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Unclear HPV diagnosis

Hi -- A few weeks ago I posted a question about a confusing diagnosis I'd gotten from my doctor about possible anal HPV.

I'd gone to see him because I'd noticed a small white lump on my anus.  He said it was either HPV or simply "hyperkeratosis" from some other cause.  I asked him to do a biopsy, which he agreed to.  

You can see the original post here: http://www.medhelp.org/posts/STDs/Confusing-info-from-my-doctor/show/1552231

I just got the biopsy results back.  The pathologist told my doctor (a dermatologist) that it looked like a "common wart," the kind people get on their hands and feet. He said I probably got it from scratching my finger then having contact with my anus or something. I forget the actual technical term he used, but it was specifically NOT condyloma, he said.  While he said all warts are technically caused by HPV, he said this was not the traditional "genital wart," and he said I don't need to disclose this to any future partners. Basically, he said this is nothing that I need to worry about whatsoever.

To me this is very confusing -- it's HPV, it's on my anus, so it's by definition anal warts, right? And if the virus is present down there, I can transmit it a partner, right? Is the distinction between HPV sub-type really that meaningful?  How is this not something I should define as "genital warts" ?

6 Responses
239123 tn?1267651214
Welcome back to the forum.

I cannot blame you for finding all this "very confusing".  In our last discussion, I said your dermatologist either was mistaken or you misunderstood him.  It now is clear it is the former, not the latter.  MedHelp asks its professional moderators to do our best to avoid overtly disagreeing with questioners' own doctors.  But I'm afraid your dermatologist (and perhaps the pathologist as well) does not undersand HPV very well, and in particular misunderstands sexual transmission of the virus or has chosen to put his head in the sand about it.  The advice he has given you would have been state of the art 20 years ago.  But not today.

The biopsy is definitive:  you have an anal wart.  To the best of my knowledge, the microscopic examination cannot distinguish HPV types, and it cannot distinguish between common warts of the hands or genital, anal, or warts of any other anatomic site.  The HPV types that cause common warts of the hands and feet (dominantly HPV-1, plus others) rarely affect the genital or anal area, and are not sexually transmitted or acquired.  The types that dominate in the genital area, such as HPV-6, 11 (the usual causes of genital and anal warts), 16, 18, 45, and many others, are sexually transmitted.  Finally, the statement that your lesion was "not condyloma" makes no sense to me.  Condyloma is the Latin word for wart; it does not refer exclusively to anal or genital warts.

As for disclosure to partners:  You haven't mentioned whether your anal area has been sexually exposed, but it may not matter.  Although anal warts are most common in people who have had receptive anal intercourse, they are also frequent in both heterosexual men and women who have never had anal sex.  In this respect, your dermatologist may be correct:  your anal wart may have resulted from auto-inoculation, i.e. by hand contact from a genital infection.

You don't mention treatment.  Did the biopsy remove the entire lesion?  If not, or if other warts are present, then additional treatment (e.g., imiquimod, podofilox) may be wise.

Unfortunately, there is no way to know whether you have an asymptomatic genital area infection that hasn't caused visible warts.  If you do, it is possible you could transmit it to a partner; and of course your anal infection could be transmitted if a partner has sexual contact with your anal area.  However, most HPV infections are controlled by the immune system within a few months.  If by 6 months from now your anal lesion has not recurred and no other warts have appeared, it is probable you will no longer have an active infection that can be transmitted.

If you are concerned about any current, ongoing sex partners, you can assume he, she, or they are already infected -- indeed may be the source of your infection -- and they won't catch it again.  So you need not change your sexual activities with any current partners.  However, I would recommend you either abstain or at least discuss your infection with any new partners, until a few months have passed.

Sorry about the diagnosis you would rather not have, and about the misinformation you have had.  But in the long run, this won't be a big deal for you.  In the event you remain confused -- e.g. if you are uncertain whether to believe me or your dermatologist -- you could look at HPV information available from other expert sources, such as CDC (www.cdc.gov/std) or the American Social Health Association (www.ashastd.org).  (Disclosure:  I am on ASHA's Board of Directors and have consulted frequently with CDC on STD prevention, epidemiology, etc).

