Human papillomavirus. Subclinical and atypical manifestations

Human Papillomavirus Infection and the Risk of Erectile Dysfunction: A Nationwide Population-Based Matched Cohort Study

Background: Male patients with genital warts are known for higher rates of sexual dysfunction. This study was conducted to investigate whether human papillomaviruses (HPV) infection is associated with an increased risk of erectile dysfunction (ED). Methods: Patients aged over 18 with HPV infection (n = 13,296) and propensity score-matched controls (n = 53,184) were recruited from the Longitudinal Health Insurance Database (LHID). The primary endpoint was the diagnosis of ED. Chi-square tests were used to analyze the distribution of demographic characteristics. The Cox proportional hazards regression was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the development of ED in both groups, after adjusting for sex, age, relevant comorbidities, co-medication, and surgery. Results: ED developed in 181 patients of the study group. The incidence density of ED was 2.53 per 1000 person-years for the HPV group and 1.51 per 1000 person-years for the non-HPV group, with an adjusted HR (95% CI) of 1.63 (1.37–1.94). In stratification analysis, adjusted HR of diabetes-, chronic obstructive pulmonary disease (COPD-), and stroke-subgroup were 2.39, 2.51, and 4.82, with significant p values for interaction, respectively. Sensitivity analysis yields consistent findings. Conclusions: The patients with HPV infection had a higher risk of subsequent ED in comparison to the non-HPV controls. The mechanism behind such association and its possible role in ED prevention deserves further study in the future.

Asian guidelines for condyloma acuminatum

The present guidelines aim to provide comprehensive information on genital condyloma acuminata, including the epidemiology, clinical features, diagnosis and management. The guidelines provide evidence-based recommendations on the diagnosis, prevention and treatment of genital condyloma acuminata in adults in Asia, including patients with HIV co-infection.

METHODOLOGY

A PubMed search was performed, using the keywords "condyloma acuminata", "anal wart", "anogenital wart", "genital wart" and "genital HPV". A total of 3031 results were found in publications during last six years. A careful review of the titles and abstracts was done to find all the studies pertaining to epidemiology, clinical features, diagnosis, treatment and prevention of condyloma acuminata.

DIAGNOSIS

Various diagnostic procedures described are: 1. PCR (LE: 2b). 2. Serology (LE: 2b). 3. In-situ hybridization (LE: 3).

PREVENTION

1. Vaccination (LE: 1a): Quadrivalent vaccine reduced the frequency of anogenital warts in both vaccinated and unvaccinated contacts. According to the update Advisory Committee on Immunization Practices (ACIP) recommendations, the following protocol is recommended: (a). HPV vaccination at age 11 or 12 years for both males and females. (b). Catch-up vaccination for all persons through age 26 years. (c). Shared clinical decision-making regarding potential HPV vaccination for persons aged 27-45 years, who are at risk of new HPV infection. 2. Male circumcision (LE: 2a): conflicting evidence.

HIV AND CONDYLOMA ACUMINATA

In HIV-affected individuals, the course of HPV is more aggressive, with a greater risk of treatment resistance, increased chances of intraepithelial neoplasia as well as cancers.

TREATMENT

Physician administered. 1. Photodynamic therapy (LE: 1a). 2. Laser (LE: 2b). 3. Surgery (LE: 1a). 4. Electrosurgery (LE: 2c). 5. Cryotherapy (LE: 1b). 6. Immunotherapy (LE: 1b). 7. Podophyllin (LE: 1b). Provider administered. 1. Imiquimod 5%(LE: 1a). 2. Podophyllotoxin (LE: 1b). 3. Sinecatechins (LE: 1a). 4. Cidofovir (LE: 3). 5. 5- Fluorouracil (LE: 1a). 6. Interferon (LE: 1a).

Efficacy and safety of combined high-dose interferon and red light therapy for the treatment of human papillomavirus and associated vaginitis and cervicitis: A prospective and randomized clinical study

BACKGROUND

We evaluated the efficacy and safety of combined high-dose interferon (IFN) and red light therapy for the treatment of subclinical and latent human papillomavirus (HPV) infections.

