[Question #6229] Assessing GW diagnosis. Absolutely devastated.

69 months ago

I found a groin bump about 4 in. above the base of my penis, right at the crease where my groin meets my thigh. I saw a dermatologist. In < 2 seconds she said it was GW. I’m devastated-- I read so many stories, but this wasn't supposed to be part of mine. I began cyro then and there. I used an online dermatologist service for a second opinion, and based on (pre-cyro) photos, they said it’s either seborrhoeic keratosis or GW.

- How often are GW misdiagnosed? It happened so fast and even dismissive: no magnifying glass to closely examine, and wouldn’t even look for nearby warts if I didn’t ask (seems important to me!?).

- I noticed a hair growing out of the bump. Is this even possible with GW? I've had ingrown hairs before, but this looked different..also concerned the online doc didn’t rule out GW despite mentioning this.

- How common is it for a single wart to appear in the area I described? Please share stats here, because online GW info is frustratingly vague.

- I've only had sex with one woman in ~2 years, who’s been vaccinated (not sure if she had the GW-specific ones). Online says GW can show up weeks or years later, but how LIKELY is it that this came from 18 months+ ago? I’d actually feel better knowing that this came from her since I truly did all I could in that case.

- Can I get another in-person opinion after starting cryo? I.e., do warts react in such a distinct manner to cryo that another doc could dx based on current presentation?

H. Hunter Handsfield, MD

69 months ago

Welcome to the forum. Thanks for your question.

My first thought is that you are overreacting. Don't take it personally: I understand. Warts are not pleasant and have always had a "yuck" factor. But "absolutely devastating" is never warranted. GWs are an inconvenience, not an important health threat. In addition, they are extemely common. Stand in a room with 100 people and look around: probably at least 25 of them have, have had, or will get genital warts; and 90 of them have, have had, or will get genital HPV, often more than once. So don't feel like the Lone Ranger!

Second, we cannot diagnose anything. I will answer your questions, but I cannot and will not attempt to determine conclusively whether or not you had a wart. That takes in-person care. However, I will say that most genital warts are multiple; single lesions aren't rare, but are relatively uncommon. The location you describe also is atypical. Most GWs in men involve the penis itself or occur near the anus if exposed. And for single lesions, seborrheic keratosis can indeed look similar. SKs are primarily a problem in older persons, usually >50 and almost always over age 40. (How old are you?)

To your specific questions:

1) Frequency of misdiagnosis depends mostly on the experience of the examiner. With a competent dermatologist who has seen many cases, misdiagnosis is uncommon. But not unheard of -- especially, perhaps, if the exam is quick and cursory, as it may have been in your case.

2) Hairs do not grow out of warts. At least it's very rare, and I certainly have never seen a patient with this. It argues against a wart.

3) See above: the location and only one lesion argue against warts. This doesn't prove anything, however. I am unaware of any actual statistics on this and don't think it has been studied. I'm expressing the commonly accepted understandings of experts.

4) If it was a wart, it could be from your exposure 18 mo ago. But probably more likely a long delayed recurrence of an infection acquired any time in the past. If your partner had the type of HPV vaccine that covers 4 or 9 HPV types, it was effective against HPV6 and 11, which cause 90% of GWs. But she could have had a reactivated infection from prior to being immunized, so her vaccination doesn't help much one way or the other.

5) It would be difficult for any expert to accurately make a diagnosis after cryotherapy, especially if the lesion was completely ablated and does not persist or recur. But if after 2-3 weeks there is still a bump that looks pretty much as it did before cryo, reexamination would make sense.

All things considered, this really should not be a big deal for you. I hope you find these comments reassuring, as they are intended. Let me know if anything isn't clear -- and your age and, if you know it, the age of your most recent partner.

HHH, MD

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69 months ago

Thanks for replying! I'm 34 and my last partner was 31. To clarify, I'm not asking for a diagnosis, just advice on how to get a more definitive answer after feeling so neglected.

Are you saying it's not exceedingly rare that GW could appear from exposure 18+ months ago? I assumed from other threads that "most" exposures occur within a year. I know earlier is possible, but I'm trying to understand whether it's even remotely likely. For transparency, the last sexual encounter with another partner was ~19 months ago (receiving oral and skin-to-skin grinding with underwear).

- What can I do to ensure successful cryotherapy while minimizing spreading to other areas? The doc just said to avoid shaving. Couldn’t rubbing soap in that area encourage spreading too? Should I combine with creams (the doc said no)?

- 4 days after cyro, I noticed a wet spot in the area with minor pain and what looked like dried white flakes. The doc said infection is highly unlikely and just put a bandaid on it, but if I wanted she could prescribe antibiotics (pardon me, but WTF??). I’m worried that any liquid could contain more of the virus. Is this a normal reaction for cyro?

- I’ve heard of people doing follow up cryo in as little as two weeks. My doc said to come back in 6 weeks. Is that too late?

- If treatment does work super fast (say one session) and no recurrence occurs in 6 months, is it reasonable for me to question whether they were warts to begin with?

Thank you!

69 months ago

I wanted to add that I know that the medical community doesn't regard this as an important health threat and is more of a nuisance than anything, but I'm reacting this way because even with that understanding, I'm having an incredibly difficult time reconciling that view with that of society at large. My last batch of questions will be about how to address the mental/psychological implications of being diagnosed (if that's in fact what this is).

I also wanted to add that I REALLY appreciate the resources you provide here. I seem to have surrounded myself with a bunch of doctors that, quite frankly, don't care about my declining health (the GW are just one piece of a slew of other issues going on lately). Thank you for taking the time to carefully explain every question we have about this condition.

