[Question #1659] HPV

46 months ago
Drs,

You can close out my last thread.    I'll get right to it.   I haven't my HSV-2 Igg test back yet, but I've been diagnosed with genital warts by my dermatologist and confirmed by a NP at the local planned parenthood.  

As with anything else, the information on the internet is overwhelming and confusing, but  the NP was great.  She essentially stated that HPV is very common and that most likely, I've had it for a while and that the stress and anxiety has caused an outbreak.    Essentially, treat it with the cream and it'll go away but the virus will remain in the body.

The warts look like penile papules and I felt as if though I've seen them before, though I cant be sure.   I've never been treated for them.   They are located on the underside of the shaft right below the head.

1.   How serious is this and how concerned should I be?
2.   Do they only appear at the site where the skin was infected?  meaning, would it be possible to move from location to location.
3.   How long after infection do they appear?   I've read 2 to 8 months; 3 to 12 months; 6 weeks to years.
4.   The area where they are would definitely be protected by a condom.     My exposure on 12/2 was protected.   I've only had unprotected sex with 3 women in my life.  One of them was a virgin, and one of them is my wife.       I first noticed them at approximately 6.5 weeks.      Due to their location, I can't say with certainty, when they appeared.     In your professional opinion,   what is the likelihood that I got it from the 12/2 encounter?
5.   Recurrent warts - some people say that the virus will clear itself, but other authorities say that the virus will always be there and that there is a good likelihood that the warts will return.   I saw one study a medical institution in Poland that states 30 to 70% will recur.     What is your opinion on this?      The NP stated that I can treat them with a cream but she was pretty certain that they will return.  She pointed to a wart on her leg that keeps com


46 months ago
ing back.  

6.    Should I be worried about passing this to my wife?   I understand that HPV that causes warts are not the ones that cause cancer.   
7.    If so, is there any way to prevent it?  
8.    What advice would you give to me if I were your son?

I hate to keep pestering you guys but this has caused me a lot of stress and anxiety. 

Thank you as always.




H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Welcome back to the forum. I'm sorry to see your continuing need for it, but happy to address these questions.

First comment is that even though the diagnosis of genital warts has been made by both a dermatologist and nurse practitioner, I would ask whether you made it clear to them that they look the same as the penile papules you apparently have had for a long time. The two would not usually be confused by experienced clinicians -- but the similar appearance suggests that one of those diagnoses was wrong. However, from here forward I will assume the new diagnosis of genital warts is correct. My second comment is that stress and anxiety are not known to trigger appearance of warts; I disagree with that part of your NP's evaluation. However, I agree you must have had HPV for at least a couple of months, i.e. they were not from the recent sexual exposure that triggered your three other recent questions. To your specifci quesitons:

1) Genital warts are rarely serious -- I would characterize them as a health inconvenience, not a danger.

2) Warts typically appear at the sites of inoculation of HPV, can appear in other nearby areas.

3) Warts typically appear 2-6 months after catching HPV, sometimes a year or more, once in a while recurrent warts can show up several years after the initial infection. The variable times you'll find on the web reflect genuine uncertainty:  there have been few careful studies, because in any particular patient it usually isn't possible to know exactly when or from which partner the virus was acquired -- thus difficult to analyze incubation period.

4) There is almost no chance this is from the exposure just 5-6 weeks before diagnosis.

5) HPV DNA may persist for years, perhaps for life. However, the immune system usually controls the infection to a point at which warts do not recur and cannot be transmitted, so the infection is considered cured. However, some infections reactivate months or years later. But nowhere near 30-70% of people with genital warts develop recurrent warts in later months or years, probably closer to 5%. There are several treatments for genital warts and I don't know which "cream" she is referring to, but I'm guessing imiquimod (Aldara®, Zyclara®). Others for home self treatment include podofilox (Condylox®) and sinecatechins (Veregren®); physician-applied treatments include podphyllin resin, tri- or bichloroacetic acid, cryotherapy (freezing), and laser- or electrocautery.  Your NP's personal experience with a single wart on her leg (if that's in fact what she has) says nothing about the likelihood your warts will respond to any of these treatments.

6,7) Since you have undoubtedly had this HPV infection for months or years, you can safely assume your wife has been repeatedly exposed. She likely was infected, with or without visible warts. She could have been the source of your infection. You'll never know and it doesn't matter. In any case, there is no point in taking any steps at protection at this time and I do not advise any change in your sexual practices with her. It is correct that different HPV types cause warts than cancer.

8) My advice, to you, any patient, or any family member would be the same:  First recheck with the dermatologist, or get yet another opinion -- I'm not convinced you have warts. Second, assuming the diagnosis is correct, follow the dermatologist's advice about treatment. Third, I would recommend no changes in sexual practices to protect your wife. 

I hope this information is helpful. Let me know if anything isn't clear.

Regards--  HHH, MD

---
46 months ago
I did not make that point clear to the 1st dermatologist.   I just asked her to look at the rash  to see if it was herpes, warts or something else.     I also made the mistake of telling the NP I was diagnosed with warts by a dermatologist, and asked her to take a look.     In hindsight, I probably fed her the answer.

