5-aminolevulinic acid photodynamic therapy for condyloma acuminatum of urethral meatus.

Objectives: Condyloma acuminatum are the most common sexually transmitted diseases worldwide, and they are closely associated with human papillomavirus (HPV) infection. Urethral meatus is one of the places that warts occur. Many treatments for uretheral warts have limitations. In this study, we performed 5-aminolevulinic acid-photodynamic therapy (ALA-PDT) on patients and investigated the effectiveness of reducing HPV viral loads. Materials and Methods: In our study, 21 patients diagnosed with urethral condyloma acuminatum were included. After 4 h treatment of ALA, patients received PDT. Each patient received HPV test before every PDT cycle. The frequency of PDT was dependent on viral load changes. Results: All patients achieved complete clinical remission after the last session of ALA-PDT. There were significant differences in HPV viral loads between pretherapy and after one or three rounds of PDT treatment. Conclusions: ALA-PDT is a safe and effective method for treatment of condyloma acuminatum in urethra meatus. Dynamic monitoring of HPV viral loads can more objectively demonstrate the effectiveness and guide the treatment of PDT.

A rare cause of acute urinary retention in women: meatal condyloma accuminata, a case report.

Acute urinary retention in women is a rarely seen phenomenon due to pharmacological, neuromuscular, anatomical, functional and infectious causes. Human papillomaviruses causing condyloma acuminata is one of the rarely reported viral infectious cause of acute urinary retention in case reports. A 45-year-old woman with acute urinary retention was found to have a round solid lesion on external urethral meatus. Histopathological examination revealed as condyloma acuminata. Urethral condyloma can be treated by local excision as an effective method for early improvement of voiding function. Even if the genital condyloma can be locally excised, patients should be referred to the gynecologists for cervical cancer screening.

Urethral condylomas in men: experience in 123 patients without previous treatment.

The most common sexually transmitted infection (STI) is infection by human papillomavirus. There are more than 100 types of human papillomavirus, and over 30 of them involve the genital area. Urethral involvement is uncommon and usually limited to the distal 3 cm of the meatus. There are various treatments for urethral condylomas; as a rule, they are limited by a difficult approach, by recurrences, and by potential complications, the most significant of which is urethral stenosis. The purpose of the treatments is to remove the warts and induce lesion-free periods. Such treatments do not eliminate the infection nor do they prevent continued transmission of the virus. We retrospectively evaluated 123 patients diagnosed and treated for condylomas in the genital area at our Institution between April 2009 and April 2012. The patients' mean age was 28.7 years (range 19-51). Of the 123 patients included, 48 (39%) had a history of previous STIs, most frequently gonococcal urethritis. Three of them had a urethral malformation in the form of hypospadias, and another three reported a previous urologic manipulation (catheterisation). Meatal/urethral condylomas are rare, cryotherapy is simple, easy to apply, and has a very low risk of complications in patients with externally accessible warts.

Incidence of genital warts in adolescents and young adults in an integrated health care delivery system in the United States before human papillomavirus vaccine recommendations.

BACKGROUND: Information on genital wart incidence in adolescents and young adults before human papillomavirus (HPV) vaccination is important for understanding the impact of the vaccine on the epidemiology of this early outcome of HPV infection. METHODS: The study population included 11- to 29-year-old enrollees of Northern California Kaiser Permanente between July 1, 2000, and July 1, 2005, before the availability of the HPV vaccine. We identified genital warts with an algorithm combining genital wart-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes (078.10, 078.11, and 078.19) with physician-recorded anatomic locations. We calculated sex- and age-specific incidence rates of genital warts and described the specific anatomic location of presentation, as well as recurrences of genital warts. RESULTS: We identified 1,682 cases of genital warts among 181,264 individuals. The incidence rate was highest among women (6.3/1000 person-years) and men (2.9/1000 person-years) aged 20 to 24 years old. Among women (n = 96,792), 63.4% of the 1240 incident genital wart cases occurred on the vulva and 21.1% on the cervix. Among men (n = 84,472), 91.6% of the 442 incident genital wart cases did not have a specific anatomic location recorded. Most people with an incident genital wart diagnosis (87.2%) did not have a recurrence during the observation period. CONCLUSIONS: Our study found that the incidence of genital warts was highest among persons aged 20 to 24 years using a unique method to identify the location of the wart. Information on incidence of genital warts before vaccine use provides baseline data that can be used to measure HPV vaccine impact.

Intraurethral condylomata acuminata associated with genital piercings.