H. Hunter Handsfield, MD

69 months ago

Correct, it is unlikely that warts would take 18 months from a new exposure. That's why I think it's more likely your infection is from a distant past exposure. But there are no guarantees and it isn't possible to know for sure. In fact, it is almost never possible to know when and from whom any particular HPV infection was acquired, and it doesn't matter. Why do you care? (Definitely do not contact your partner from 18 mo ago about this!)

You cannot do anything to "assure successful cryotherapy". It probably will work just fine, but there is nothing you can do to make it more or less likely to be effective.

The details what the treated spot looks like at this point don't matter. It will heal in a few days. This is irrelvant to anything. Stop looking at it!

Repeat treatment? There are no set rules. Follow your doctor's advice.

I have no idea whether the speed of resolution predicts whether or not it was a wart. I don't see that it matters!

Thanks for your kind words in the second follow-up comment. But it isn't my job to mediate your emotions vs reality. It truly is a nuisance -- that you view it differently is your issue, not mine and nothing I can do about it. We are not psychologiests or counseling experts. All we can do is give facts and scientific information. Using that to move on without worry is your responsibility. As for your doctors' attitudes, there is nothing about having a genital wart (or any other possible cause of the genital lesion) that signals "declining health". If you have other health issues that worry you, of course your doctors should pay attention. But this also is beyond what you should expect from this forum.

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69 months ago

Thanks for replying. Last batch, and thanks again for your time!

- The idea that this likely came from a distant past exposure is actually MORE concerning to me. That lends credence to the idea that this never really does go away, even if I went on for years without symptoms. I thought the idea of waiting ~6 months after the warts are gone is in case of recurrence-- meaning that they haven't been cleared yet-- but that after that period, it's safe to say that they're gone for good. How do I reconcile these two scenarios?

69 months ago

Sorry I accidentally submitted. Here's the others:

There's a MASSIVE disconnect between how the medical community views GW vs the rest of society. Despite facts, we're in an age of heightened sensitivity towards consent, so we can’t simply dismiss how it's perceived even if rooted somewhat in ignorance. I know it's not your job to mediate my emotions, but since I must continue to live in a world that still views GW as an abomination, ANYTHING you can share on how to effectively and ethically communicate with others about this would make me feel MUCH better.

- HPV is “unavoidable”, and 80+% of people have it, but isn’t it something like 1% actually has warts? Is it because 1% have a strain that causes warts? To rephrase, is it true that a high percentage of people with an HPV strain that causes warts actually get them, or are many people WITH those strains that have always been asymptomatic? I’d feel much worse if the former and much better with the latter.

- I’m having a hard time seeing how “the talk” right before sex will do anything other than massively kill a mood. Are there any recommendations on how to actually talk to a partner about it?

- To better understand why the recommended disclosure window is ~6 months after symptoms, can you share how risk of transmission drops (from what percent to what percent exactly)?

- Am I now at greater risk for other STDs?

Thank you!!!

H. Hunter Handsfield, MD

69 months ago

You're really into this! Clearly I'm not going to be effective in resolving your concerns. They are way beyond normal, especially in view of the reasoned, science based reassurance I have tried to give. You should consider professional counseling on this. I suggest it from compassion, not criticism. But here are replies to your closing questions/issues.

Big disconnect? Not necessarily. I can tell you with great confidence that when we diagnose GWs in STD clinics, the large majority of the patients are blase, not terribly upset. It's more often that we have to educate them about why they are more significant than they first thought. The opposite reaction, great fear and even horror about GWs, is by far in the minority.

How to communicate? Without hestiation or embarrassment. Most will agree it's not a big deal.

I'm not sure what you mean by your 1% figure. At any point in time, I suppose roughly 1% of people in their teens to mid thirties have GWs. It's also plausible that 1% of all gential or anal HPV infections result in warts. But very reliable data from Denmark and other Scandinavian countries, where amost all physiican visits and diagnoses go into a national database, various reports indicate that 20-30% of people are diagnosed at least once with GWs. In the US, questions of randomly selected persons in CDC's National Health and Nutrition Examination Survey (NHANES), ~15% acknolwedge having had GWs, and there are reasons to believe that many don't admit it or remember, and there is no reason to suspect the frequency would be any less than in Scandiavia. Hence my rough estimate of 25%. If anything, I suspect this is an underestimate.*

My advice to single, dating men in your situation would be to say nothing to past or future partners. You do not know you had a wart; you had an undiagnosed penile bump that is now gone. But if you want to assume it is a wart, if you were single and dating I would say you should inform potential partners of the possibility; that the bump is now gone, but you cannot guarantee you don't have HPV; and let the partner participate in a decision to have sex. If s/he agrees, there would be no reason not to go ahead. Finally, after 6 months with no recurrence, I would advise not saying anything at all. (Presumably these issues don't apply to you, since if you have or have had active warts or HPV, your wife is already infected and likely immune and will not be at risk for new warts/HPV from you.)

The 6 month period is arbitrary. We don't really know how soon after treatment HPV is no longer transmissible. Probably non-transmissible in most cases within 2-3 months and almost always within a year. 6 months after resolution of visible warts is my personal compromise. After that time, most people surely are no longer actively infected.

Past or current warts or HPV are not known to elevate the risk of catching any other STD. A few reports of increased HIV risk were not confirmed by subsequent research; and if such an effect exists, it is very minor.

That completes the two follow-up questions and comments included with each thread and so concludes this one. I hope the discussion has been helpful.

* The Scandinavia data I cited are from 15-20 years ago, before HPV immunization. The same countries have high vaccination rates, and i suspect similar data today would show lower frequencies of GWs. But immunization is not nearly as widespread in the US, so for now I would continues to estimate ~25% in our country

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