Penile warts are the most common sexually transmitted disease in men and are caused by the human papilloma virus (HPV). Penile warts usually appear as soft, flesh-colored to brown patches on the glans and shaft of the penis.
To provide an update on the current understanding, diagnosis and treatment of penile warts, a review was conducted using key terms and phrases such as "penile warts". and "genital warts". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews.
Epidemiology
HPV infection is the most common sexually transmitted disease worldwide. Having HPV does not mean a person will develop genital warts. It is estimated that 0. 5 - 5% of sexually active young men have genital warts on physical examination. The highest age of illness is 25 - 29 years old.
pathological etiology
HPV is a non-enveloped double-stranded DNA virus, belonging to the Papillomavirus genus of the Papillomaviridae family and infects only humans. This virus has a circular genome 8 kilobases long, encoding 8 genes, including genes that regulate two envelope structural proteins, L1 and L2. Virus seeds containing L1 are used in the production of HPV vaccines. L1 and L2 mediate HPV infection.
It is also possible to be infected with many different types of HPV at the same time. In adults, genital HPV infection is transmitted primarily through sexual intercourse and, less commonly, through oral, skin-to-skin, and intimate sex. In children, HPV infection can occur through sexual abuse, vertical transmission, self-infection, infection through close household contact, and through vectors. HPV enters the cells of the basal layer of the epidermis through small wounds in the skin or mucous membranes.
The incubation period of the infection ranges from 3 weeks to 8 months, with an average of 2 - 4 months. The disease is more common in people with the following risk factors: immunodeficiency, unsafe sex, multiple sexual partners, multiple sexual partners, and a history of sexually transmitted diseases. sex, early sexual activity, shorter interval between encounter and sex. new and sexually active partner who lives with him, is not circumcised and does not smoke. Other risk factors are moisture, humidity, trauma, and epithelial defects in the penile area.
Histopathology
Histological examination revealed papillomatosis, focal parakeratosis, severe acanthosis, numerous vacuolated koilocytes, telangiectasia, and large keratohyalin granules.
Clinical manifestations
Penile warts are often asymptomatic and can sometimes cause itching or pain. Genital warts are usually located in the frenulum, glans penis, inner surface of the foreskin and coronal sulcus. At the beginning of the disease, penile warts often appear as small, discrete, soft, smooth, pearl-like, dome-shaped papules.
Lesions may occur individually or in clusters (grouped). They may be pedunculated or have broad stalks (sessile). Over time, the papules can coalesce into plaques. Warts can be filamentous, protruding, papillary, verrucous, hyperkeratotic, cerebral, fungal, or cauliflower-shaped. Color may be flesh-colored, pink, erythematous, brown, purple, or hyperpigmented.
Diagnose
Diagnosis is made clinically, often based on history and examination. Dermoscopy and in vivo confocal microscopy improve diagnostic accuracy. Morphologically, warts can vary from finger-shaped, pinecone-shaped to mosaic-shaped. Among the features of angiogenesis, one can find glomerular, hairpin, and punctate vessels. Papillomatosis is an indispensable feature of warts. Some authors suggest using the acetic acid test (whitening of the wart surface when acetic acid is applied) to facilitate the diagnosis of penile warts.
The sensitivity of this test is high for hyperplastic penile warts, but for other types of penile warts and subclinical areas of infection the sensitivity is considered low. Skin biopsy is rarely warranted but should be considered when atypical features are present (eg, atypical pigmentation, sclerosis, adherence to underlying structures, induration, ulceration or bleeding), when the diagnosis is uncertain or for warts that are difficult to treat. different treatment methods. Although some authors recommend PCR diagnostics to determine the HPV type that determines the risk of malignancy, HPV type determination is not recommended in routine practice.
Differential diagnosis
Differential diagnosis includes pearly penile papules, Fordyce granules, acrochordon, syphilitic epicondyle, molluscum contagiosum, granuloma annulare, lichen planus, lichen planus, seborrheic keratosis, epidermal nevus, capillary lymphangioma, lymphogranuloma venereum, scabies, pyoma, posttraumatic neuroma, schwannoma, bowenoid papilloma and squamous cell carcinoma.