Regards--  HHH, MD
Avatar universal
Thanks so much for your detailed information.  In response to your questions (and in the hopes that you can clarify a few final things for me):

1.  I recall now that the doctor used the term "verruca," as opposed to "condyloma." Google reveals that there are at least two types of verruca -- verruca vulgaris, the "common wart," or verruca acuminata, which affects the genitals. Does the distinction of verruca vs. condyloma mean anything?

2. You indicate that this is clearly a genital wart that was either sexually transmitted or self-inoculated from a non-symptomatic genital infection. I have never had any kind of anal sexual exposure, and i've never had a visible genital wart before.  HOWEVER, I am somewhat neurotic about anal hygiene, and often wash my anus using my hand in the shower. Is it at all possible that this is a self-inoculated infection of HPV-1 or another non-sexual wart?

3. Yes, I believe the biopsy removed the entire legion. However, I'm unclear about how this affects contagiousness. It's my understanding that contagiousness is indicated by the presence of the virus itself, not the presence of the wart which is merely the symptom of the virus. If I've had the wart removed by a doctor, this doesn't really indicate that the virus has "gone away" or been controlled, even if several months pass, right?

Thanks again, sincerely.
239123 tn?1267651214
1) This strikes me as old-style dermatologic terminology.  As far as I know, verruca is simply another word for wart, along with condyloma.  To my knowledge this makes no difference.

2) You're never going to know when and how your anus was infected.  I suggest you not worry about it and stop trying to figure it out.  I doubt it has anything to do with your hygienic practices.

3) These issues have never been researched.  It is likely that the infection involves surrounding tissues that did not appear abnormal and may have not been removed.  But still, infectiousness probably is reduced by removal of the lesion, and residual infection likely will resove over time, as discussed above.  The immune system eventually controls HPV very well.
Avatar universal
Hi again -- I hope I'm not abusing the privileges of the board, but I would truly appreciate one more clarification, and I promise it will be the last.

I've now also seen a rectal/colon surgeon and also spoke directly to the dermatopathologist who examined my biopsy.

1. The dermatopathologist said that he used the term verruca instead of condyloma deliberately. He said there is a meaningful distinction between the two -- one is the common wart, and the latter is sexually transmitted.  I said that I thought the only way to distinguish that kind of thing was subtype testing.  He said that wasn't true, and that actually a common wart or a sexually transmittable condyloma can often share the same subtype but be different.  Does this make any sense to you?

2. The rectal/colon specialist suggested I come back every three months for an examination, but that if i had no symptoms she would confidently declare me "cured."  That seems in line with other things I've read about HPV clearance, but she also said that as long as I had no active warts, I wasn't contagious -- she said transmission is only possible when the virus is present, and it's only present when symptoms are manifesting.  Is that correct?
Avatar universal
To be clear -- the pathologist said he was very certain that from simply a microscopic examination that my wart was NOT sexually transmittable.
239123 tn?1267651214
1) The dermatopathologist's comments are not consistent with my understanding, but pathology is not my field.  This seems a legitimate difference of opinion between equally qualified (but differently trained) professionals, so I'm not criticizing him.  However, as far as I am concerned, any wart of the genital or anal area is a "genital wart" and virtually all are caused by the sexually transmitted types of HPV.  I would bet dollars to donuts that if your wart tissue had been tested for virus type, one of the genital/sexually transmitted types (probably HPV-6 or 11) would be found, not HPV-1 or other common wart type.

2) Half of the rectal/colon surgeon's comment is correct:  clearance of warts, with no recurrence in a few months, is pretty good evidence the HPV infection is gone and cannot be transmitted.  However, HPV clearly can be transmitted in the absence of symptoms.

That will have to end this thread.  Follow the surgeon's advice about follow-up; and try to stop worrying about all these details if the wart does not recur.
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