Treatment of urethral condylomata acuminata or flat condylomata with interferon-alpha 2a

Topical medication as an initial therapeutic option for protruding and non-protruding condylomata acuminata of the distal urethra

Genital warts (also known as condylomata acuminata) caused by the human papillomavirus (HPV) represent one of the most common sexually transmitted infections. Although they are usually found in the outer genital region, a small proportion of men can present with (often unrecognised) intraurethral warts, generally limited to the distal urethra and urethral meatus. This poses a treatment challenge not adequately addressed by the current guidelines. Here, we present two cases of low-risk HPV-positive patients with protruding and non-protruding condylomata acuminata of the distal urethra, which were treated successfully by using two different topical regimens (ie, a combination of policresulen and imiquimod for one patient and 5-fluorouracil monotherapy for the other). Although this type of management results in lower rates of tissue destruction and complications and may be given preference as an initial therapeutic option, additional prospective comparative clinical studies are needed to elucidate its potential in similar cases.

The place of 5-aminolaevulinic acid-photodynamic therapy in the treatment landscape of urethral warts: A systematic review

BACKGROUND

Human papilloma virus (HPV) infection is the most common sexually transmitted disease worldwide and the main cause of genital warts. Clear recommendations for the management of urethral warts, which are often hard to detect and difficult to treat, are still lacking.

OBJECTIVE

To summarize all available data describing treatment modalities of urethral warts, compare their efficacy and side effects, and provide physicians a treatment strategy outline.

MATERIAL AND METHODS

Till June 2020, we conducted a systematic review of articles studying the different treatment modalities of urethral condylomas. A chi-square test was used to compare the recurrence rates between treatment modalities, the complete clearance rates at first follow-up and the rates of adverse events.

RESULTS

A total of 26 articles with 1730 patients were included in our review. 61 % of patients were deemed completely cured on the first follow-up while 21 % recurred. 5-aminolevulinic acid (ALA) mediated photodynamic therapy (PDT) was the most common treatment and yielded the lowest recurrence rate (7.5 %) followed by laser therapy (24 %) and topical therapy (31 %) (p < 0.01). ALA-PDT resulted in a higher rate of clearance on follow up (96 %) compared to laser therapy (69 %) and topical therapy (14 %) (p < 0.01). Adverse events were more frequent in the ALA-PDT group (69 %) compared to laser therapy (28 %) and topical treatment (30 %) (p < 0.01).

CONCLUSION

ALA-PDT appears to be the most effective treatment of urethral condylomas in term of clearance and recurrence rate, but with a higher risk of adverse events. Management should be tailored to the type of lesion found at presentation.

Treatment of intraurethral condylomata acuminata with surgery and cidofovir instillations in two immunocompromised patients and review of the literature

Condylomata acuminata (CA) or anogenital warts are benign proliferative lesions caused by low-risk human papillomaviruses (HPV). Treating CA can be very frustrating for patients and clinicians due to the high recurrence rates. Immunosuppression is associated with larger size of CA that are more frequently resistant to treatment. Surgical approaches tend to be poorly effective in the long-term because of high recurrence rates related to the persistence of HPV-infected cells. In our search to find an agent to treat intraurethral CA with minor or no side effects, we evaluated intraurethral cidofovir in two male patients, who were under immunosuppressing therapy due to organ transplantation and suffered from extensive urethral HPV lesions. Both patients underwent biopsy of the lesions and initial transurethral resection. In our first case, intraurethral cidofovir instillations were started after 2 months due to recurrence after surgical treatment. In our second case, intraurethral cidofovir was administered after surgery because of incomplete resection of extensive lesions. Because of persistent or rapidly recurrent lesions despite intraurethral cidofovir instillations, the first patient needed two additional surgical interventions while the second patient underwent one additional surgical intervention. After surgical intervention, both patients received again adjuvant cidofovir instillations without side effects. Over a period of 56 weeks, both patients received each a total of 28 instillations with cidofovir. Following 3.5 years (patient 1) of the last cidofovir instillation, no recurrences were observed in our first patient. Following 6 months of the last cidofovir instillation (patient 2), two very small recurrent lesions in the most distal part of the urethra were observed in our second patient for which he will receive a cycle of 6 cidofovir instillations in the near future. Intraurethral cidofovir is a safe, easy-to-use, well-tolerated and an effective adjuvant to surgery for extensive intraurethral CA in immunocompromised patients.

[Urethral condylomata acuminata]

Condyloma acuminata are the most frequent cause of infections in the anal genital area. They are caused by the human papilloma virus (HPV). Risk factors are early onset of sexual activity, multiple sexual partners, a history of sexually transmitted disease, and immunosuppression. The urethra is afflicted in only 20% of cases; of these, 80% of the warts are at the meatus and 20% in the proximal urethra. This article reports on two cases with condyloma acuminata affection of the total urethra. The current diagnostic, different treatment modalities, and prophylaxis are reviewed.

5-FU for genital warts in non-immunocompromised individuals

BACKGROUND

Genital warts are common and usually are harmless but can be painful and psychologically burdensome. Several local treatments can be used, including topical 5-Fluorouracil (5-FU).

OBJECTIVES

To determine the effectiveness and safety of 5-FU topical treatment for genital warts in nonimmunocompromised individuals.

SEARCH STRATEGY

Databases searched were Cochrane Central Register of Controlled Trials (The Cochrane Library 2009 Issue 3), MEDLINE (1966 to August 2009), EMBASE (until August 2009), LILACS (1982 to August 2009). The search had no language or publication restrictions.

