Proctoscopy should be mandatory in men that have sex with men with external anogenital warts

INTRODUCTION

The aim of this study was to evaluate anal pathology in men having sex with men (MSM) seen at our proctology outpatient clinics.

METHODS

The charts of 74 MSM treated by the author between January 2002 and April 2006 were reviewed.

RESULTS

Three of 74 patients (4%) had proctitis and 96% had anogenital condylomata acuminata (warts). 49 out of 71 (69%) had external anogenital as well as intra-anal warts and 13 (18%) had only intra-anal warts. In 14 an intra-anal dysplasia and in 2 patients intra-anal verrucous carcinomas were detected. The average duration of disease before referral to our institutions was more than 9 months. Half of the patients were previously treated for anogenital warts with ointments and suppositories at other institutions, including 17 that were "treated" with ointments and/or suppositories for hemorrhoids prescribed by family physicians. The patients mostly had widespread disease and sixty-nine of them required surgery. In the follow-up period there was no recurrence of warts and only itching was observed in 31 (44%) patients. Therapy with imiquimod was introduced for 3 months in twenty-two cases with intra-anal dysplasia. No major side effects were noticed despite intra-anal use.

CONCLUSION

Proctoscopy and histological examination of intra-anal lesions in cases of external anogenital warts should be mandatory in MSM patients. I would like to encourage other physicians to use this approach, which enables detection of intra-anal warts, dysplasia, and even carcinoma in the asymptomatic stage.

[Condyloma acuminatum]

Condyloma acuminatum is a sexually transmitted disease caused by human papillomavirus infection, especially HPV DNA types 6 and 11. Its appearance is distinctively papillary and it can be diagnosed by careful observation of its particular appearance. The treatment for condyloma acuminatum is generally classified into surgical and medical therapies. In Japan, imiquimod has finally been approved and can be prescribed in the clinical situation. Treatment with 5% imiquimod cream is highly effective and noninvasive compared with surgical therapy. We anticipate that imiquimod will contribute to efficient control of the disease in the future.

Benign masses of the female periurethral tissues and anterior vaginal wall

Due to their rarity, benign masses of the periurethral tissues and anterior vaginal wall are poorly understood. Arriving at the proper evaluation and treatment is challenging because many of these masses have similar presenting signs and symptoms, as well as overlapping differential diagnoses. The literature regarding these lesions mainly consists of level III evidence, mostly involving case reports and series. Clinical management has traditionally been based on established surgical principles and expert opinion. This review presents the pertinent embryologic and anatomic background for these benign masses, as well as other pertinent etiological processes. Furthermore, the most current evidence is reviewed regarding the differential diagnosis, evaluation, and treatment for each mass.

Treatment patterns and associated costs for genital warts in Italy

OBJECTIVE

Genital warts are caused by human papillomavirus (HPV), principally types 6 and 11, and are highly contagious. This study assessed treatment patterns and costs of management of genital warts in Italy.

RESEARCH DESIGN AND METHODS

This was a retrospective, observational study conducted among gynaecologists, dermatologists, and specialists at sexually transmitted disease clinics in Italy. Resource-use data related to genital warts were collected for patients at risk in the age range 14-64 years examined during 2005. Unit costs were assigned to resource use to provide estimates of the direct, indirect and total costs per case of genital warts.

RESULTS

Twenty-eight investigators enrolled 341 patients aged 15-64 years, including 194 (56.9%), 81 (23.7%) and 66 (19.4%) patients with newly diagnosed, recurrent and resistant genital warts, respectively. Most patients (333/341; 97.7%) had at least one outpatient visit, while 43 (12.6%) patients were hospitalised, including 39 patients without an overnight stay (day-hospital cases, 11.4%). Self-applied medication was prescribed for 124 (36.4%) patients. Most outpatient cases (267/333; 80.2%) underwent an office-based procedure. Mean annual direct medical costs per patient, which were funded predominantly by the Italian National Health Service (there was some patient co-payment), were €242 for men and €332 for women. When productivity losses were included, mean total annual costs were €325 for men and €464 for women.

CONCLUSIONS

This is the first study of treatment patterns and costs for genital warts in Italy. Treatment patterns differ in some respects from those observed in other European countries, but costs generally appear similar. Despite the limitations of physician selection bias and over-representation of North Italy in the patient sample, the findings of this study may be useful in estimating the cost-effectiveness of introducing a quadrivalent HPV vaccination programme in Italy.

