Penile warts are the most common sexually transmitted disease in men and are caused by the human papillomavirus (HPV). Penile warts usually appear as soft, flesh-colored to brown patches on the glans and shaft of the penis.To provide up-to-date information on the current understanding, diagnosis, and treatment of penile warts, we have conducted a review using key terms and phrases such as "penile warts" and "genital warts. "The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews.
Epidemiology
HPV infection is the most common sexually transmitted disease worldwide. Being infected with HPV does not mean a person will develop genital warts. It is estimated that 0. 5 - 5% of sexually active young adult men have genital warts during physical examination. The peak age of the disease is 25-29 years old.
Pathogenesis
HPV is a non-enveloped capsid double-stranded DNA virus belonging to the genus Papillomavirus of the family Papillomaviridae and only infects humans. The virus has a circular genome of 8 kb in length, encoding eight genes, including two genes that encapsulate structural proteins L1 and L2. L1-containing virus-like particles are used in the production of HPV vaccines. L1 and L2 mediate HPV infection.It is also possible to be infected with different types of HPV at the same time. In adults, genital HPV infection is spread primarily through sexual contact and, less commonly, through oral sex, skin-to-skin contact, and fomites. In children, HPV infection can occur as a result of sexual abuse, vertical transmission, self-infection, close household contact, and fomite infection. HPV penetrates into cells in the basal layer of the epidermis through microtrauma on the skin or mucous membranes.The incubation period of infection ranges from 3 weeks to 8 months, with an average of 2 to 4 months. The disease is more common in individuals with the following predisposing factors: immunodeficiency, unprotected intercourse, multiple sex partners, having multiple sex partners, history of sexually transmitted infections, early sexual activity, meeting sex partnersThe time interval is shorter. New partner and living with him, having sex, uncircumcised and smoking. Other predisposing factors include moisture, maceration, trauma, and epithelial defects in the penile area.
Histopathology
Histological examination revealed papillomatosis, focal parakeratosis, severe acanthosis, multiple vacuolated koilocytes, vasodilation, and large hyaline keratin granules.
clinical manifestations
Penile warts are usually asymptomatic and may occasionally cause itching or pain. Genital warts are usually located on the frenulum, glans penis, inner surface of foreskin, and coronal sulcus. At the onset of the disease, penile warts usually appear as small, discrete, soft, smooth, pearly, dome-shaped papules.Lesions may occur singly or in groups (grouping). They can be pedunculated or broad (sessile). Over time, papules can coalesce into plaques. Warts may be filiform, exophytic, papillary, verrucous, hyperkeratotic, brain-like, fungal, or cauliflower-like. The color may be flesh-toned, pink, erythematous, brown, purple, or hyperpigmented.
diagnosis
Clinical diagnosis is usually made based on history and examination. Dermoscopy and in vivo confocal microscopy can help improve diagnostic accuracy. Morphologically, warts come in a variety of shapes, ranging from finger-like to pineal-shaped to mosaic-like. Among the vascularized features, glomeruli, hairpins, and punctate vessels can be found. Papillomatosis is an important characteristic of warts. Some authors recommend the use of an acetic acid test (the surface of the wart becomes white when acetic acid is used) to facilitate the diagnosis of penile warts.The test has high sensitivity for hyperplastic penile warts but less sensitivity for other types of penile warts and areas of subclinical infection. Skin biopsy is rarely necessary but should be considered in the presence of atypical features (eg, atypical pigmentation, induration, attachment to underlying structures, firmness, ulceration, or bleeding), diagnostic uncertainty, or refractory wartsSkin biopsy. Various treatments. Although some authors have suggested that PCR diagnostics can determine HPV type and thus the risk of malignancy, HPV typing is not recommended in routine practice.
