Sexually transmitted diseases
TREATMENTS OF SEXUALLY TRANSMITTED DISEASES
Papilloma Virus - HPV
The first demonstration that HPV caused cancer was made in 1935 by Francis Peyton Rous. Later in 1983, the German virologist Dr. Harald Zur Hausen (2008 Nobel Prize in Physiology and Medicine) discovered for the first time that cancer of the uterine cervix was caused by HPV 16
Papilloma Virus - HPV
Table of Contents
What is HPV?
Genital infection by the human papillomavirus (HPV) is the most common sexually transmitted disease (STD) of all, with genital warts occupying approximately one-third of the consultations in specialized centers such as ours.
Over 170 types of the human papillomavirus (HPV) have been sequenced, with about 200 still to be sequenced, and approximately 40 of them can infect the genital area or the mouth and throat of men and women. Most of these infections are asymptomatic and subclinical and can only be diagnosed by genitoscopy, cytology, or through a test that detects viral DNA. In 90% of cases, it is a self-limited infection, meaning, the immune system naturally eliminates the virus by itself in about two years.
What symptoms will we see if we become infected?
Most of these infections are asymptomatic and subclinical, that is, we cannot know if we have contracted the virus with the naked eye because there will be no obvious signs. It can only be diagnosed by physical examination, cytology, or through a test that detects viral DNA. Genital warts are the most visible manifestation of HPV infection. These warts can be located in different areas, so it is essential to thoroughly examine the entire genital area.
The first demonstration that HPV caused cancer was made in 1935 by Francis Peyton Rous. Later in 1983, the German virologist Dr. Harald Zur Hausen (Nobel Prize Physiology / Medicine 2008), discovered for the first time that uterine cervix cancer was caused by HPV 16.
What are the different kinds of HPV viruses we can find?
The different types of HPV that infect the anogenital region are divided into groups: non-oncogenic or low risk (6, 11, 42, 43, 44), related to the appearance of the genital warts, mild dysplasias that do not evolve to high-grade lesions, and recurrent respiratory papillomatosis and oncogenic or high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, …), which are associated with the appearance of dysplasias that can progress to a higher degree or even cancer.
There are different types of classifications depending on the clinical forms of presentation (i.e., the dermal lesions they produce):
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How is the papillomavirus spread or transmitted?
The main route of transmission of genital HPV infection is penetrative sexual contact, even though, transmission by genital skin-to-skin contact is also possible. Although the main route is sexual, there are other ways of transmission that are not strictly sexual, such as digital or through objects. 55% of patients with genital warts have been shown to have the same HPV in the fingers. The incubation period of HPV varies between 2-8 months, although it may be longer.
We must differentiate between men and women from an epidemiological point of view:
75% of sexually active women will be infected by at least one type of HPV throughout their lives. Approximately 15% are currently infected, of which, 50-75% are high-grade, and only 1% have genital warts.
Men have been less studied, partly because the diagnostic methods are less standardized. The data indicate that the incidence is similar to that of women and in both cases, it has increased in the last 30 years.
In our center in Seville, we provide analysis of venereal diseases within 48 hours, accompanied by safe and educational medical interpretation, with total discretion and privacy.
Age is the most important risk factor since the highest number of infections occurs in young women. Then, there are other factors related to sexual activity such as the number of sexual partners throughout life, the number of recent sexual partners, or the number of sexual partners of the couple. Other factors to consider are smoking, pregnancy and the use of oral contraceptives. There is no evidence that circumcision protects from infection.
Prevention is, therefore, the best weapon. The condom protects against fluid-borne infections such as gonorrhea or HIV, but it offers very little protection against those transmitted through contact such as HPV or herpes. For HPV, condoms protect women more than men and are only good at preventing the appearance of clinical manifestations of HPV (genital warts, squamous intraepithelial lesion, cervical cancer, etc.).
