I'm a 21 year-old gay man. I was vaccinated correctly against HPV with Gardasil(6, 11, 16 and 18). The only thing is that I was vaccinated after I started my sexual life, even though I have never had symptoms of HPV and was most of the times I was having protected sex. My partners didn't have any symptoms aswell. Three months ago I started a relationship with a guy, after the vaccination was completed. We're now dating.  From that time to now we have had unprotected sex several times and a few protected sex; first we decided to get tested for STI's and it came back ok. 

So, here's the problem: I'm a med student and JUST NOW I noticed some warts in his genitals. There's a big one, hiperpigmented, in his pubic area, and little ones in his scrotum and penile shaft. They look much alike HPV. He's going to see an urologist.

So, here's my question: assuming they're really genital warts caused by HPV, should I worry about being infected and developing genital warts, even though I was vaccinated and completed the 3 doses?  I'm really freaking out, like I'll carry this for the rest of my life.  Please help me.

Good move for your partner to be professionally examined; that's the most important first step. There are other causes of genital bumps, including some that look wart-like, but are not warts. And most genital warts in men involve the penis, or the anus in men who have had receptive anal sex; groin and scrotum are not uncommon sites, but these locations reduce the chance they are warts or otherwise due to HPV. If they are warts, his doctor will recommend treatment.

Gardasil is one of the most effective vaccines ever developed, for any infection. Protection is complete against the types covered by the vaccine; soon after your second dose, you were 100% protected against HPV 6, 11, 16 and 18. Since ~90% of genital warts are caused by HPV 6 or 11, if your partner has warts, you probably are protected against them. It's not certain, because 10% are caused by HPV types not prevented by the vaccine. So you should be on the alert for new warts in exposed areas (your genital or anal areas, depending on your sexual practices with your partner). New warts typically appear 3-6 months after exposure, sometimes up to a year. Probably nothing will come of it, but this shouldn't cause significant anxiety in the meantime. Nobody wants genital or anal warts, but almost always they are an inconvenience, not an important health problem, and are easily treated.

You can assume you have and will continue to acquire HPV, despite being vaccinated. Almost every sexually active person, including those immunized with Gardasil, gets HPV. There are over 100 sexually transmitted types, only 4 or 9 of which are prevented by the vaccine. (In some countries, including the US, the type of Gardasil in routine use covers 5 additional HPV types.) Of course immunization is still very important, because it prevents 90% of genital warts 70-90% cancers caused by HPV. The point is that HPV is an expected and unavoidable consequence of being sexual. Happily, the large majority of infections never cause symptoms or disease, especially in vaccinated persons.

Let me know if anything isn't clear. But you might hold off on additional questions until your partner has been examined, when you will know whether or not he actually has warts. In the meantime, I hope this information is helpful.

HHH, MD

So, my boyfriend went to the appointment with the urologist. The doctor said a lesion is indeed HPV and the others are fordyce spots(though I disagree with this last statement because I find them really big and wart-like to be fordyce spots). Anyway, he'll follow the treatment proposed and if it doesn't heal, he'll go to an infectologist I trust.

So, my questions are: 

1. I've read the body usually clears the infection of HPV on its own, so most people never show symptoms or signs of the infection. But is it applicable to the HPV strains that cause genital warts? Will the body clear this kind of infection that shows symptoms(warts) or they'll stay in the body forever?

2. If I'm unlucky enought to get it from my boyfriend(even with the vaccine), but take the right treatment, will I have to tell to every future sexual partner that I had genital warts? Will I be at risk on spreading the infection to them?

1) Exactly right, and yes this also applies to warts or other overt, visible manifestations of HIV, e.g. abnormal pap smears in women (also somtimes done anally in persons who have had receptive anal sex). For any and all HPV infections, HPV DNA may persist, but active, transmissible infections generally are cleared by the immune system over several months.

2) Nobody is requried to inform future sex partners of past, apparently resolved HPV infections. It makes sense for currently active infections, and maybe for a few months after they have been treated. But not beyond that. Why not? Because HPV is so common that every sexually active person has been infected and can expect to have ongoing infections, depending of course on sexual lifestyle. Being informed of any particular possible exposure provides no health benefit -- they are equally at risk from other partners as from those partners who happened be diagnosed or to have symptoms.

Given your ongoing medical training, you may want to delve more deeply into these issues -- you probably know (or will learn) how to access the scientific medical literature. You could start with information available from CDC (www.cdc.gov/std) and the American Sexual Health Association, the sponsor of this forum (http://www.ashasexualhealth.org/stdsstis/hpv/).

I'm quite anxyous about all the situation and I'm trying not to freak out. My last questions are:

1. To put an end on it, do you consider my chances of developing genital warts high? Should I worry about it? I'm really anxyous. (Considering I was indeed exposed to the genital warts since my boyfriend and I had unprotected and protected sex several times; and that I took the 3 doses of Gardasil4 before getting intimate with him). I read that the vaccine is less efficient in men than in women.

2. Does recurrences of genital warts after the treatment occur frequently? The chances of success are high or low? Or does it depends indeed in the clear of the infection by the body's imune response?

3. Should I avoid having sex with my partner during his treatment, even I having been exposed earlier? Can it make the infection ''worse'' or spread to another areas?

Thank you

1) An estimated 20-25% of unvaccinated persons in industrialized countries get anal or genital warts (the most reliable data are from Scandinavia), and although I am unaware of data on this among men having sex with men, my guess is that it's at least 50% of MSM. About 90% of anogenital warts are caused by HPV 6 and 11, prevented by the vaccine. That still leaves something like a 5% chance you'll have warts someday. Not a great risk, but not trivial either. But warts usually are a  minor inconvenience, not a major health risk. You may be experiencing a very common "yuck factor" in regard to warts. (There are psychosocial reasons that warts have been associated with toads and other vermin.) But as a physician, you're going to have to learn to deal with a hundred clinical conditions that may generate similar emotions. Just do your best to get over it! Nobody wants anogenital warts, but in general they're just not a big deal.

2) The majority of treated warts do not recur. I suggest you address wart recurrence after treatment if and when it happens in your partner, or if you have warts yourself someday.

3) There's no clear answer to continuing sex with a partner with active warts. Having had multiple sexual exposures with your partner, additional exposures as he is treated probably will not increase your risk of infection. And remember, there's a 90% chance his warts are caused by HPV 6 or 11, in which case you are immune because of vaccination. But another factor is comfort:  wart-treated tissues can be sore or irritated, in which case sex might be uncomfortable. But if not, I see no strong reason not to continue your usual sexual practices, i.e. whatever non-coercive practices are mutually pleasurable for you and him.

That concludes the two follow-up comments and replies included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes in your medical training and career.