Diagnosis: Condyloma Acuminata
The larger verrucous papules are genital warts, also known as condyloma acuminata. These are caused by the human papillomavirus (HPV) and are sexually transmitted. The patient most likely acquired these from his last unprotected sexual encounter, but he may have been infected earlier and the warts just became visible in the last 3 months. The differential diagnosis includes condyloma lata, the flat warts of secondary syphilis, but these are much less common.
The small pearly papules on the corona are not warts but a variation of the normal male anatomy, called pearly penile papules. The reason to recognize these papules is to reassure worried men that they are normal and to avoid performing any invasive treatments to remove them.
Laboratory Examination
All patients with any sexually transmitted disease should be tested for syphilis and HIV regardless of other risk factors.1 In this case, testing for syphilis with either a rapid plasma reagin (RPR) or VDRL will also be helpful to rule out condyloma lata.
These genital warts do not need to be biopsied to make the diagnosis. No data support the use of type-specific HPV nucleic acid tests in the routine diagnosis or management of visible genital warts.1
Treatment: Removal With Medication Or Surgery
The primary goal of treating visible genital warts is the removal of symptomatic warts.1 Treatment can induce wart-free periods. Available therapies for genital warts may reduce, but probably do not eradicate, infectivity.1 No evidence suggests any available treatment is superior to another, and no single treatment is ideal for all patients or all warts. The natural history of genital warts is benign, and the types of HPV that usually cause external genital warts (HPV 6 and 11) are not associated with cancer.
The Centers for Disease Control and Prevention (CDC) 2002 treatment guidelines1 for STDs recommend the following options. Cost data are given in the Table.
TABLE
Self-administered medications for HPV
| Medication | Method | Cost |
|---|---|---|
| Podofilox 0.5% solution or gel (podophyllotoxin) | Apply twice daily for 3 days, then off 4 days. May repeat cycle total of 4 times | Gel 0.5%, one 3.5-g tube:$164 Solution 0.5% one 3.5-g tube:$121* |
| Imiquimod 5% cream | Apply nightly 3 times per week. | 12 packets:$159* (enough for 4 weeks of therapy if 1 packet is used per application;using a packet for more than 1 day is possible) |
| Wash off after 6 to 10 hours. | ||
| May use up to 16 weeks. | ||
| * Prices from ePocrates,accessed on October 3,2004. | ||