Pearly penile papulesPresents as small, smooth, soft, yellowish, pearly white or flesh-colored, conical or dome-shaped papules 1 - 4 mm in diameter. Lesions are usually uniform in size, shape, and symmetrically distributed. Usually, the papules are located in single, double or multiple rows in a circle around the top and groove of the glans penis. Papules tend to be more noticeable on the back of the crown and less visible toward the frenulum.
Fordyce county- these are enlarged sebaceous glands. On the glans and penile shaft, Fordyce granules appear as smooth, discrete, creamy yellow, asymptomatic papules 1 - 2 mm in diameter. These papules are more noticeable on the shaft of the penis when erect or when the foreskin is retracted. Sometimes a dense, chalky or cheese-like material can be pressed out of these granules.
Acrochordon, also known as skintags ("skin tags"), are soft, flesh-colored to dark brown, stalked or broad skin masses with smooth borders. Sometimes they can be hyperkeratotic or have a warty appearance. Most acrochordons are between 2 and 5 mm in diameter, although they can sometimes be larger, especially in the groin. Acrochordon can appear on almost any part of the body, but is most commonly seen in the neck and interstitial areas. When they appear in the penile area, they can resemble penile warts.
Condylomas lata- These are skin lesions in secondary syphilis caused by the spirochete Treponema pallidum. Clinically, condylomas lata appear as large, grey-white, velvety, flat or cauliflower-like papules or plaques. They tend to develop in warm, moist areas of the genitals and perineum. Secondary syphilis is characterized by a symmetrical, diffuse, non-itchy maculopapular rash on the trunk, palms, and soles of the feet. Systemic manifestations include headache, fatigue, sore throat, myalgia, and arthralgia. Erythema or white rash on the oral mucosa may occur, as well as hair loss and generalized lymphadenopathy.
Annular granulomais a benign inflammatory disease, self-limited to the dermis and subcutaneous tissue. The pathology is characterized by asymptomatic, firm, purple-brown, erythematous, or flesh-colored papules, often arranged in rings. As the condition progresses, central contractures may be noted. A ring of papules often grow together to form a ring-shaped patch. Granulomas are usually located on the extensor surfaces of the distal limbs, but may also be detected on the shaft and glans of the penis.
Lichen planus of the skinis a chronic inflammatory skin disease that manifests as flat, polygonal, purple, itchy patches and papules. Typically, the rash appears on the folded surfaces of the hands, back, trunk, legs, ankles, and glans of the penis. About 25% of lesions occur in the genitals.
reduce epidermisis a hamartoma arising from the embryonic ectoderm that differentiates into keratinocytes, apocrine glands, eccrine glands, hair follicles, and sebaceous glands. The typical lesion is a single, asymptomatic patch with clear boundaries along Blaschko's line. The onset of the disease usually occurs during the first year of life. Color varies from flesh to yellow and brown. Over time, the lesions can thicken and become warts.
Capillary varicose lymphangioma is a benign saccular dilation of cutaneous and subcutaneous lymph nodes. This condition is characterized by clusters of blisters that resemble frog eggs. The color depends on the content: white, yellow or light brown color is due to the color of the lymph fluid, and red or bluish color is due to the presence of erythrocytes in the lymph fluid due to hemorrhage. The blisters may change and have a wart-like appearance. Most commonly seen in the extremities, less commonly in the genital area.
Venereal granular lymphomais a sexually transmitted disease caused by Chlamydia trachomatis. The disease is characterized by a transient painless genital papule and, less commonly, erosions, ulcers, or pustules, followed by inguinal and/or femoral lymphadenopathy called bullae.
Frequent,pyogenic diseaseare small, soft or dense, flesh-colored or brown papules, 1 - 3 mm in diameter, without symptoms. They are often found in the area around the eyes and on the cheeks. However, cysts can appear on the penis and buttocks. When located on the penis, pustules can be confused with penile warts.
Schwannomas- These are tumors originating from Schwann cells. Schwannoma of the penis usually presents as a single, asymptomatic, slowly growing nodule on the dorsal aspect of the shaft of the penis.
