Hello Drs. I've read through the forum and have a good understanding of your past responses to questions related to HPV & warts, but wanted to see if there is any nuance/ difference for my particular scenario. The reason for this is the information I have read in the 'Ask the Experts' forum is somewhat different from what I was led to believe in my initial conversation with my doctor. I don't know if that is because there is a difference of opinion between you and my doctor, or because I am remembering incorrectly, or perhaps a bit of both. 

I am a male in my mid-30s and about 5 years ago, my doctor identified warts (approximately 5-7 small white bumps located on the shaft of my penis). No biopsy was done, and instead, I went in for two treatments (4 sessions total) of cyrotherapy over a two-month period. Since then, there has been no recurrence. At the time, I also remember having severe headaches/  migraines, as well as lower back pain. 

My questions are: 

1. What is the % likelihood of having warts misdiagnosed? I can't find anything related to the symptoms described above (headaches & back pain), which is why I am asking. 

2. If I was misdiagnosed, is there any way to find this out given that this was many years ago and no biopsy was done and there currently isn't any test for male HPV? 

3. At the time, my doctor described this as a "forever thing" and something that I would have to disclose to sexual partners. I understand your stance on disclosure, but am wondering what is the % likelihood that this has been cleared (if properly diagnosed as warts), given no recurrence? 

4. Do you know why this may have been sold as a "forever thing"? The initial conversation with my doctor seemed very doomsday-esque than what I've read on your forums, and I'm struggling to square this circle. 

5. How effective is the Gardasil vaccine in preventing genital warts? I understand it is practically 100% effective against the two strains that cause 90% of warts. I also understand that roughly 10% of warts are caused by other strains. Does that make the Gardasil vaccine approx. 90% effective? 

Some of the issues you ask about, especially difference in opinions or advice about persistent HPV, could take pages or entire books to address. On a forum like this, the replies have to be pretty brief. Here goes:

1) If your doctor is experienced in diagnosing and managing warts, and especially if he is a dermatologist, misdiagnosis is unlikely. Few physicians who treat with cryotherapy would use it if there were doubt about the diagnosis. Biopsy usually is not necessary for accurate diagnosis and usually isn't done. The cure with freezing also supports the diagnosis:  many other skin bumps would not be affected. So it seems pretty certain you had genital warts, but I can't put a percentage on the chance of misdiagnosis. Neither warts nor HPV cause headache or back pain:  anxiety or stress over the diagnosis or its treatment could contribute, but not HPV or warts directly.

2) I know of no way to confirm the diagnosis at this late remove, other than perhaps to have another discussion with the doctor. 

3,4) HPV DNA can persist for a long time, perhaps for life. There is debate among the experts whether dormant infection or DNA (they aren't quite the same thing) can persist indefinitely. But even when there is persistence, the immune system generally keeps things in check to a point that there is no recurrence, DNA cannot be detected with currently available methods, and there is little or no risk of transmission. So for practical purposes, in most cases the infection is gone -- but impossible to know for sure in any particular patient. Given these uncertainties, it's pretty easy to understand how different clinicians may have differing interpretations of the data and the advice they give to patients. But the odds are strong you'll not experience warts again, that your current or future sex partners aren't at risk.

5) Your analysis of the HPV vaccine's effectiveness in prevention warts is accurate. But it's really not relevant to your case:  if you had been immunized before you were exposed to the HPV that caused your warts, probably you would not have been infected. 90% reduction in risk is darn good -- few vaccines are so effective. (From a purely biological perspective, HPV vaccine is among the most effective ever developed -- 100% protection against the 9 types it covers. Few if any other vaccines can make that claim -- just look at the news recently about immunization against COVID.) All things considered, the vaccine lowers the rate of both genital warts and cancers caused by HPV by around 90%.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

Are you also able to explain the difference (and/ or linkages) between DNA and dormant infection? Is the idea here that you could have the DNA persist indefinitely, but not have any future infection (and one doesn't necessarily lead to the other)? 

I appreciate you not being able to provide exact %s or certainty, but I worry about even the slightest possibility of spreading warts to anyone else. While I understand this is not one of the high-risk HPV strains, there is still very much a stigma around it.  I am trying to educate myself as best as possible so that I can have informed conversations with future partners, and appreciate any information/ guidance you can provide. 

Thanks very much for your time. 

The idea that your future sex partners consider vaccination depends mostly on their age:  in general, HPV vaccine is recommended only up to age 26 or, in some cases, up to 45. With increasing age, there is a rising chance prior infection with more and more of the 9 HPV types covered by the vaccine, and hence reduced benefit. That someone's partner has been diagnosed with HPV, or has had a known problem like genital warts (or for men, a female partner with a past abnormal Pap smear) is not a valid reason for immunization. The chance that partner still has active (transmissible) infection is no higher than in any randomly selected partner who has not had an HPV diagnosis.