Differential diagnosis
Differential diagnosis includes pearly penile papules, Fordyce granules, short cords, syphilitic condyloma plana, molluscum contagiosum, annular granuloma, lichen planus, lichen planus, seborrheic keratosis, epidermal nevus, capillary lymphatic varicostumors, lymphogranuloma venereum, scabies, syringoma, post-traumatic neuroma, schwannoma, Bowenoid papulosis, and squamous cell carcinoma.Pearly penile papulesIt presents as asymptomatic, small, smooth, soft, light yellow, pearl white or flesh-colored, conical or dome-shaped papules with a diameter of 1 to 4 mm. The lesions are usually uniform in size, shape, and symmetrical in distribution. Usually, the papules are located around the crown and groove of the glans penis in single, double or multiple rows and in a circle shape. Papules tend to be more noticeable on the back of the crown and less noticeable on the frenulum. Fordyce granules- These are enlarged sebaceous glands. Fordyce granules appear as asymptomatic, solitary or clustered, discrete, creamy-yellow, smooth papules 1 to 2 mm in diameter on the glans and penile shaft. These papules are more noticeable on the penile shaft during erection or when the foreskin is pulled. Sometimes a dense chalky or cheese-like material can be extruded from these pellets.BrachylophosaurusSkin tags, also known as skin tags ("skin tags"), are soft, flesh-colored to dark brown, pedunculated or broad-based skin growths with a smooth outline. Sometimes they may be hyperkeratotic or have a verrucous appearance. Most brachysaurs were between 2 and 5 millimeters in diameter, but sometimes were larger, especially in the groin. Brachynecks can appear almost anywhere on the body, but are most commonly found on the neck and intertriginous areas. When they appear in the penile area, they can mimic penile warts.Flat genital warts- These are skin lesions of secondary syphilis caused by Treponema pallidum. Clinically, flat condyloma appear as moist, gray-white, soft, flat or cauliflower-shaped, broad papules or plaques. They tend to develop in the warm, moist areas of the genitals and perineum. Secondary syphilis is characterized by a non-pruritic, diffuse, symmetric maculopapular rash on the trunk, palms, and soles. Systemic manifestations include headache, fatigue, pharyngitis, myalgia, and arthralgia. There may be erythema or a white rash on the oral mucosa, as well as hair loss and generalized lymphadenopathy.annular granulomaIt is a benign, self-limiting inflammatory disease of the dermis and subcutaneous tissue. The pathological characteristics are asymptomatic, hard, brown-purple, erythematous or flesh-colored papules, usually arranged in a ring. As the disease progresses, central involution may occur. A ring of papules usually grows together to form an annular plaque. Granulomas are usually located on the extensor surfaces of the distal extremities but may also be detected on the penile shaft and glans.skin lichen planusIt is a chronic inflammatory skin disease that manifests as flat, polygonal, purple, itchy papules and plaques. Most commonly, the rash appears on the flexor surfaces of the hands, back, trunk, legs, ankles, and glans. About 25% of lesions occur on the genitals.epidermal nevusIt is a hamartoma derived from the embryonic ectoderm that differentiates into keratinocytes, apocrine glands, eccrine glands, hair follicles, and sebaceous glands. The typical lesion is a solitary, asymptomatic, well-circumscribed plaque that follows Blaschko's lines. The disease usually occurs in the first year of life. Color varies from flesh-colored to yellow and brown. Over time, the lesions may thicken and become wart-like.Varicose lymphangiomas are benign cystic dilations of the skin and subcutaneous lymph nodes. This condition is characterized by clusters of blisters that resemble frog spawning. The color depends on the contents: white, yellow, or light brown is due to the color of the lymph, while red or blue is due to the presence of red blood cells in the lymph due to hemorrhage. The blisters may change and take on a wart-like appearance. Most commonly seen on the extremities and less commonly in the genital area.lymphogranuloma venereumIt is a sexually transmitted disease caused by Chlamydia trachomatis. The disease is characterized by transient, painless genital papules and, less commonly, erosions, ulcers, or pustules, followed by enlargement of the inguinal and/or femoral lymph nodes (called inguinal lymphadenitis).usually,Syringomaare asymptomatic, small, soft or dense, flesh-colored or brown papules, 1 - 3 mm in diameter. They usually appear in the periorbital area and cheeks. However, syringomas can appear on the penis and buttocks. When syringomas are located on the penis, they may be mistaken for penile warts.Schwannoma- These are tumors derived from Schwann cells. Penile schwannoma usually presents as a single, asymptomatic, slowly growing nodule on the dorsal aspect of the penile shaft.Bowenoid papulosisIt is a precancerous focal intraepidermal dysplasia that usually manifests as multiple reddish-brown papules or plaques in the anogenital area, especially the penis. Pathology was consistent with squamous cell carcinoma in situ. Progression to invasive squamous cell carcinoma occurs in 2% to 3% of cases. usually,squamous cell carcinomaThe penis appears as nodules, ulcers, or erythematous lesions. The rash may appear as warts, white spots, or hardening. The most popular site is the glans, followed by the foreskin and penile shaft.