Vaccination is an effective way to prevent the transmission of HPV and its sequelae. Women from 13 to 26 years of age who are not vaccinated are a high-priority group for vaccination and can benefit from it without prior cytological or viral screening. The optimal time to start the vaccination is before the woman becomes sexually active. It should also be a recommended vaccination to children for the direct benefits indicated.
How is it diagnosed?
In our consultations in Seville, we always follow the same protocol with HPV:
Follow-up and revisions
Genital warts infections are usually diagnosed by visual examination accompanied by appropriate lighting and a magnifying lens. Another test is with acetic acid, which involves soaking a gauze with acetic acid (3-5%) and covering the genital area for 5-10 min. The gauze is later removed and examined with white light and magnifying lens.
If there are still any doubts, the biopsy is the definitive diagnostic method, particularly indicated in those cases in which malignancy is suspected and being recommended for diagnostic confirmation and definition of the exact type of virus contracted.
Other genital warts with which HPV can be confused:
Caused by HPV types 2, 3 and 4. Warts usually appear in the lower abdomen, groin, and thighs.They usually have a thicker, dry, and hyperkeratotic appearance. Its treatment is similar, so it is not indicated for specific diagnostic tests.
Molluscum Contagiosum (MC)
It is marked by the appearance of some papules with a characteristic umbilication in their center. They don’t usually appear in moist areas such as mucous membranes. The route of transmission can be through sexual contact or not. When they appear in the genital area of a sexually active individual, it is considered an STI. They are usually self-limited.
Caused by HPV types 2, 3 and 4, Similar to condylomata acuminate. They can coexist with other types. They usually appear in humid areas Your treatment is specifically for syphilis HPV-penis
Techniques and treatments
Can it be treated?
The treatments do not eradicate the infection, but reduce it, in addition to the self-limitation of the transmission of HPV to other areas of the body. The influential factors when selecting a treatment are:
Solutions applied by the patient: it is important that the patient knows how to recognize warts, can reach them, and comply with the treatment.
Podophyllotoxin (0.15% or 0.5% solution) cream
It is applied twice a day for 3 consecutive days, followed by 4 days of rest. It can be repeated for up to a total of 4 cycles. Maximum surface area for application is less than 10 cm2 with a maximum volume of 0.5 ml/day.
Imiquimod 5% cream
Applied only once, three times a week. Preferably before going to bed. It must be washed 6-10 hours after application and the treated area should never be covered. Make sure you never apply on the mucous membranes (genital, urethral, rectum, vaginal, buccal, etc).
Solutions applied by the medical professional
Tenofilino resin 10-25% in benzoin tincture
Apply with a stick on each wart and let it dry. Do not apply on open wounds or injuries. It must be properly washed between 1-4 hours after application. It can be repeated weekly. The treated surface must never exceed 10 cm2 and the maximum volume applied should be 0.5 ml/day.
Bichloro-trichloroacetic acid 80-90%
A small amount is applied to the warts and allowed to dry while changing color. They have a low viscosity and spread easily, injuring adjacent areas. If this happens, you must sprinkle with talc or liquid soap to neutralize the acid. This treatment can be repeated weekly. Despite its wide use, this treatment has not been thoroughly investigated.
It can be by contact (nitrous oxide) or by aspersion (liquid nitrogen). The most commonly used is by contact. It is applied until freezing occurs two millimeters below the lesion. This process is performed twice per wart for every session and the sessions can be once every week. It requires training and the appropriate materials, so we recommend our patients go to specialized medical centers, not healers or other people without qualification (yes, even in 2019 we have to remember this). Usually, it is not necessary to administer local anesthesia. Pain, necrosis, and blisters may appear only if the application time is excessive.
Surgical techniques that require anesthesia
Curettage, electrocoagulation, surgical exeresis or CO2 laser vaporization.
Can they come back?
Relapses are frequent, especially in the first three months of treatment. Approximately 20-50% of patients will have a relapse. It is important to inform the patient that this does not mean the treatment has failed, and that sometimes, more than one treatment session will be needed to eradicate the warts. Follow-ups should be conducted every 3 months.