[Question #3132] HPV Genital Warts Impasse

38 months ago
I did absolutely everything wrong and I can't cope. 

Background: Male 32 yrs was in a monogamous relationship w GF for over 10 years with the ONLY sex partner I've had. In December 2015 I noticed 3 small , flesh colored bumps on my penile shaft. Went to GP at Urgent Care same day. After a lengthy examination she tentatively Dx'd me and gave me Aldara after ruling out MC etc. She also told me to see a urologist for 2nd op ( I didn't) Warts persisted for nearly 2 yrs unchanged. I used Aldara off and on  (longest application time was apx 1 month) with no result. I didn't tell my GF out of denial of infidelity. She confided in me recently that she may have been sexually assaulted by a friend in (Aug 2015). She was blackout drunk and didn't recall. I then told her about my HPV Dx. Neither of us had no other  sexual contact outside of our relationship. 

This is ACCURATE timetable and sequence of transmission (GF and I were living in separate cities during this time so all the information is correct): 
1)  (Aug 2015), presumed single episode of unprotected sex bt GF and her friend 
2)  (Sep 2015), 1-2 episodes of unprotected sex between GF and myself
3) (Dec 2015)  received my HPV Dx

In summary GF contracted HPV from a single unprotected encounter, passed it to me a 3-4 weeks later (max) in 1-2 unprotected encounters, and warts show up 3 months later.  Neither of us noticed any lesions on her the whole time (tho she didn't get examined).  She did DNA test positive with HPV-18 in December 2017. Her gyno also tested for 6,11 and 18 which she was negative ( didn't know they could test low risk types ).  We broke up a while ago but she hasn't been with anybody since so the HPV-18 wasn't new. 

I treated the lesions at home 5 months ago (more on this stupidity later) and I'm convinced what I had was GW's given the timetable and ex GF's recent HPV 18 Dx. 

Does this timeframe for transmission seem likely? 


38 months ago
What I meant by my question was, does transmission seem likely given this completely accurate timeframe and the background details?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
38 months ago
Welcome to the forum. Thanks for your question.

I am not convinced the penile bumps you describe were warts. Warts generally do not persist as long as two years without changing appearance. The uncertainty of the diagnosis also seems to be supported by the original doctor's uncertainty ("she tentatively Dx'd [warts]"). In addition. failure of imiquimod (Aldara) to have any effect argues against warts. Although imiquimod is not always effective in eradicating warts, it almost always has a visible effect in reducing size, causing inflammation, or other changes.

As for whether your partner at the time might have acquired HPV during the apparent sexual assault is speculative. It could happen, but is unlikely after a single exposure. Also, HPV type 18 doesn't cause warts. It is rarely possible to know when and from whom any particular HPV infection is acquired. Almost all people are infected at one time or another, often several times, and some newly diagnosed infections were acquired years earlier. In any case, since HPV18 doesn't cause warts, this issue is unrelated to your previous diagnosis (whether or not it was accurate).

So "Does this timeframe for transmission seem likely?" Probably not. You don't know you have HPV at all -- although you probably have had it, since it's a normal consequence of human sexuality. But as far as I can tell, it is causing you no health problem. And if your partner apparently isn't having any outward problem from her HPV18, that also isn't an issue at this point. If she has had an abnormal pap smear, in addition to detection of HPV18 DNA, of course she should follow her doctor's advice about follow-up and perhaps treatment. But the large majority of HPV infections clear up and never cause important health problems, including those with high risk types like HPV 18. So from all I can tell, all is well in regard to HPV and your health and that of your partner.

I hope this information is helpful. Let me know if I have misunderstood the situation or if my comments aren't clear.

HHH, MD

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38 months ago
Thank you so much, Dr.  My amended question was 'does transmission seem likely given timeframe (which was certain).?' That timetable  1)-3) from OP was 100% accurate. No sexual contact occurred bt GF and I bc we were in a long dist relationship. I was hoping for you to apply your clinical knowledge and parsimony to determine if transmission sequence was plausible vs alternative hypothesis. Given: Only 1 episode occurred bt GF and her friend, only 1-2 episodes occurred bt GF and I, GF was asymptomatic with short incubation period (3-4wks max) bf passing it to me. Her ONLY Dx was THIS month (pos HPV18). This is significant. To me, it suggests she contracted HPV18 upon the exposure w. her friend 2.5yrs ago. I don't know what to make of absence of HPV 6/11 in DNA test. 

The alternative is that she had contracted HPV18  bf we met that persisted for 13yrs (w normal PAP btw) and I coincidentally discovered lesions  w.in 4 mos after encounter bt GF and her friend (which was unknown to me).  I feel incredibly unlucky but believe the former to be more likely. How about you?