METHODS

Ninety women diagnosed with subclinical or latent HPV infection were randomized to receive topical application of low-dose recombinant IFNα-2b (1 million IU), high-dose IFNα-2b (9 million IU), or a combination of high-dose IFNα-2b and red light therapy on the cervix and vagina. All patients received treatment once daily for 4 weeks. HPV titer was measured immediately and 4, 8, and 12 weeks after treatment to determine the rates of viral clearance and infection cure. Treatment of HPV-associated vaginitis and cervicitis was also evaluated.

RESULTS

Results showed that immediately and 4, 8, and 12 weeks after treatment, the HPV clearance rates and infection cure rates were higher in the high-dose IFN and combination groups compared to the low-dose IFN group. High-dose IFN and combination therapies were significantly effective against both low-risk and high-risk HPV infections. Although the cure rates for vaginitis and cervicitis were significantly higher in the high- compared to the low-dose IFN group, rates were even higher in the combination group compared to the high-dose IFN group. Mild adverse effects were reported by a very small subset of patients (3/30) in the combination group.

CONCLUSIONS

This study suggests that combination of high-dose IFN and red light therapy is safe and effective against subclinical and latent HPV infections.

Prevalence of genital human papillomavirus infections established using different diagnostic techniques among males attending a urological clinic

OBJECTIVE

To compare the accuracy of different diagnostic methods and their use in estimating the prevalence of genital human papillomavirus (HPV) infections in males attending a urological clinic.

MATERIAL AND METHODS

The study population was derived from a series of 1,153 consecutive males attending a urological clinic in São Paulo between January 1996 and November 1998. Of these 1,153 males, 334 had clinically suspected genital HPV infection and comprised the study cohort. The diagnostic methods used included peniscopy, directed biopsy and HPV detection by means of the Hybrid Capture 2 (HC) assay for both oncogenic and non-oncogenic HPV types.

RESULTS

Peniscopy was performed for 297 males, positive results being reported in 237 cases (79.8%). Directed biopsy was performed in 188 males, and histology suggested HPV in 140 of these cases (74.5%). HC confirmed the presence of HPV in only 35.2% of the histologically HPV-suggestive cases. Peniscopy has good sensitivity for identifying male carriers of genital HPV. However, the technique has an inherent low specificity, limiting its usefulness to the correct identification of those who never present with HPV infection. Characteristic histological alterations are useful in suggesting HPV infection, but their correlation with HPV detection using HC is not particularly good.

CONCLUSIONS

These data suggest that both histology and peniscopy have low specificity in detecting male genital HPV. Accurate diagnosis of HPV infection can be confirmed by molecular detection methods only. Histology, however, plays an important role in the differential diagnosis. An appropriate diagnostic protocol for male genital HPV infections in a urological clinic should include peniscopy, histology and molecular diagnostic tools (HC or polymerase chain reaction).

Cervicovaginal coinfections with human papillomavirus and Chlamydia trachomatis

Human papillomavirus (HPV) and Chlamydia trachomatis (CT) are the two most common sexually transmitted pathogens, and infection with either reportedly was associated with cervical intraepithelial neoplasia (CIN) in women. In view of their similar mode of transmission, CT infection was examined as a possible HPV cofactor in the etiology of CIN disease. In total, 129 women were included in the study, of whom 80 were negative (mean age 34.17 +/- 6.9) and 49 were positive (mean age 33.16 +/- 6.8) for HPV DNA (assessed by PCR). CT DNA was determined in endocervical and first-catch urine specimens by PCR. Whereas HPV-positive and HPV-negative women were similar with respect to age (p = 0.419) and pregnancy outcomes (p = 0.628), the number of smokers (p = 0.001), women with multiple male sex partners (p = 0.002) or with abnormal cytology (p < 0.001) was higher in the HPV-positive group. There was an increase in CT infection rate in HPV-positive (29/49) as compared to HPV-negative (10/80) women (p < 0.01). Within HPV-positive patients, there was no significant difference between CT-positive and CT-negative patients with regards to the risk factors studied. Collectively, this suggests that CT infection is a cofactor of HPV in CIN disease development, possibly by modulating the host's immunity and/or precipitation of chronic inflammation.

Detection of human papillomavirus (HPV) genotypes in cervico-vaginal scrapes of women with normal and abnormal cytology

BACKGROUND

Certain types of human papillomavirus (HPV) are associated with cervical intraepithelial neoplasia (CIN) and invasive cervical carcinoma. The study addressed the expression and detection of HPV genotypes in cervical and vaginal specimens of women with normal and abnormal cytology by polymerase chain reaction (PCR), each woman serving as her own control.