SELECTION CRITERIA

The review included randomised controlled trials (RCTs) among women, men, or both sexes, aged 18 years and older, comparing: 5-FU versus placebo or no treatment; 5-FU in any dose versus other isolated treatment, topical or systemic; 5-FU in any dose associated with other treatment versus placebo; 5-FU in any dose associated with other treatment versus other isolated treatment, topical or systemic; 5-FU in any dose associated with other treatment versus other associated treatment, topical or systemic.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data from the original publications.

MAIN RESULTS

Six trials involving 988 patients (645 women and 343 men) and reporting eight comparisons were found. Two studies reported withdrawals and dropouts, but none mentioned analysis by intention to treat (ITT). 5-FU presented better results for cure than placebo or no treatment (relative risk (RR) 0.39, 95% confidence interval (CI) 0.23 to 0.67), meta-cresol-sulfonic acid (MCSA) (RR 2.11, 95% CI 0.83 to 5.37), Podophylin 2%, 4% or 25% (RR 1.26, 95% CI 0.86 to 1.82). There were no statistical differences for treatment failure for 5-FU versus CO2 Laser (RR 0.69, 95% CI 0.43 to 1.11) versus 5-FU + INFalpha-2a (low dose) (RR 1.02, 95% CI 0.87 to 1.119). Worse results were found for 5-FU versus 5-FU + INFalpha-2a (high dose) (RR 10.78, 95% CI 1.50 to 77.36), and 5-FU + CO2 Laser INFalpha-2a (high dose) (RR 7.97, 95% CI 2.87 to 22.13).

AUTHORS' CONCLUSIONS

The reviewed trials were highly variable in methods and quality, and the evidence provided by these studies was weak. Cure rates with several treatments were variable, and although 5-FU presents therapeutic results that are inferior to those seen with 5-FU + Inf alpha-2a (high dose) and 5-FU + CO2 Laser + Inf alpha-2a (high dose), the treatment should not be abandoned. Topical treatment with 5-FU has a therapeutic effect; however, the benefits and risks have not been determined clearly and further studies are needed.

MVA E2 recombinant vaccine in the treatment of human papillomavirus infection in men presenting intraurethral flat condyloma: a phase I/II study

BACKGROUND

Human papillomavirus (HPV) is the etiologic agent for warts and cervical cancer. In Mexico, the death rate from cervical cancer is extremely high, and statistical data show that since 1990 the number of deaths is increasing. Condylomas and cancer of the penis are the most common lesions presented in men; bladder and prostate cancer in men are also associated with the presence of HPV. Since HPV is transmitted by sexual intercourse, treating both partners is necessary in order to eliminate the virus in the population. Approaches to this include preventative vaccines such as Gardasil, and therapeutic vaccines to treat established infections in both men and women. This will be the only way to decrease the numbers of deaths due to this malignancy.

PATIENTS AND METHODS

We conducted a phase I/II clinical trial to evaluate the potential use of the recombinant vaccinia viral vaccine MVA E2 (composed of modified vaccinia virus Ankara [MVA] expressing the E2 gene of bovine papillomavirus) to treat flat condyloma lesions associated with oncogenic HPV in men. Fifty male patients with flat condyloma lesions were treated with either MVA E2 therapeutic vaccine or fluorouracil (5-fluorouracil). Thirty men received the therapeutic vaccine, at a total of 10(6) virus particles per dose, administered directly into the urethra once every week over a 4-week period. Twenty control patients were treated with 5% fluorouracil 1mL twice weekly over a 4-week period directly into the urethra. Reduction of lesions or absence of papillomavirus infection was monitored by colposcopy and histologic analysis. The immune response after MVA E2 treatment was determined by measuring the antibodies against the MVA E2 virus and by analyzing the lymphocyte cytotoxic activity against cancer cells bearing oncogenic papillomavirus. Presence of papillomavirus was determined by the Hybrid Capture method.

RESULTS

Twenty-eight of 30 patients showed no lesion or presence of papillomavirus as diagnosed by colposcopy and brush histologic examination after 4 weeks of MVA E2 treatment. These patients showed complete elimination of flat condyloma in the urethra and no acetowhite spots were detected over the prepuce. In two other patients the acetowhite spots and flat condyloma did not diminish. All patients developed antibodies against the MVA E2 vaccine and E2 protein, and generated a specific cytotoxic response against papilloma-transformed cells. Viral DNA was not detected in MVA E2-treated patients. In the control group, 13 of 20 patients were free of lesions. Three of these patients had recurrence of lesions after 3 months of treatment and none of the patients developed specific antibodies against cancer cells. In contrast, patients treated with MVA E2 did not show any recurrence of lesions after 1 year of treatment. In addition, none of the patients had local or systemic adverse effects according to the WHO classification 1-4.

CONCLUSIONS

Therapeutic vaccination with MVA E2 proved to be very effective in stimulating the immune system against papillomavirus, and in generating regression of flat condyloma lesions in men.

Therapy of external anogenital warts and molluscum contagiosum: a literature review

Anogenital warts and mollusca contagiosum are virally induced, benign skin tumors for which there is no single preferable therapy. Treatments include physical and chemical destruction, surgical removal, and biological response modifiers to enhance the natural immune response. The choice of therapy is an art, and depends upon patient preference, finances, number of lesions, and lesional morphology. However, the therapy of these lesions can sometimes be very painful and expensive, and therapy should not be worse than the disease.