[Question #432] HPV timeframe

34 months ago
I had an anal pap done to determine if I have an intra-anal HPV infection. The results are not back but I suspect that is the case. My question is how long I should wait to determine if an HPV infection will clear up on its own or if surgical treatment is required? I realize most cases are asymptomatic to begin with. But when there are symptoms, how long should I wait to see if it "clears up". I would estimate that it has been about 2 months so far. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Welcome to the forum. Thanks for your question. This the first question about anal HPV and paps that I have fielded since the forum started, so I'm taking the opportunity to include some blog-like comments as background, which may be useful in responding to other questions in the future.

The notion of routine anal pap tests and HPV testing in MSM is relatively new and somewhat controversial. No authoritative agencies (CDC, the US Preventive Services Task Force, etc) recommend it routinely, and opinions about it vary between experts. Probably we're moving toward more routine testing, but more research is needed to understand even such basic details as how to best collect specimens, as well as how effective it is in preventing the main outcome of interest, anal cancer. As you may know, anal cancer is pretty common in MSM (but interestingly not as frequent in women, even those who have anal sex). The current rate of anal cancer in MSM is about the same as cervical cancer was in women before pap testing became the norm (around 40 cases per 100,000 per year before, around 10-15 per 100K now). But whether early detection is effective in reducing the frequency of invasive cancer remains unclear for abnormal anal paps or HPV testing.

Now to your questions. As implied above, it would help to know whether you are male or female. The epidemiology of anal HPV has been better studied and appears to be quite different in men (men who have sex with men in particular) compared with women. I'm going to assume you are male and probably MSM -- this is the only group for which anal pap smears and HPV testing have become somewhat common. Other issues also are potentially important, especially whether or not you have HIV, which probably elevates the speed and frequency of progression of early abnormalities to anal cancer. For now I'll assume you are HIV negative.

Having said that more data are available in men, it doesn't mean we have good answers to these questions. You seem to be asking this:  Among men without anal symptoms who have anal HPV, what proportion will develop symptomatic disease (warts, pre-cancer, etc) and when that will happen? To my knowledge, there are no data on this. Among those who do have diagnosed anal or rectal warts, there also are no data on whether and how fast the warts might clear up if not treated. Whenever such a diagnosis is made, treatment usually is administered -- and it would be questionably ethical to even do a study to follow such men without treatment. Distinguishing benign anal warts from early cancer or pre-cancer can be difficult, and obviously the latter should not be left untreated.

That you "suspect" you have anal HPV seems to imply that you have noticed symptoms, e.g. bumps consistent with warts, or that the examiner observed such problems when collecting the HPV specimen.  Normally anal pap and HPV testing would have included not only external inspection, but a digital (finger) rectal exam and anoscopy to look inside. If you had visible HPV disease, probably it would have been seen. What did the examiner say about it?

Sorry I can't better answer your specific questions, but I hope this information is helpful. Let me know if anything isn't clear. And if you'd like to fill in some of the missing information, I may have more comments or advice.

Best wishes--  HHH, MD


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34 months ago
Dr. Hansfield,

You are correct on your assumptions: 32 year old MSM with no visible external but internal bumps that might be consistent with HPV. The examiner did not do a digital or other examination but proceeded directly to conduct an anal pap. 

That may seem counterintuitive but I suspect it was because she had conducted that exam a few weeks earlier when I complained of irritation and she saw/felt nothing. I did not feel any bumps until a few weeks after her initial digital exam. 

HIV negative and negative for other STIs including Herpes 1 & 2. 

I understand that you are saying if the pap is indicative of HPV along with a digital exam, treatment should occur without waiting to see if the infection clears up? I ask because I would suspect it is not easy to treat an intra-anal infection. Thanks. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Thanks for the clarifications, confirming my expectations.

If your HPV test is positive, you'll need a proper exam to evaluate for both internal and external warts. I would advise that be done by a provider with special expertise, such as a proctologist, colorectal surgeon, or someone with substantial experience in evaluating anorectal problems in MSM. Most people with anal warts have external ones as well; combining that fact with your recent negative exam, my guess is nothing is wrong and you are overly sensitive to your rectal self examination. In any case, there is no realistic treatment for asymptomatic HPV of the anus or anywhere else. In that case, watchful waiting is all you can do.

External warts are pretty easy to treat, but internal ones more difficult. There are no firm rules -- each case is different, and different providers have varying recommendations. But in general, simple treatments are best tried first (freezing, podofilox, etc), and fall back to surgery if that doesn't work or if warts are particularly numerous or large. (If the initial recommendation is surgical, I would suggest getting a second opinion before proceeding.)

If your HPV test is negative and your sensation of internal bumps persists, reevaluation (also by an expert) in 3-6 months would make sense.


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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
On reflection, I need to clarify my statement about nothing to do for asymptomatic anal HPV except wait and watch. Some (most? all?) of the research teams investigating anal pap smears, HPV, and anal cancer in MSM would examine you with magnification (colposcopy) and perhaps special methods (acetic acid) to identify areas of HPV infection, and would biopy any lesions that they find with these methods. However, many (most?) providers in clinical practice probably have little experience in these procedures, and their value in early detection or in preventing later anal cancer are unknown.

To put it another way, in most settings watchful waiting would be the best option. But if you're located where more sophisticated evaluation is available and the providers have experience with it, that might be an option.

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33 months ago
The pap came back negative for HPV. But a digital exam I do myself, I can feel growths just inside. So something is there that wasn't for 32 years. I assume I should see a proctologist?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
That would make sense. But the negative HPV test suggests you're not feeling warts or anything else related to HPV. Perhaps nothing is wrong at all. Such self diagnosis probably is pretty unreliable. But professional exam makes sense in this situation.

That concludes the two follow-up questions and replies included with each new question, and so ends this thread. Good luck and best wishes.


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