[Sexually transmissible infections of the anus and the rectum]

A recent increase of sexually transmitted infections (STI) of rectum and anus has been observed in France, particularly in men who have sex with men. Symptoms of STI are not specific and sometimes patients have no symptom, which implies a high risk of contamination. Ulcerations, vegetant lesions and proctitis are the main anorectal lesions observed. Infection by multiple germs is frequent. STI, particulary those including ulceration, facilitate the transmission of HIV. New therapeutic strategies have to be established as antimicrobial resistance of several sexually transmitted pathogens is increasing. The treatment of sex partners of patients diagnosed with an STI is essential. Education and counseling (use of condom) taking into account each patient's individual risk factors, are the main strategies in the prevention and control of STI.

Economic burden associated with the management of cervical cancer, cervical dysplasia and genital warts in Belgium

OBJECTIVE

Human papillomavirus (HPV) infections can lead to cervical intraepithelial neoplasia (CIN) lesions, cervical cancer (CC) and genital warts (GWs). This study intended to assess the annual cost of CC, CIN and GW management in Belgium.

METHOD

A retrospective study using a Belgian Hospital Disease Database (for yearly hospital cost of CC and GW patients) and a clinical expert survey were performed to assess the medical management of CC, CIN and GW patients. Belgian official sources were used to estimate the annual costs of management of CC, CIN and GW patients both from a healthcare payer perspectives (HCPP) and a societal perspective.

RESULTS

Based on the 667 patients diagnosed annually in Belgium with CC and an annual cost per patient of euro9,716, the total annual cost of CC is euro6.5 million (HCPP). The 10,495 estimated CIN 1, 2 and 3 patients led to an annual cost of euro1.97 million (HCPP). The 7,989 estimated annual number of diagnosed GW patients led to an estimated annual cost of euro2.53 million (HCPP).

CONCLUSION

HPV-related diseases represent an important burden on Belgian society, especially when considering that the estimates in this study are probably underestimations, as the management costs of other HPV-related diseases (vulvar, vaginal, penile, oropharyngeal (pre-) cancers, recurrent respiratory papillomatosis etc.) are not included in this analysis.

[Genital warts associated with HPV infection during II and III trimester of pregnancy--a case report and analysis of treatment options]

More than 30 HPV types can infect the genital tract. Viral infection can be present in clinical, subclinical or latent form. A visible genital form of HPV infection are genital warts, which are commonly caused by HPV types 6 and 11, and appear on the vulva, cervix, vagina, urethra and anus. Oncogenic HPV types 16, 18, 31, 33 and 35 are also found in genital warts and are associated with vulval (VII), cervical (CIN) and anal (AIN) intraepithelial neoplasia. The general prevalence of HPV infection in the form of visible genital warts estimates to about 1% of sexually active adults. Approximately 15% of the infected group / of all adults have a subclinical or latent infection and at least 80% had been infected with one or more genital HPV types at some point in their lives. The highest rate of frequency of infections occurs in the group of adults, aged from 18 to 28. Over the last twenty years figures have shown a constant growth of the infection rate, which also includes pregnant women. Genital warts can proliferate during pregnancy due to altered immunity and increased blood supply. Cryotherapy, electrocautery, laser therapy, surgery or trichloroacetic acid may be used to remove the warts. In the paper a case report on genital warts associated with HPV infection during II and III trimester of pregnancy and analysis of treatment options has been presented.

[Advances in human papillomavirus therapeutic vaccine]

Human papillomavirus (HPV) infection is very common but with limited therapies available. Although the prophylactic vaccination will be promoted worldwide soon, it can only show its benefits decades later. For individuals who already have established infections and dysplasias, it has little efficacy. In contrast, the therapeutic vaccines bridge the temporal deficit by fighting against the established HPV infections and HPV-related diseases. HPV oncogenes may be delivered in viral and bacterial vectors, in peptides or protein, in nucleic acid form, or in cell-based vaccines. This review summarizes the clinical trials of HPV therapeutic vaccines under the way and the different preclinical research strategies that are under investigations.

Papillomaviruses and interferon

Papillomaviruses are infectious agents which cause benign tumours, or warts, of cutaneous, uterine cervical and laryngeal epithelia. These infections are very common, yet no uniformly effective therapy exists. Current treatments do not selectively inhibit viral processes but destroy the infected epithelial cells. Since interferons have antiviral effects in vivo and in vitro, it was hypothesized that they might be useful for treating papillomavirus-induced conditions. Interferons have now been demonstrated to be effective in several forms of papillomavirus infection. In vitro, chronic treatment of bovine papillomavirus-transformed cells led to the loss of the papillomavirus genomes and return of the cells to a normal morphology. In humans, interferons have been used for treating laryngeal papillomatosis, cutaneous and anogenital warts and epidermodysplasia verruciformis. Partial and total remissions have been achieved with both intralesional and systemic administration. Ongoing studies aim to identify which conditions are most responsive, the optimal dosage and regimen and the most effective class of interferon. The mechanisms by which these responses occur are unknown, but are thought to depend on interferon inducing specific cellular proteins.