Bowen's papillomatosisis a precancerous localized intraepidermal dysplasia that often appears as multiple reddish-brown papules or patches in the genital area, especially the penis. Pathology was consistent with squamous cell carcinoma in situ. Progression to invasive squamous cell carcinoma occurs in 2 to 3% of cases.
Frequent,squamous cell carcinomaPenis manifests as papules, ulcers, or erythematous lesions. The rash may appear warty, leukoplakia, or sclerosus. The most popular location is the glans penis, followed by the foreskin and shaft of the penis.
symptoms
Penile warts can be a cause of significant anxiety or distress for patients and their partners due to their cosmetic appearance and potential for spread, stigma, fertility concerns, and riskfuture cancers as well as their association with other sexually transmitted diseases. It is estimated that 20 - 34% of patients have sexually transmitted diseases. Patients often have feelings of guilt, shame, low self-esteem, and fear. People with penile warts have higher rates of sexual dysfunction, depression and anxiety than healthy people. This condition can have a negative psychosocial impact on patients and negatively affect their quality of life. Large exophytic lesions can bleed, cause urethral obstruction, and interfere with sexual intercourse. Malignant transformation is rare, except in immunocompromised individuals. Patients with penile warts are at high risk of developing anogenital cancer, head cancer, and neck cancer due to co-infection with high-risk HPV types.
Forecast
Without treatment, genital warts may go away on their own, remaining unchanged or increasing in size and number. About 1/3 of penile warts will regress on their own without treatment, and the average time until they disappear is about 9 months. With appropriate treatment, 35 to 100% of warts will disappear within 3 to 16 weeks. Even though the warts are gone, the HPV infection can still persist, leading to recurrence. Recurrence rates range from 25 to 67% within 6 months of treatment. Among patients with subclinical infection, recurrent infection (reinfection) after sexual intercourse and an immunocompromised state, recurrence rates are higher.
Treatment
Aggressive treatment of penile warts is preferred over monitoring because it helps resolve lesions more quickly, reduces concerns about infecting sexual partners, reduces emotional stress, improves cosmetic appearance, and reduces menstrual periods. social marketing associated with penile damage and relief of symptoms (eg, itching, soreness, or bleeding). Penile warts that last more than 2 years are much less likely to go away on their own, so aggressive treatment is recommended first. Partner counseling is mandatory. Screening for sexually transmitted diseases is also recommended.
Active treatments can be divided into mechanical, chemical, immunomodulatory and antiviral. There are few detailed comparisons of different treatments with each other. Effectiveness varies depending on the treatment method. To date, no treatment has been proven to be superior to other treatments. The choice of treatment should depend on the doctor's skill level, the patient's preference and ability to tolerate treatment, as well as the number of warts and severity of the disease. Comparative effectiveness, ease of use, side effects, cost and availability of treatment should also be taken into account. In general, self-treatment is considered less effective than self-treatment.
Patients perform treatment at home (as prescribed by the doctor)
Treatment methods are applied at the clinic
Methods used in the clinic include podophyllin, cryotherapy with liquid nitrogen, bichloroacetic acid or trichloroacetic acid, oral cimetidine, surgical excision, electrocautery, and carbon dioxide laser therapy.
Liquid Podophyllin 25%, derived from podophyllotoxin, works by blocking mitosis and causing tissue necrosis. The medication is applied directly to penile warts once a week for 6 weeks (maximum 0. 5 ml per treatment). Podophyllin should be washed off 1 to 4 hours after treatment and should not be applied to areas of high humidity. Wart removal efficiency reaches 62%. Because of reports of toxicity, including deaths, associated with podophyllin use, podofilox, which has a much better safety profile, is considered preferred.
Liquid nitrogen, the treatment of choice for penile warts, can be applied using a spray bottle or cotton-tipped applicator directly onto and 2 mm around the wart. Liquid nitrogen causes tissue damage and cell death by rapidly freezing to form ice crystals. The minimum temperature required to destroy warts is -50°C, although some authors believe that -20°C is also effective.
