[Question #9292] HPV confusion

34 months ago

Dear Doctor(s),

I am a 28 straight male, had some sexually active past.

Around mid June 2022, I have seen one bump in my genital area, after various doctors telling me nothing, molluscum, condyloma, one made a biopsy (translated):

Macroscopy

Several tangential excidations totaling 3 x 2 x 1 mm

microscopy

Section steps, HE, immunohistochemistry (p16/Ki67)

Squamous epithelium with papillomatosis, hyperkeratosis and focal parakeratosis.

Superficially enlarged nuclei with optically clear perinuclear halos. Sectional basal stratification disorder with enlarged, hyperchromatic, anisomorphic cell nuclei and mitoses. Thin subepithelial inflammatory cell infiltrates. The lesion is pigmented.

Diagnosis:

condyloma with low-grade intraepithelial neoplasia (AIN 1/ LSIL)

No evidence of malignancy.

Some other doctor ordered a DNA test with the same sample, translated result:

HPV typing was carried out as requested. Here (cf. report of findings) no HPV can be detected. This is possibly due to the altered tissue, so DNA extraction is not possible. (or This is possibly due to the altered tissue, as DNA extraction is not possible)

Some new things appeared, and the doctor said they are too small to confirm DNA, so she wouldn’t take samples. I went to the another one, she took same samples from one tissue she said folliculitus, and other one she said also could be folliculitus (I do not think it is, it has been a long time). They only tested for high risk ones, and it is all negative, however this didn’t confirm whether the tissues were correct in my opinion, because low risk HPV was not tested/found. Also they assigned my gender as female in this test, just FYI.

I am confused, can you help me to put this in perspective?

1.Does (AIN 1/ LSIL) mean it is from anal area? My tests were not from anal skin.

2.In the biopsy report does p16 mean it is found or just means it is searched?

3.Can we say I had low risk HPV for sure and not high risk HPV?

H. Hunter Handsfield, MD

34 months ago

Welcome to the forum. Thank you for your confidence in our services.

You have had a surprisingly thorough evaluation and provide great detail on the biopsy and ancillary lab evaluation. Presumably one or more of your doctors is a dermatologist. You could ask if any of them is also a pathologist (i.e. dermatopathologist). If not, I would seek such an expert's advice in interpretation. Neither I nor Dr. Hook have such expertise, so I'm not sure how helpful this forum can be. But I'll give it my best shot.

You say nothing about the clinical presentation. Apparently you had a single bump, not several, right? Exactly where was it: penis? scrotum? groin? True genital warts, caused by sexually transmitted types of HPV, generally involve the penis or anal area, less commonly the scrotum, and uncommonly the groin, pubic area, lower abdomen, etc. This info might help interpret these results. That said, clearly it was a wart; that's what the Diagnosis line means (condyloma = wart), but no evidence of cancer or pre-malignant changes (the "low grade" statement). It may well have been on the way to resolution by the time the biopsy was done, with wart tissue largely replaced by scar tissue or normal skin. This might explain the difficulty in testing for HPV DNA.

Whatever the explanation, it sounds like the lesion was small enough that the biopsy removed it entirely. If so, and even if we conclude you had a genital wart caused by HPV, it may now be gone and hence cured. To your numbered questions:

1. The pathologist who interpreted the biopsy may use the same terminology regardless of the exact location of the biopsied lesion, i.e. covering both anal and genital. Or maybe s/he wasn't even aware of the exact location of the biopsy as s/he was examining the tissue, and covered things by referring to both locations. In other words, I do not interpret "AIN" as indicating any anal pathology, which of course would be impossible to evaluate from a non-anal specimen.

2. I do not know the meaning of "p16/Ki67". I have not seen such terminology in connection with HPV typing. The statement that "no HPV [DNA] can be detected" suggests that these notations do not indicate HPV type.

3. Not knowing the meaning of that part of the report, I cannot say whether or not you had a low risk or high risk HPV infection (i.e. HPV16). But it doesn't matter. It is a mistake to focus on whether the HPV strain itself is high or low risk. The report of LSIL (low grade squamous intraepithelial neoplasia) is the important part, meaning no malignant or pre-malignant changes were seen.

It seems to me you can move on with no further worry about all this. It seems nothing important is wrong. But as I said at the outset, your own doctors (or a dermatopathologist) might know better how to interpret this than we do. But I hope these comments were partly helpful.

HHH, MD

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H. Hunter Handsfield, MD

34 months ago

Please note that the reply above is edited from what I wrote initially, to correct an error in my interpretation. If you saw my reply before about 10:55 am Pacific time, please re-read it now. Sorry if any confusion or misunderstanding.

HHH, MD

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33 months ago

Dear Doctor,

Thank you for the reply.

No I had multiple bumps over time, one in the upper part of where shaft meets body, and the rest is above there, more in the waist line. One on the shaft itself. One under belly button… Some removed in the first biopsy (pathologic test + later DNA made with it), some removed with laser, some removed in second biopsy for high risk testing… I still have one bump.