complication
Penile warts may cause significant worry or distress to patients and their sexual partners due to their appearance and contagiousness, stigma, concerns about future fertility and cancer risk, and association with other sexually transmitted diseases. It is estimated that 20-34% of affected patients have an underlying sexually transmitted disease. Patients often experience guilt, shame, low self-esteem, and fear. Compared with healthy people, people with penile warts have higher rates of sexual dysfunction, depression, and anxiety. This condition can have a negative psychosocial impact on patients and negatively impact their quality of life. Large exophytic lesions may bleed, cause urethral obstruction, and interfere with sexual intercourse. Malignant transformation is rare except in immunocompromised individuals. People with penile warts are at increased risk for anogenital, head, and neck cancers due to co-infection with high-risk HPV.
forecast
If left untreated, genital warts may resolve on their own, stay the same, or increase in size and number. About one-third of penile warts resolve without treatment, and the average time to disappear is about nine months. With appropriate treatment, 35 to 100 percent of warts disappear within 3 to 16 weeks. Although the warts have resolved, the HPV infection may remain, causing recurrence. Recurrence rates within 6 months of treatment range from 25% to 67%. Among patients with subclinical infection, recurrent infection after sexual intercourse (reinfection) and immunodeficiency, the rate of recurrence is higher.
treat
Aggressive treatment of penile warts is preferable to subsequent treatments because it resolves the lesions more quickly, reduces fear of an infected partner, relieves emotional stress, improves appearance, reduces the social stigma associated with penile lesions, and relieves symptoms (e. g. , itching, pain or bleeding). Penile warts that persist for more than 2 years are less likely to go away on their own, so they should be treated aggressively first. Sexual partner counseling is mandatory. Screening for sexually transmitted diseases is also recommended.Active treatment can be divided into mechanical treatment, chemical treatment, immunomodulatory treatment and antiviral treatment. Detailed comparisons between different treatments are rare. Results vary depending on the treatment. To date, no one treatment has been proven to be consistently superior to the others. The choice of treatment should depend on the physician's skill level, the patient's preference and tolerance of treatment, as well as the number of warts and severity of the disease. The relative effectiveness of the treatment, ease of administration, side effects, cost, and availability should also be considered. In general, self-administered treatments are considered less effective than self-administered treatments.The patient is treated at home (as prescribed by the doctor)
Clinically used treatments
Methods used clinically include podophyllin, liquid nitrogen cryotherapy, dichloroacetic acid or trichloroacetic acid, oral cimetidine, surgical resection, electrocautery, carbon dioxide laser treatment, etc.Liquid Podophyllin 25% is derived from podophyllotoxin, which acts by arresting mitosis and causing tissue necrosis. This medication is applied directly to penile warts once a week for 6 weeks (maximum 0. 5 ml per treatment). Podophyllin should be washed off 1 to 4 hours after treatment and should not be applied to areas of high skin moisture. The effective rate of wart removal is 62%. Because of reports of toxicity, including death, associated with the use of podophyllin resin, podophyllin, which has a better safety profile, is considered preferred.Liquid nitrogen is the treatment of choice for penile warts and can be sprayed directly 2mm around the wart using a spray bottle or cotton swab. Liquid nitrogen causes tissue damage and cell death by rapidly freezing to form ice crystals. The minimum temperature required to eliminate warts is -50°C, although some authors believe that -20°C is also effective.The effective rate of wart removal is 75%. Side effects include pain during treatment, erythema, scaling, blistering, erosion, ulceration, and pigmentation at the application site. A recent phase II parallel randomized trial of 16 Iranian men with genital warts showed that cryotherapy using Wartner's formula containing a mixture of 75% dimethyl ether and 25% propane was also effective. Further research is needed to confirm or refute this conclusion. It must be noted that cryotherapy using Wertner's composition is not as effective as cryotherapy