Wart removal efficiency reaches 75%. Side effects include pain during treatment, erythema, desquamation, blistering, erosion, ulceration, and pigmentation at the application site. A recent randomized parallel phase II trial in 16 Iranian men with genital warts showed that cryotherapy using Wartner's formulation containing a mixture of 75% dimethyl ether and 25% propane was also effective. fruit. Further research is needed to confirm or refute this conclusion. It must be said that cryotherapy using the Wartner preparation is less effective than cryotherapy using liquid nitrogen.
Bichloroacetic acid and trichloroacetic acid can be used to treat small penile warts because their ability to penetrate the skin is limited. Each of these acids works by coagulating proteins, which then destroy cells and thereby remove penile warts. A burning sensation may occur at the application site. Relapses after the use of bichloroacetic or trichloroacetic acid occur as often as with other methods. The medicine can be used up to three times a week. Wart removal efficiency ranges from 64 to 88%.
Electrocautery, laser therapy, carbon dioxide laser or surgical excision mechanically destroys warts and can be used in cases where there are quite large warts or a cluster of warts that are difficult to remove withconservative treatment methods. Mechanical treatments have the highest rate of effectiveness, but their use carries a higher risk of scarring the skin. Local anesthetic applied to unoccluded lesions 20 minutes before the procedure or a local anesthetic mixture applied to occluded lesions one hour before the procedure should be considered. reduces discomfort and pain during the procedure. General anesthesia may be used to surgically remove large lesions.
Alternative treatments
Patients who do not respond to the first treatment may respond to other treatments or a combination of treatments. Second-line therapy includes topical, intralesional, or intravenous cidofovir, topical 5-fluorouracil, and topical ingenol mebutate.
Antiviral therapy with cidofovir may be considered for immunocompromised patients with refractory warts. Cidofovir is a cyclic nucleoside phosphonate that competitively inhibits viral DNA polymerase, thereby preventing viral replication.
Side effects of topical (intrawound) cidofovir include irritation, erosion, post-inflammatory pigmentary changes, and superficial scarring at the site of application. The main side effect of intravenous cidofovir is nephrotoxicity, which can be prevented by saline hydration and exploration.
Prevent
Genital warts can be prevented to a certain extent by delaying sexual activity and limiting the number of sexual partners. Latex condoms, when used regularly and correctly, reduce the transmission of HPV. Sexual partners with genital warts should be treated.
HPV vaccine is effective before sexual activity in preventing primary infection. This is because the vaccine does not provide protection against diseases caused by HPV vaccines that an individual has acquired through previous sexual activity. Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Academy of Family Practice, and Human Papillomavirus SocietyRoutine vaccination of girls and boys with HPV vaccine is internationally recommended.
The target age for vaccination is 11 - 12 years for girls and boys. The vaccine can be given as early as age 9. Three doses of HPV vaccine are recommended at month 0, month 1 to 2 (usually 2), and month 6. Catch-up vaccination is indicated for men under 21 years of age and women under 26 years of age if they have not already been vaccinatedstrain at the target age. Vaccination is also recommended for gay or immunocompetent men under 26 years of age if they have not been previously vaccinated. Vaccination reduces the likelihood of becoming infected with HPV and subsequently developing penile warts and penile cancer. Vaccinating both men and women is more beneficial in reducing the risk of penile genital warts than vaccinating men only, because men can get HPV from you. love. Genital wart rates decreased significantly between 2008 and 2014 thanks to the introduction of the HPV vaccine.
Conclusion
Penile warts are a sexually transmitted disease caused by the HPV virus. This pathology can have a negative psychosocial impact on the patient and negatively affect his quality of life. Although about one-third of penile warts resolve without treatment, aggressive treatment is preferred to hasten wart resolution, reduce fear of infection, and reduce emotional distress. exposure, improved cosmetic appearance, reduced social stigma associated with penile damage, and reduced symptoms.
Active treatments can be mechanical, chemical, immunomodulatory, and antiviral and are often combined. To date, no treatment has been shown to be superior to others. The choice of treatment should depend on the doctor's proficiency in this method, the patient's preference and tolerance of treatment, as well as the number of warts and the severity of the disease. Comparative effectiveness, ease of use, side effects, cost, and availability of treatments should also be taken into account. Pre-coital HPV vaccine is effective in preventing primary infection. The target age for vaccination is 11 - 12 years for both girls and boys.