A 33-year-old man was referred to our institution with papillary masses at the urethral meatus and difficulty urinating. Genital examination showed two piercings on the frenulum, which were penetrating the external urethra. Endoscopic examination revealed papillary tumours over the entire circumference of the penile urethra and the piercing site. The tumours were resected transurethrally. Microscopic examination revealed condylomata acuminata. Human papillomavirus types 6 and 66 were detected in the lesions. Retrograde urethral viral infection is rare because of the protection provided by the mucosal immune system. Genital piercing may have facilitated spread of the human papillomavirus into the urethra.

A case study of human papillomavirus-associated bladder carcinoma developing after urethral condyloma acuminatum.

We report a 35-year-old man with bladder carcinoma developing 2 months after urethral condyloma acuminatum, with an 8-year history of persistent human papilloma virus-58 infection in the urinary tract. DNA was extracted from paraffin-embedded tissue specimens. Human papilloma virus-6 and -58 were detected in the condyloma, whereas human papilloma virus-58 was detected in the carcinoma. In situ hybridization analysis also demonstrated high-risk human papilloma virus-DNA signals in the condyloma and carcinoma tissues. Immunohistochemistry showed that p16-INK4a and mcm-7, surrogate markers of oncogenic human papilloma virus E7 protein, were weakly expressed in the condyloma tissue but were strongly expressed in the carcinoma tissues, suggesting that human papilloma virus-58 was present in the episomal state in the condyloma, whereas human papilloma virus-58 DNA was integrated into the host cells and its infection may have a role in the development of bladder carcinoma. Human papilloma virus-58 was continuously detected in the urethral brushing samples 8 years after treatment for urethral condyloma, and human papilloma virus-58 infection was still persistent in the urethra.

Human papillomavirus (HPV) infection in heterosexual South African men attending sexual health services: associations between HPV and HIV serostatus.

OBJECTIVES: To investigate the distribution of human papillomavirus (HPV) genotypes and determine the associations between HPV infection and HIV coinfection in sexually active heterosexual men with anogenital warts (GW), male urethral discharge or asymptomatic men. METHODS: Valid specimens for HPV genotyping were obtained from three patient groups consisting of 108 men with GW, 56 men with urethral discharge syndrome and 50 asymptomatic men attending for HIV voluntary counselling and testing. The Linear Array HPV Genotyping Test was used to determine the HPV genotype distribution among study participants. Sera were tested for HIV antibodies using two commercial rapid tests. RESULTS: The prevalence of anogenital HPV among study participants was 78% (166). HPV DNA was detected in 100% (108) of GW, 48% (27) of men with urethral discharge syndrome and 62% (31) of voluntary counselling and testing participants. HPV types 6, 11, 16 and 18 were prevalent as either single or combined infections in 81% (134) of all HPV-positive study participants. HPV types 6 and/or 11 were significantly higher among GW patients (p<0.001). After adjusting for patient groups, HIV seropositivity was significantly associated with multiple HPV infections (OR=3.98, 95% CI 1.58 to 10.03) but not with the presence of a foreskin (OR=0.67, 95% CI 0.32 to 1.40). CONCLUSIONS: Infections with HPV were prevalent among sexually active heterosexual men attending the men's sexual health clinic. Associations were observed between HIV coinfection and multiple HPV infections. Further population-based studies on the prevalence of HPV genotypes are required to determine if men should be included in any future national HPV vaccination programme in South Africa.

Intraurethral fluorouracil and lidocaine for intraurethral condyloma acuminata.

PURPOSE: A new and convenient means of administering fluorouracil and lidocaine for the treatment of intraurethral condyloma acuminata is discussed. SUMMARY: Condyloma acuminata are warts of the genital and perianal region caused by various types of human papillomavirus (HPV). Intraurethral condylomas are associated with complications such as urinary burning, frequency, urgency, urethral bleeding, obstruction, fistula formation, and dyspareunia. A 55-year-old white man had a chief complaint of profuse, but painless, hematuria when he urinated. Cystourethroscopy confirmed extensive intraurethral condylomatous lesions at the external urethral meatus. A biopsy revealed mild squamous dysplasia and cellular changes consistent with HPV infection. A treatment was prepared that included fluorouracil 250 mg combined with 0.18% lidocaine hydrochloride gel. This mixture was given intraurethrally once weekly, and the tip of the penis was clamped immediately after administration using an occlusive penile clamp. The clamp was retained for 10 minutes for the first treatment, 15 minutes for the second, and 20 minutes for the remainder of the treatments. Six treatments were given initially and were well tolerated, although the patient did report occasional pain while urinating and occasional drops of urine. After six weeks of rest, another cycle of six weekly treatments was given. Two weeks after the second course of treatment, one small condyloma was observed in the distal anterior urethra. The urethra was found to be unblocked after three months, and the six-month evaluation revealed no new growth and a clear urethra. CONCLUSION: Urethral instillation via urethral syringe of fluorouracil injection mixed with lidocaine gel reduced the size and number of a man's intraurethral condyloma acuminata, allowed cystourethroscopy, and eliminated hematuria. There was no new growth of condyloma acuminata after six months.

