.

First some general comments, then I will address your specific questions.  First, don't feel like the Lone Ranger:  at least 80-90% of sexually active people get one or more sexually transmitted HPV infections.  At least 10%, perhaps 20%, get overt warts.  Second, you and your partner may be sharing more than one HPV infection.  The high risk types rarely cause warts, which are caused by low risk HPV types.  (Or perhaps your partner's infection is not really high risk after all.  The low risk, wart-causing HPV strains often cause abnormal pap smears.

Why did the urologist recommend surgery rather than another round of medical treatment?   If there are additional warts deeper inside the urethra, I agree surgery might be the best approach -- but you should discuss it with the doctor.  Although many urologists are highly expert in managing genital warts, others are not.  If you have any doubts about your doctor's expertise and experience, consider seeing a dermatologist for another opinion.

To your questions:

1) You and your gf are sharing at least one HPV infection, and have been doing so for several months.  At this point, there is no reason for you not to continue sex, and I see no need for condoms.  Having sex has nothing to do with the fact that your wart recurred after the initial treatment.

2) Recent research indicates that circumcised men are less readily infected with HPV, have fewer HPV infections, and less likely have overt warts then uncircumcised men.  These facts do not, in themselves, mean that all men should be circumcised or that you should.  There are no data on whether established HPV infections clear up any more rapidly after circumcision; I doubt they do.

3) As noted above, you and she may be sharing more than one HPV infection.  Or her "high risk" infection was misdiagnosed.  Or your wart, atypically, is due to the same high risk strain she has.

4) Older data suggested a possible role for HSV-2 in cervical cancer and perhaps pre-cancerous dysplasia.  However, those studies were not confirmed.  A minor interaction has not been entirely disproved, but HSV is not generally believed to be a significant factor.  There is nothing in your story that suggests herpes is part of the problem.

These are complex issues. But when all is said and done, your and your partner's HPV infection(s) are going to clear up entirely; neither of you is likely to end up with cancer; and eventually this whole business will fade into a distant inconvenience.  It's a hassle, but eventually that's all it will be.

I hope this helps.  Best wishes--  HHH, MD