Female genital warts

Genital warts are a clinical manifestation of HPV types 6 and 11, and are estimated to affect 1% of sexually active adults aged between 15 and 49. HPV leading to a broad spectrum of human diseases, ranging from benign warts to malignant neoplasms, depending on the location of the lesion, the immune status of the patient and the type of HPV. Current therapies for human papillomavirus-associated disease are based on the excision or ablation of involved tissue and are associated with a high frequency of recurrent disease, discomfort and costs.

Comparison of the effectiveness of commonly used clinic-based treatments for external genital warts

We describe a prospective study designed to assess the effectiveness of the commonly used clinic-based treatments for genital warts individually and in combination. Patients presenting with new or recurrent genital warts were randomly allocated to one of five treatments on a weekly basis. The clinical endpoint was wart clearance or eight treatments, whichever occurred sooner. If there was not a good response by the eighth treatment, an alternate modality was offered. Four hundred and nine individuals were enrolled in the study. Almost no patients withdrew in any group due to adverse effects. Three-quarters of patients treated with podophyllin 25% and cryotherapy concurrently required only two treatments to clear their warts. All had clearance in less than eight treatments. Single therapy with either trichloracetic acid or podophyllin 25% resulted in longer time to wart clearance, and more persistent warts.

[Acupoint-injection of BCG polysaccharide nuclear acid for treatment of condyloma acuminatum and its immunoregulatory action on the patient]

OBJECTIVE

To probe into immunological mechanisms and clinical therapeutic effect of acupoint-injection of BCG polysaccharide nuclear acid (BCG-PSN) for treatment of condyloma acuminatum (CA).

METHODS

Two hundred cases were randomly divided into 4 groups. After removed the CA by laser, the treatment group (group A) was treated with acupoint-injection of BCG-PSN, the control group I (group B) with intramuscular injection of BCG-PSN, the control group II (group C) with intramuscular injection of interferon, and the blank control group (group D) with no treatment. The levels of cellular immune function were detected before treatment and after treatment of 6 months, and the cases of relapse were recorded.

RESULTS

The cured rate of 94.3% in the group A was significantly higher than 78.0% in the group B, 80.4% in the group C and 78.2% in the group D, with significant differences (P < 0.05); in the group A, CD4+ percent increased, CD8+ percent decreased, CD4+ /CD+ ratio increased, and NK cell activity increased with a low relapse rate, and with significant differences as compared with the control groups (P < 0.05, P < 0.01).

CONCLUSION

Acupoint-injection of BCG-PSN has a better therapeutic effect and it can obviously reduce the recurrence rate of CA. The cellular immunoregulatory action is one of the mechanisms of this therapy in preventing relapse of CA.

The diagnosis and treatment of human papillomavirus-mediated genital lesions

Genital warts (condyloma acuminatum, venereal warts) are common highly contagious benign epithelial lesions occurring on the genitals, perianal area, and inguinal folds, and are caused by human papillomavirus (HPV). Diagnosis is based largely on the clinical appearance of lesions. New home-based treatments, including podofilox and imiquimod, have revolutionized the therapeutic management of genital warts, empowering patients to participate in their own treatment with products that primarily have local side effects. This article reviews the diagnosis and treatment (office based and home based) of genital warts.

MVA E2 recombinant vaccine in the treatment of human papillomavirus infection in men presenting intraurethral flat condyloma: a phase I/II study

BACKGROUND

Human papillomavirus (HPV) is the etiologic agent for warts and cervical cancer. In Mexico, the death rate from cervical cancer is extremely high, and statistical data show that since 1990 the number of deaths is increasing. Condylomas and cancer of the penis are the most common lesions presented in men; bladder and prostate cancer in men are also associated with the presence of HPV. Since HPV is transmitted by sexual intercourse, treating both partners is necessary in order to eliminate the virus in the population. Approaches to this include preventative vaccines such as Gardasil, and therapeutic vaccines to treat established infections in both men and women. This will be the only way to decrease the numbers of deaths due to this malignancy.