METHODS

Study participants (127) were subgrouped into CIN-positive and CIN-negative, based on cytology screening, and endocervical and vaginal scrapes were collected by a gynecologist and placed immediately in saline. HPV DNA was assessed by PCR, and HPV genotypes were determined by hybridization of PCR products with type-specific biotinylated probes.

RESULTS

Of the 127 participants, 55 tested positive and 72 tested negative for HPV DNA. While there was no difference between the two groups with regards to age or to number of pregnancies, higher numbers of smokers and of women with multiple sexual partners and abnormal cytology were seen in the HPV-positive group (P < 0.001). HPV DNA was detected in the vaginal scrapes of all HPV-positive, but in none of the HPV-negative women (sensitivity and specificity = 1.0). Furthermore, the HPV genotype was the same in vaginal and endocervical specimens in all the HPV-positive women.

CONCLUSION

HPV detection by PCR, using endocervical or vaginal sampling, is a sensitive and highly specific test for the identification of HPV infection, in particular in women with cytomorphologically normal cervices.

Condylomata acuminata (genital warts): patient demographics and treating physicians

BACKGROUND

Condylomata acuminata (genital warts), caused by the human papillomavirus, are common and sexually transmitted. However, the use of healthcare services for condylomata has never been characterized from a national probability sample study.

GOAL

To understand better the demographics of patients seen by physicians for this disorder.

STUDY DESIGN

Data from office visits for warts, both condylomata and noncondylomatous types, were obtained from the 1994 to 1998 National Ambulatory Medical Care Survey.

RESULTS

The age distribution of those treated for condylomata peaked in 20- to 39-year-olds, with more than 70% of patients in this age category. A younger and wider age distribution was seen in patients with noncondylomatous warts. Women accounted for 67% of the population seen for condylomata, whereas a more equal number of women and men were seen for noncondylomatous warts. Per capita healthcare use for condylomata was equal between blacks and whites, and whites had almost five times more per capita healthcare use than blacks for noncondylomatous warts. Obstetrician/gynecologists were the most commonly consulted physicians for condylomata. Per capita condylomata visits per physician were highest for obstetrician/gynecologists, dermatologists, and urologists, and lower for all other physicians.

CONCLUSIONS

The difference in age distribution between condylomata and noncondylomatous visits likely results from differing modes of transmission and age at first sexual contact. Females are more likely than males to use health care for condylomata, which may be attributable to increased prevalence, differences in treatment efficacy, differences in the gender frequency of genital health screenings, or psychosocial causes. Healthcare use for condylomata appears equal between blacks and whites. Patients with condylomata acuminata were most often seen by obstetrician/gynecologists, whereas patients with noncondylomatous warts most often consulted dermatologists. The fact that per capita condylomata visits per physician were highest for obstetrician/gynecologists, dermatologists, and urologists may imply that specialists in these fields have expertise in treating these patients.

Molecular diagnosis of human papillomavirus: comparison between cervical and vaginal sampling

BACKGROUND

Human papillomavirus (HPV) is the most significant cause of cervical cancer. In view of the number of drawbacks associated with endocervical sampling, the gold standard for HPV detection, this study examined the utility and specificity of vaginal sampling as an alternative for endocervical sampling for the routine detection of HPV.

CASE STUDY

The study comprised 51 women who tested positive and 54 women who tested negative for endocervical HPV by polymerase chain reaction (PCR), confirmed by histopathology. At the time of specimen collection, both (speculum-assisted) endocervical and vaginal (no speculum) scrapings were isolated from HPV-positive and negative women, and HPV DNA was assessed by PCR using the MY09/MY11 primer system; HPV type was identified by hybridization of PCR products with type-specific biotinylated DNA probes. Each participant served as her own control. HPV was detected in vaginal and cervical scrapes from all HPV-positive but not HPV-negative women. In HPV-positive women the same HPV type was found in vaginal and endocervical scrapings (positive predictive value = 1.0).

CONCLUSION

Correlation between vaginal and endocervical sampling methods was excellent in detecting the presence of HPV DNA and for identifying distinct HPV genotypes. Utilization of vaginal testing for routine HPV detection, and for the long-term follow-up of persistent HPV infection, is therefore recommended.