Follow up question: I met a girl (early 30's, no Vax, 10 partners lifetime). 6 wks after lesions resolved (no disclosure) we had about 6 encounters involving oral sex (only received briefly), very vigorous mutual masturbation (fingerbanging) anal fingering and anilingus. Don't remember if I touched her genitals bf touching hers or vice versa. No intercourse of any kind nor genital apposition occurred. Thought warts were behind me and I couldn't conceive how this behavior could put her at risk. After doing some reading on the internet (as well as from CDC HPV page) about HPV transmission, I'm am worried to the point of being physically sick that I gave her HPV. I've since terminated the relationship  I can't eat or focus for months. I'm especially concerned to learn from from these threads that HPV6/11 acquisition virtually guarantees development of warts (contrary to the common semantics misapprehension that most HPV infections are asymptomatic). I believe comes from conflating HPV 6/11 with every other type which makes disentangling GW information impossible. Please comment.

 I'm terrified to ask this but if the risk in indeed negligible w. out intercourse how do scientists reconcile these observations?: 1) parity of HPV infection in lesbians 2) common Anal HPV in hetero men via auto inoculation? Both of these facts presuppose hand genital and oral routes would be incredibly common. Also there are confounding factors in a clinical setting (oral / hand genital would most of the time occur with vaginal sex). What am I missing? Someone asked Dr. Hook a similar question on medhelp and his answer was basically 'stuff happens.' 

As an aside I treated the lesions w. Apple Cider vinegar (not smart). I did so due to the 100s of positive reviews on the web. Also due to successfully treating recurring finger warts w ACV for after disastrous cryo therapies that blistered grew and spread warts that came back. I just didn't think genital warts were that serious at the time. I was diagnosed by qualified dermatologist (3mos after treatment) and NP at free clinic (5mos after treatment) and told I was clear. I'm worried the scarring might be obscuring their Dx. They don't seem to think so. 

Does the fact that I used ACV affect your advice or answers at all? I'm concerned that the usage of a non-medical remedy might undermine any advice you give. FWIW the dermatologist who said I was clear at 3 months didn't seem to think GW were the lesions bc they went away w 'a little ACV.' The ACV was very destructive so I don't see how it would be different than OTC finger wart cream. 

Thanks again for your help. There is a criminally staggering amount of misinformation on this subject so I appreciate all your efforts. I apologize if the post is too long. The forum automatically cut me off last time. Please let me know if this is an annoyance as I do not want to monopolize your valuable time. 






38 months ago
*** there is a typo in 2nd sentence of my last comment. Should read " No other sexual contact occurred between GF and I during that timetable because we were in a long distance relationship. 

Also my GF and I are no longer together. She's my former partner.  Not sure that matters but I only mention that bc you kept referring to her as my 'partner' in your last reply. 

Very sorry.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
38 months ago
First paragraph, origin of her HPV18:  I stand by my previous comments. It's possible she was infected at the time you suspect, but not necessarily. Not enough is known about HPV transmission dynamics to know much more than this. However, it is unlikely that HPV can be transmitted as soon as 3-4 weeks after acquiring it. Visible warts (or cervical cell changes detectable by pap smear) typically appear a few months or longer after acquisition, and I suspect the same is true for ability to transmit. In any case, I still encourage you to stop obsessing about when and where either of you acquired HPV18 or any other type.

As for "I don't know what to make of absence of HPV 6/11 in DNA test", a few possibilities:  Not genital warts at the time (although I agree diagnosis by a dermatologist is usually reliable); that they were starting to clear with treatment or by your immune system; or the test just missed it. The DNA tests are not perfect and miss many HPV infections. A positive test says for sure HPV is present, but a negative result never excludes HPV with certainty.

"I'm am worried to the point of being physically sick that I gave her HPV"  This is irrational. Everybody gets HPV, if not from one sex partner, from another. Since she had about 10 lifetime partners, you can assume she has been infected, maybe several times. (50-60% of people have acquired genital HPV by the time they have had just 3 partners.) Her increased risk from the events you describe, which didn't even include intercourse, was trivial. In any case, since the large majority of HPV infections never cause symptoms and are never diagnosed, even if you infected her, it's probably a non-event from the standpoint point of her health or that of her future partners.

Who said that HPV cannot be sexually transmitted except by penile inseration? Clearly some cases occur without it. Lesbians have plenty of opportunity for transmission through genital apposition; in this context, penis in vagina isn't necessarily crucial. Anal HPV can occur in heterosexual men, but it's not all that common; and such infections may occur by contiguous spread along skin surfaces, not necessarily be auto-inoculation. And maybe some cases in fact occur by hand-genital contact. That said, genital HPV is very rare in people who have never had sex but have had lots of fingering and similar sorts of heavy petting. The issue isn't whether such contact CAN transmit infection, but the apparent fact that the risk for any single exposure is low, undoubtedly far lower than through genital-genital contact.

I agree that vinegar (apple cider or any other) is unlikely to have any benefit in clearing warts. Anecdotes and uncontrolled studies don't count at all for a condition that almost always resolves on its own.

Finally, as for "staggering amount of misinformation", in one sense, I agree; anyone can publish, or especially post online, anything they want. OTOH, a large part of the problem is the presence of major gaps in scientific knowledge, so that even among experts, a lot of advice and opinions are based on differing interpretations of uncertain data or clinical experience.