PATIENTS AND METHODS

We conducted a phase I/II clinical trial to evaluate the potential use of the recombinant vaccinia viral vaccine MVA E2 (composed of modified vaccinia virus Ankara [MVA] expressing the E2 gene of bovine papillomavirus) to treat flat condyloma lesions associated with oncogenic HPV in men. Fifty male patients with flat condyloma lesions were treated with either MVA E2 therapeutic vaccine or fluorouracil (5-fluorouracil). Thirty men received the therapeutic vaccine, at a total of 10(6) virus particles per dose, administered directly into the urethra once every week over a 4-week period. Twenty control patients were treated with 5% fluorouracil 1mL twice weekly over a 4-week period directly into the urethra. Reduction of lesions or absence of papillomavirus infection was monitored by colposcopy and histologic analysis. The immune response after MVA E2 treatment was determined by measuring the antibodies against the MVA E2 virus and by analyzing the lymphocyte cytotoxic activity against cancer cells bearing oncogenic papillomavirus. Presence of papillomavirus was determined by the Hybrid Capture method.

RESULTS

Twenty-eight of 30 patients showed no lesion or presence of papillomavirus as diagnosed by colposcopy and brush histologic examination after 4 weeks of MVA E2 treatment. These patients showed complete elimination of flat condyloma in the urethra and no acetowhite spots were detected over the prepuce. In two other patients the acetowhite spots and flat condyloma did not diminish. All patients developed antibodies against the MVA E2 vaccine and E2 protein, and generated a specific cytotoxic response against papilloma-transformed cells. Viral DNA was not detected in MVA E2-treated patients. In the control group, 13 of 20 patients were free of lesions. Three of these patients had recurrence of lesions after 3 months of treatment and none of the patients developed specific antibodies against cancer cells. In contrast, patients treated with MVA E2 did not show any recurrence of lesions after 1 year of treatment. In addition, none of the patients had local or systemic adverse effects according to the WHO classification 1-4.

CONCLUSIONS

Therapeutic vaccination with MVA E2 proved to be very effective in stimulating the immune system against papillomavirus, and in generating regression of flat condyloma lesions in men.

Combined surgery and chemoradiation as a treatment for the Buschke-Löwenstein tumour

BACKGROUND

The Buschke-Löwenstein tumour (BLT) or giant condyloma acuminata is a rare disease which affects the anogenital region. Although histologically benign, it behaves in a malignant fashion, infiltrating the surrounding tissues. The morbidity and mortality from this tumour is high, as is the risk of recurrence following treatment. It lies on the continuum between the benign condylomata acuminata and squamous cell carcinoma. The human papillomavirus is implicated in its aetiology. Treatment is controversial, with topical chemotherapy, radiotherapy, immunotherapy and radical surgery all having been employed. Chemoradiation remains the mainstay of treatment for anal cancers but has not been routinely employed in the management of the BLT without squamous cell carcinoma transformation.

METHODS

Two cases of extensive perineal BLT treated with chemoradiation and subsequent surgical excision are presented.

RESULTS

The first patient had a good symptomatic response to the chemoradiation but unfortunately died of recurrent disease following surgery. The second patient had a macroscopically complete response to chemoradiation and remains well following abdominoperineal excision.

CONCLUSION

Pre-operative chemoradiation has proved to be useful in management for histologically proven benign BLT

[Anogenital condylomata in the children. Practice guidelines for a medical expertise]

Belgium has been confronted to cases of paedophilia for years. It seems adequate to suggest some guidelines in cases of a child or a teenager diagnosed with ano-genital warts during a consultation. They are not always the consequence of sexual abuse. Three contaminations are possible: ante natal and peri natal (in utero or during delivery), by direct contact (auto or hetero inoculation), through sexual contact. This trusted practitioners to handle this unusual situation from the child protection, to multidisciplinary management and judicial prosecution against suspect. When using some different way to know what kind of HPV type; it's possible to give some information about transmission and it's possible to do confrontations with the results of the lesions' suspect. It is also interesting to identify very highs oncogenic potential HPV for the survey's patient. Finally the most important is to know that the most recurrences result into reactivations from infra-clinically infections and are not new contaminations. It is important do not drop a new suspicion through hypothetic contaminator.

[Clinical and benign aspects of human papillomavirus-associated lesions]

Human papillomaviruses (HPV) are found in most human epithelia and some tumors. Most HPV strains associated with cutaneous lesions belong to three types, named alpha, beta and gamma. Although the causal link between genital human papillomavirus infection and cervical neoplasia is well established, the role of beta-HPV in non melanoma skin cancers is unclear. HPV mainly causes benign cutaneous lesions on the hands and soles. Genital HPV infection is the most common sexually transmitted infection. It is generally asymptomatic. The genitals can be infected by two low-risk HPV types (6 and 11), which are responsible for benign anogenital warts (condylomata acuminata). The implications of anogenital warts in children are highly controversial as regards sexual abuse. Treatments (chemical, physical or immunological) are lengthy, expensive, inconvenient and often painful. Recurrence is frequent because of HPV persistence in perilesional skin.