Hi, I'm a married male (late 40s) in Asia. Wife has sacral herpes, HPV status unknown. One week ago, I noticed 2 small pimple-like bumps on penis (shaft + foreskin), no symptoms or growth since then. I visited two different doctors who gave conflicting advice. The first seemed to be trying to use scare tactics/upsell: 

Doctor 1 (urology/dermatology): Said HPV warts, warned risk of rapid spread including into urethra which could cause cancer, pushed urine test (claimed detects herpes), laser removal + HPV vaccine (~$475).

Doctor 2 (STI/general): Said not typical HPV (no cauliflower), maybe viral wart. Suggested swab (not standard in men), prescribed imiquimod, no urine test.

Questions:

1) Who/what advice to follow—diagnosis, treatment, HPV vaccine, sex with wife?

2) If HPV warts, is it true most adults get HPV, it can stay dormant for years, and source (wife vs past partner) can’t be known?

3) During the course of my marriage, I have received nuru massages. No intercourse, but in some instances, the female masseuse has performed unprotected genital rubbing of her vagina against my penis. Could HPV realistically come from genital rubbing or is unprotected intercourse more likely?

Up to 90 of all people acquire genital HPV at least once, often several times; and anyone with past HPV is at risk of reactivation of an old infection. Whether that is the explanation in your case I cannot say.

However, I would advise that there is absolutely no reason to stop having sex with your wife. Having been her regular partner perhaps for many years, if your penile lesions are warts, you can be sure she has been repeated exposed to them. With no visible warts herself, she likely is already infected and/or immune. Further exposures at this time will not raise her chance of having warts or other HPV problem (like an abnormal Pap smear).

I would not advise HPV vaccination at this point. I'm not familiar with "nuru" massage, but from your description I doubt that has ever been a source of HPV infection. I cannot say it is impossible, but vaginal or anal sex are by far the main risks for genital HPV.

As for which diagnosis is accurate, you might suggest your two doctors discuss the situation with one another. Perhaps a biopsy would give the answer. You also could do some research on their training and expertise; maybe you could learn who likely is more expert in recognizing and advising about genital warts or HPV. Or consider a third opinion from someone you can be sure is an expert, such as a dermatologist or STI expert at an academic medical center.

Sorry I can't give clear answers, but I hope these comments are a little bit helpful.

HHH, MD

A few final questions but in the event these are/were hpv warts, there is still no risk from acts like unprotected genital rubbing during a massage (with no penetration) for more serious stds like hiv etc, right? 

I read a similar question from a male from about five years ago where you essentially explained:

- for penetrative intercourse, there is higher risk with a male who who may have hsv/herpes infection, but consensus is that hpv warts have not been correlated with higher hiv/std risk.

 - for a male who has hpv warts and engages in genital rubbing with a female (no penetration), there is no risk as the key factor will always be penetration.