using liquid nitrogen. Dichloroacetic acid and trichloroacetic acid may be used to treat micropenile warts because of their limited ability to penetrate the skin. Each of these acids works by coagulating proteins and then destroying cells and ultimately removing penile warts. A burning sensation may occur at the application site. Relapse occurs as frequently after using dichloroacetic acid or trichloroacetic acid as with other methods. These medications can be used up to three times per week. Effectiveness in removing warts ranges from 64% to 88%.Electrocoagulation, laser therapy, carbon dioxide laser, or surgical excision, which mechanically destroys warts, can be used if the warts are quite large or if the wart cluster is difficult to remove with conservative treatments. Mechanical treatments are the most effective, but their use increases the risk of scarring of the skin. Local anesthesia for non-occlusive lesions 20 minutes before surgery or mixed local anesthesia for occlusive lesions 1 hour before surgery should be considered to reduce discomfort and pain during surgery. General anesthesia can be used to surgically remove large lesions.
alternative treatment
Patients who do not respond to first-line therapy may respond to other therapies or combinations of therapies. Second-line treatments include topical, intralesional, or intravenous cidofovir, topical 5-fluorouracil, and topical ingenol mebutyrate.Antiviral therapy with cidofovir may be considered for immunocompromised patients with refractory warts. Cidofovir is an acyclic nucleoside phosphonate that competitively inhibits viral DNA polymerase, thereby preventing viral replication.Side effects of local (intralesional) cidofovir include irritation, erosion, post-inflammatory pigmentary changes, and superficial scarring at the application site. The major side effect of intravenous cidofovir is nephrotoxicity, which can be prevented with salt hydration and probenecid.
prevention
Genital warts can be prevented to some extent by delaying sexual activity and limiting the number of sexual partners. Latex condoms can reduce HPV transmission if used consistently and correctly. Sexual partners with anogenital warts should receive treatment.Getting the HPV vaccine before having sex can effectively prevent infection. This is because the vaccine does not provide protection against disease caused by HPV vaccine types that an individual acquired through previous sexual activity. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Medicine, and the International Human Papillomavirus Society recommends routine vaccination of girls and boys with the HPV vaccine.The target age for vaccination for girls and boys is 11-12 years. The vaccine can be given as early as age 9. Three doses of HPV vaccine should be given at month 0, months 1 to 2 (usually 2), and month 6. Men under 21 years of age and women under 26 years of age need catch-up vaccinations if they are not vaccinated at the target age. The vaccine is also recommended for gay or immunocompetent men under 26 years of age if they have not been vaccinated before. Vaccination reduces the likelihood of getting infected with HPV and subsequently developing penile warts and penile cancer. Vaccination of both men and women is more beneficial in reducing the risk of genital warts than men only, because men can contract HPV from their sexual partners. Due to the introduction of the HPV vaccine, the prevalence of anogenital warts decreased significantly between 2008 and 2014.
in conclusion
Penile warts are a sexually transmitted disease caused by HPV. This pathology can have a negative psychosocial impact on the patient and negatively affect his quality of life. Although approximately one-third of penile warts resolve without treatment, aggressive treatment is preferred to hasten resolution of the warts, reduce fear of infection, reduce emotional distress, improve appearance, reduce social stigma associated with penile lesions, andRelieve symptoms.Active treatments can be mechanical, chemical, immunomodulatory, and antiviral, and are often used in combination. So far, no one treatment has been proven to be better than the others. The choice of treatment should depend on the physician's proficiency with the method, the patient's preference and tolerance for treatment, as well as the number of warts and severity of the disease. The relative effectiveness, ease of use, side effects, cost, and availability of the treatment should also be considered. Getting the HPV vaccine before having sex can effectively prevent infection. The target age for vaccination is 11-12 years for both girls and boys.