Recurrence of condylomata acuminata of the urethra after conventional and fluorescence-controlled Nd:YAG laser treatment.

OBJECTIVES: To report our experience with conventional and fluorescence-controlled neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapy of urethral condylomata. Urethral condylomata can sometimes only be reached by endoscopy and are in general very susceptible to recurrence. They must therefore be considered as a therapeutic problem that has not yet been resolved. METHODS: One hundred sixty-eight patients with urethral condylomata were treated with the Nd:YAG laser (93 men using conventional white-light endoscopy and 75 men using fluorescence control after topical application of 5-aminolevulinic acid). The relapse characteristics were investigated according to the location and extent of the urethral lesions and with regard to the different endoscopy techniques. RESULTS: Of all patients, 35.7% developed recurrences of urethral condylomata after laser therapy. These were mainly located on the meatus and in the distal urethra. Only 4.8% of patients had proximal condylomata, and this was only seen in people with distal urethral involvement. Extensive, complete, or semicircularly arranged condylomata developed recurrence and complications (eg, strictures) more frequently after laser therapy. Significantly fewer recurrences (21.3% versus 47.3%) were observed in fluorescence-controlled laser therapy in a retrospective comparison with laser therapy under conventional conditions with a corresponding extent of human papillomavirus lesions. CONCLUSIONS: Nd:YAG laser therapy enables a specific topical clearance of human papillomavirus lesions at different locations in the urethra. 5-Aminolevulinic acid-induced fluorescence diagnostics enhances the effectiveness of Nd:YAG laser therapy of human papillomavirus lesions. Urethral instrumentation of any kind leads to viral contamination of the proximal urethra.

Developmental factors of urethral human papillomavirus lesions: correlation with circumcision.

OBJECTIVE: To assess the relationship between circumcision and urethral human papillomavirus (HPV) lesions, and the influence of urethritis on the development of urethral HPV infections on inducing squamous metaplasia of the urethral epithelium. PATIENTS AND METHODS: The study included 210 heterosexual, HIV-negative men (median age 29 years) who all had female partners with genital HPV infection. The patients were divided into three groups according to clinical findings, i.e. 97 patients with no clinical HPV lesions on peniscopy and urethroscopy, 70 patients with balanopreputial lesions but no urethral lesions, and 43 patients with urethral HPV lesions, including 17 who had associated penile lesions. They all underwent meatopeniscopy for HPV screening, urethral biopsy for histological analysis, and bacterial cultures were taken. The results in each subgroup were compared between circumcised and uncircumcised men. RESULTS: There was no significant difference in the incidence of HPV infection (58% vs 42%, odds ratio, OR, 1.8; 95% confidence interval, CI, 0.98-3.62) between uncircumcised and circumcised men, but this relationship differed with the developmental site of HPV lesions (shaft-foreskin, P<0.02; urethra, not significant). There was also a significant difference in the prevalence of urethritis between uncircumcised and circumcised men (34.5% vs 19%, OR 2.35, 95% CI 1. 08-5.11), and between HPV-infected and uninfected men (41.5% vs 18%, OR 3.17, 95% CI 1.71-5.83). This positive relationship of the prevalence of urethritis for both factors (circumcision and HPV) depended on the type of organism (sexually transmitted disease, not significant; common organism, P<0.02). The frequency of urethritis was related to the site of HPV lesions; urethritis was present in 36% of the patients with preputial HPV lesions, compared with 51% of those with urethral HPV lesions. Chlamydia trachomatis was detected in 1% of the patients without and in 7% of those with HPV lesions. In 68% of the patients, histological analysis of the urethral mucosa showed a squamous metaplasia of the urethral epithelium associated with urethritis. CONCLUSIONS: Being uncircumcised did not seem to increase the risk of HPV urethral infection in young men. Genital bacterial infections and urethral HPV lesions appear to be linked. Urethritis can induce squamous metaplasia of the urethral epithelium, which appears to favour the colonization of the anterior urethra by HPVs.