I'm pretty sure I've seen these bumps before.   I can see some on the other side.  The only difference is that these bumps are more pronounced and have a small rash.    I don't know if they're more pronounced because of the rash.   Honestly, It does not look that bad unless I stretch out the skin (its right on the foreskin).

In between this, my IGG test at 7 weeks for hsv-2 came in negative.   A week later, the rash really has not changed at all.   When I went in to discuss those results with my PCP, I came clean about my 12/2 encounter.  While she was not concerned she just told me to repeat the test in 6 weeks but she highly doubts that its herpes.     She never even mentioned warts.   She re-examined it and said that those bumps are sweat glands and that she can see some on the other side, just that the problematic side has a bit of a rash.    I asked her point blank about genital warts and she said no.   Her diagnosis - contact dermatitis.

I took your advice and saw another dermatologist for a 2nd opinion.     This guy has been in practice for a long long time.    Pretty well known around here.    He took 1 look at  the rash and said - contact dermatitis and prescribed some cream.      Literally spent less than a minute.       He was pretty adament.

The dermatologist who spent the most time examining it with a magnifying glass says GW.    PCP and 2nd dermatologist says contact dermatitis. 

Your take?      I just can't figure out how I can have 2 diagnosis that are so far off.


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Seems to me this information makes it unlikely you have genital warts. However, I'm not your doctor and there's no way I can mediate between the conflicting diagnoses you have had, except to point out that you have two opinions versus one. My advice is to speak with your PCP and/or second dermatologist about their reasoning, how confident they are you don't have warts, and then make your own judgment about which ones likely are correct.

You can forget herpes. As per your previous thread and nature of your symptoms, there is no chance your penile problem is genital herpes. I recommend against another HSV blood test, but that's also up to you and your doctor(s).

---
46 months ago
In terms of confidence, both of them were pretty emphatic.   My PCP never even suggested it.   I was the one that asked her and she said no way, end of discussion.    She's been practicing medicine for 17 years and she said she sees plenty of rashes on genitalia.     As to the 2nd dermatologist,  he was even more emphatic that it wasn't.   He's been practicing dermatology for almost 40 years.    Neither one remotely suggested taking Aldare (sp?).  The  2nd dermatologist did prescribe Desonide ointment and I will take that for 3 weeks to see if it improves and then take it from there.

Last set of questions.

1.  How confident  are you in your view that if these are GW, I did not get them from the 12/2 exposure?   Location where they appear was covered and low end (6 weeks) of time frame.      I haven't had relations with the wife since.   My main concern still is to protect her.      There was no one else.

2.   General question RE: HSV-1.   I've always thought that if one had oral herpes, it provide immunity against genital HSV-1 infection.   But through out this ordeal, I've read that while rare, its not impossible.     So, other than simultaneous acquisition,  how likely is it that if one has oral HSV-1, they can acquire genital HSV-1 from a partner.

3.  I have oral HSV-1, not sure if my wife has it.     I've also read that the virus sheds even when no sores are present.     I'm just worry about giving it to her thru oral sex.    Should this even be a valid concern?

As always, thank you for your time.     You have been a great source of information.   I'm going to give up googling and move on.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
1) I am confident that if these are warts, they came on too soon to be from that exposure.

2) People generally are at least highly resistant, but not necessarily totally immune to new infections with the same HSV type. But immunity probably is especially strong to the specific virus strain they are already carrying. That's why couples never "ping pong" their mutual infections back and forth, and experts recommend no precautions to avoid transmission when both members of a couple are infected.

3) Your wife could be tested. If positive for HSV1, you need take no precautions and shouldn't worry about infecting her by performing oral sex, for the reasons just discussed. If negative, or if she isn't tested, you should avoid performing oral sex when you have an oral herpes outbreak. Otherwise no worries. It is true that virus can be present without outbeaks, so this strategy reduces the risk but doesn't eliminate it. However, most committed couples in this situation (i.e. on member infected with either HSV1 or 2) don't worry much about herpes transmission. If it happens, they are on the alert and prompt treatment can be started. And for HSV1, recurrent genital oubreaks are uncommon, so it's really not an ongoing problem for most people. Up to half of all adults have oral HSV1, and the large majority of their spouses or other regular partners never get genital herpes from them even when they regularly have oral sex with one another.

Finally, be clear that there is nothing in your story that suggests herpes. The penile symptoms you report are not consistent with herpes and I'm confident that's not the cause.

That completes this thread. Please note that the forum does not permit repeated questions on the same symptoms or exposures. This will have to be your last one; future new questions on this topic will be deleted without reply and without refund of your posting fee. This policy is based on compassion, not criticism, and is designed to reduce temptations to keep paying for questions with obvious answers; because experience shows that continued answers tends to simply prolong such anxieties, when the real answer normally should be professional counseling; and because such questions have little educational value for other users, one of the forum's main purposes. I trust you will understand.

---