I got an opinion from another doctor, they explained p16 and said this pathologic report doesn’t mean high risk… And as I said before, DNA testing has been made with the tissue used in first pathology, said it might be damaged so no HPV found, and second DNA testing has been made with some tissues doctor wasn’t sure if they were warts, and my gender is assigned as female there (I am male). Considering this whole, I really would like to be certain that I had low risk, and not high risk. Now, should I send the last bump to “all HPV types” testing, and if I get a result of 6 or 11 there, should the confidence that this was low risk HPV increase, or it wouldn’t change and there is enough proof that it was low risk? I am worried about past or future sexual partners getting cancer… I even read actually low risk “may” cause cancer, how worried one should be about that?

Other questions:

If after everything is gone and I have waited 3 months (there is the last bump I will consult with my doctor to take action), does it mean my body totally cleared the virus? Should I tell future partners about this infection?
If after everything visible to me is gone, should I still visit a doctor to get it checked under my testicles or my anus (I am a straight male but heard they can spread there somehow) How can I make sure that there is no more warts in the future, how should I check it in the future?
Should I get the vaccine, just incase… (28 Male)
I had a bump under my belly button, but this faded in a relatively short time whereas the rest stayed strong for longer time, one doctor said it looks like condyloma also, do you think it is a place for HPV caused warts? If so, since under the belly button is a touchable place by other people, do you think I would transmit that in social ways other than sex (hugging with a shirt that goes up or any other way)?
Is there a possibility I could transmit any of these via social non-sexual ways to other people?
We continue to have sex with my current partner, considering all the info we have about this situation, but I cannot wrap my head around about receiving oral sex… What is your opinion on this?

H. Hunter Handsfield, MD

33 months ago

From both your original question and these comments, I remain unclear on whether or not the bumps were genital warts or caused by HPV. Certainly their location is atypical: true genital warts in males usually involved the penis, less commonly the scrotum, and rarely the pubic area or lower abdomen. Also, I don't entirely understand why "damaged" tissue cannot be tested for HPV DNA. In general, DNA is an extraordinarily hardy substance (after all, it often can be extracted from fossils hundreds or even hundreds of thousands of year old). Perhaps something else to clarify with your doctors. But for the moment, I suspect you have not had genital warts or any sexually acquired problem. But if they were warts, you can be quite confident they were caused by a low risk HPV, i.e. a strain not likely to risk future cancer.

I'll address these questions as if you had warts, however -- but keep in mind I am not convinced.

1. Sorry, but physical removal or destruction of warts is no guarantee the underlying HPV infection is gone. Think of warts as like an iceberg: the wart is the tip, with a larger area of infected skin that appears entirely normal. However, removing warts probably does reduce total viral load, and thus likely reduces transmission potential. In addition, eventually the immune system entirely clears most HPV infections, at least to a point that transmission doesn't occur.

2. I see no reason for examination for bumps or lesions you cannot see or find for yourself.

3. Vaccination is reasonable to prevent new HPV infections, assuming you will be sexually active in coming years. Recent research also suggests a possible benefit in reducing the frequency of HPV reactivation, although any such benefit is probably minor.

4. As noted above, this location is unusual for genital warts.

5. Sexually transmitted or acquired HPV is never transmitted by casual, nonsexual contact. For example, household members of persons with GWs never are infected despite sharing of toilets, towels, eating utensils, and so on.

6. I see no reason at all for you to limit or change your sexual practices with your partner. If you have HPV, you can assume s/he has already been intensively exposed and presumably infected. Changing practices now will not change her or his risk of being infected or having a significant clinical outcome, like warts, cancer, etc. I see no need or reason to avoid oral sex or any other sexual practice that gives you mutual pleasure.

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33 months ago

Dear Doctor,

Thank you for shedding a light onto my questions.

1. I know destruction doesn't mean the body cleared it, but you are saying eventually the transmission possibility will vanish... When can I say it, after the last visible "wart" is gone? Can we say something like after the last visible wart is gone, 3 or 6 months partner information is not required as there is no risk of transmission?

4. If we assume the bump under my belly button is also a sexually acquired HPV caused wart, can we say there is no possibility to transmit it via non-sexual ways? I am worried because the location can become open while hugging etc...

These will be my last questions,

Thank you for being here for people.
Best regards.

H. Hunter Handsfield, MD

33 months ago

1. The large majority of HPV infections cease to be transmissible with time, typically (as best we understand) within several weeks to a couple of years. Infection may reactivate thereafter, with transient transmission potential, but for the most part transmission ceases entirely.

4. The body area infected has no apparent effect on transmission potential. Many people with genital HPV have the virus in their oral cavities, under their fingernails, and elsewhere -- but still there are no known transmissions except by sex (see my comment above about sharing of toilets, eating utensils, etc); or nonsexual transmission is so rare that it can and should be ignored.

That completes the two follow-up exchanges included with each question and so ends this thread. I do hope the discussion has been helpful. I honest feel you can go forward with pretty good confidence your skin bumps were not genital warts; or that even if they were, the responsible HPV infection has no health implications of importance for you, your current or future sex partners, or certainly for people in your environment.

Best wishes and stay safe.

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