Human papillomavirus identification and typing of both sexual partners.

OBJECTIVE: To investigate the efficacy of diagnostic methods for human papillomavirus (HPV) infection. STUDY DESIGN: The diagnostic methods were morphologic and immunohistochemical techniques and in situ hybridization. The first ones consisted of (1) a cytologic smear on the females, (2) cytologic examination of a urethral brushing on the males, (3) colposcopy on the females, and (4) histologic examination of the uterine cervix. RESULTS: A synchronous HPV infection was found in 50% of the sexual partners. HPV was detected also in 30% of cervical biopsies by immunohistochemistry. In situ hybridization was performed on both the cervical biopsies and urethral samples from the males. By this method the same subtype of the virus was observed in both sexes. The types of HPV were identified in 45% of 20 females and 80% of 20 males. Analytically, in men, 7 cases of HPV 6/11 types, 3 cases of 16/18, 5 cases of 31/33/35 and 1 case each of 16/18 and 31/33/35 were observed. In women, in 4 cases subtypes 6/11, in 2 cases types 16/18 and in 3 cases types 31/33/35 were identified. CONCLUSION: Male partners of women with HPV infection should be investigated in order to produce greater insight into HPV prevalence and the mechanisms of viral transmission.

Human papillomavirus DNA in urine specimens of men with condyloma acuminatum.

BACKGROUND AND OBJECTIVES: Because warts are often found in the male urethra, human papillomavirus (HPV) may well be present in urine of patients with urethral condylomata. GOAL: To detect HPV DNA in urine specimens of men with condylomata acuminata using polymerase chain reaction. STUDY DESIGN: Forty-seven urine specimens and 25 paraffin-embedded tissues of condylomata acuminata were obtained from men. Of the 47 urine specimens, 29 were from patients with urethral condylomata, 3 from patients with penile condylomata only, and 15 from control subjects without condylomata. Both L1 consensus primers and type-specific primers for-HPV 6, 11, 16, 18, and 33 were used. RESULTS: HPV DNA was detected in 22 of the 29 (76%) urine specimens from patients with urethral condylomata, in none of the 3 urine specimens from patients with penile condylomata, and in none of the 15 controls. Paraffin-embedded tissues of all 25 condylomas were positive for HPV DNA. The HPV types detected in urine were identical to those detected in urethral condylomas. CONCLUSIONS: HPV DNA is present in urine of patients with urethral condylomata. Urine may be used for noninvasive screening of asymptomatic HPV infections of the male genital tract. Detection of HPV DNA in urine may be useful for monitoring the response to treatment of urethral condylomata.

Treatment of subclinical intraurethral human papilloma virus infection with interferon alfa-2b.

OBJECTIVES: Anogenital human papilloma virus (HPV) infection represents a growing concern among physicians in the United States. An intraurethral reservoir of the virus has been suggested as a possible source for reinfection between sexual partners, and may contribute to the increase in the number of affected individuals. Treatment reports of intraurethral HPV infection with adequate follow-up have been lacking. Our goals in this study were to identify the patients with cytologic evidence of HPV intraurethral infection, and to attempt treatment with intraurethral instillations of interferon alfa-2b. METHODS: Eighty-nine men with anogenital lesions or known exposure to HPV underwent cytologic examination using a urethral swab after all visible disease was adequately treated. Sixteen patients with positive cytology results were treated with weekly instillations of 25 million U of interferon alfa-2b solution for 6 weeks. Urethral cytology was monitored at 2 and 6 weeks post-treatment, as well as every 3 months thereafter up to a year. Those who had a recurrence during the study were retreated with a 6-week course using 50 million U per instillation. Patients were monitored for possible side effects. RESULTS: Seventeen (19%) of 89 patients who entered the study had urethral cytology positive for HPV infection with no evidence of visible disease. Seven (41%) of these 17 patients did not show external (meatal or skin) manifestations of the disease. Fourteen of 16 (88%) men who underwent the therapy were followed for an average of 11.8 months. Nine of those 14 (64%) remained disease free throughout the follow-up. Of the 5 who had a recurrence, 3 were successfully retreated, with a mean of 7.2 months of disease-free follow-up after the second course. No adverse effects of the treatment were noted by blood testing, semen analysis, and patient report. CONCLUSIONS: The urethra is a significant HPV reservoir and should be investigated in patients exposed to the virus. Interferon is a potentially safe and effective treatment option for intraurethral HPV.