But the good news is that, as noted above, the large majority of HPV infections are never clinically apparent and cause no harm. Nevertheless, it appears you are obsessed by all this. I encourage you to do your best to gain a new perspective on HPV as an expected, unavoidable, most mostly harmless consequence of human sexuality. Young people should be immunized, women should have pap smears, and everyone should have any unexplained genital lesions or sores professionally examined. Otherwise, just forget HPV and go on with life.

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37 months ago
Thanks again for your reply. I've read it multiple times  and appreciate the encouragement. Unfortunately, I don't see the good news here. I've read every HPV post on ASHA (and many on other forums) and the more I read the more hopeless I become. 

I missed out on any therapeutic alliance by seeing the wrong Dr. from the beginning and have no reason to believe the lesions would have resolved, on their own at the time I started treating them with ACV (they didn't after 2 years). There is also mild scarring that concerns me greatly. I'm consulting a plastic surgeon tomorrow, although I doubt they will be able to improve the issue. 

Because I used ACV as a destructive therapy, which you and many others consider 'quackery' of no benefit,  why would I not assume that my efforts did nothing to resolve the infection and that it's still present and contagious? 

""I'm am worried to the point of being physically sick that I gave her HPV"  This is irrational. Everybody gets HPV, if not from one sex partner, from another. Since she had about 10 lifetime partners, you can assume she has been infected, maybe several times. (50-60% of people have acquired genital HPV by the time they have had just 3 partners.) Her increased risk from the events you describe, which didn't even include intercourse, was trivial. In any case, since the large majority of HPV infections never cause symptoms and are never diagnosed, even if you infected her, it's probably a non-event from the standpoint point of her health or that of her future partners.""

"But the good news is that, as noted above, the large majority of HPV infections are never clinically apparent and cause no harm."

Do these statements apply to the types of HPV that cause GW (namely 6/11, yes I know there are a few more)? It doesn't seem that way. I'm not concerned w. other HPV types not because I'm a male, but because they remain largely are asymptomatic or only go on to cause health problems in a tiny minority of unmonitored cases. That would be irrational. But from reading these threads it seems like the exact opposite is true of HPV 6/11, whereas infection nearly guarantees warts. Nor does it seem most people acquire HPV 6/11 at any point in their sexual life. In contrast to HR HPV, these seem quite rare. Merck puts lifetime risk of GW apx 10%. So it would seem the prevalence of HPV 6/11 at any given moment wouldn't be higher than a few %. And CDC says 1 in 100 have GW. Could you please tell me if I've interpreted this information wrong?

Because I don't understand the benefit of couching a GW discussion in the context of every other HPV. Every single website that is an authority does this some form of this conflation. The strains that cause GW have nothing to do with the ones that don't.  It's apples and oranges. Smuggling in HPV 6/11 into a broader HPV conversation gave me a lot of reassurance at first due to the fact that I (along with the majority of readers) believed that the kinds of HPV that cause warts are common but warts only manifest in an unlucky few due to variations in immune response etc. Although I would like it if this were the case, despite being what most people believe, It isn't true. 

Should inform my last partner of my situation, even if the risks were insubstantial? I want to be a good person but I don't want to cause her any undue panic (which I'm sure will happen with almost everybody). I know you guys think warts or more or less a nuisance and that's probably true in the strictly medical sense. But most people wouldn't take it lightly the prospect of getting an incurable std that is disfiguring, has no test for men, no gold standard treatment, may or may not 'clear' (whatever that means), almost no good clinical data regarding transmission, that can't be protected by condom use and can come back at any  time. That's saying nothing of the shame, humiliation and social stigma that is uniquely associated with genital warts. I would have liked to keep the relationship going but it just isn't possible when the only 2 choices are 1) lie by omission and put her health at risk or  2) disclose and cease to be looked upon as a sexual object. 

Thank you again Dr. for your valuable service. I appreciate your time  immensely and will read any replies you grant very carefully and seriously. 






 




H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
37 months ago
You continue to seriously overeact. Unforunately, I cannot help that your fears and axieties are making it dificult for you to understand, believe, or act upon the reassaces I have tried to give.

Using a particular treatment for warts does not reduce the efficacy of different treatments in the future. And apple cider vinegar is totally inactive anyway; if you still have active warts, and not just scar tissue, the standard treatments should be effective. 

Yes, my "good mews" statement applies to all 100+ HPV types that infect the genital area. And you have very mistaken understandings about HPV 6 and 11, which are considered low risk, mild HPV types rarely associated with serious health outcomes. Genital warts should be viewed as a medical inconvenience, not a serious healht threat. And I do not understand your frankly irrational analysis of why there are not parallels in HPV 6/11 versus the other types, especially the potentially dangerous (cancer causing) ones like HPV 16, 18, and a handful of others.

If your plastic surgeon confirms that you still have active warts, then it would be a kindness to inform your current and any potential new sex partners, until the warts are definitely gone. But in general, it is not necessary nor recommended to inform partners of past HPV infections that have cleared up. Doing so does not reduce their risk of infection or of serious health outcomes.

In addition to the original question, we answer two follow-up comments/questions, and so that concludes this thread. Please do not be tempted to start a new thread on this topic. There is no additional information you can provide that would change our opinions or advice. Thank you for your understanding. That said, I hope the present discussion has been helpful.

HHH, MD

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