Anal condylomas, also called condylomata acuminata, are warts transmitted by the human papillomavirus or HPV. Clinically, they are manifested by warts with a very characteristic coralliform appearance, as if they were small cauliflowers. These lesions can be single or they can grow and become multiple. They affect both men and women, especially in the genital area. The involvement can be external or internal. This is important, as we will see later, in terms of treatment. There are different serotypes. The serotypes are, if you understand me, like different breeds. Dogs, for example, you can have a German shepherd and a Pekingese, it’s the same animal, different breed. HPVs also have different breeds, and that is where low-risk and high-risk HPVs come in. Clinically they are manifested by itching, stinging, sometimes bleeding. If they are external, they are seen earlier. When they are internal, that is, they affect the unseen part of the rectum and anal canal, diagnosis is delayed and they are usually manifested by bleeding. The patient comes for consultation when he/she has internal bleeding and itching.
How are they spread?
This is a big discussion. They are mainly transmitted sexually, but sexual transmission is not the only way. They can also be spread through intimate objects, towels, in public bathrooms, saunas and swimming pools. We will see later that this is important because of the social connotation of HPV.
What is its treatment?
The first thing I want to say in this section is to send a message of reassurance. There are many black legends about condyloma, that if you are infected for life, that if it causes cancer, that if you never get rid of it, well this is not true. What is true is that sometimes the treatment is a little heavy, but patients who have condyloma must be clear that one can be cured of this, and it is also cured definitively.
Let’s begin. The treatment depends on the degree of involvement and the location of the lesions. It is not the same to have small, external lesions in a visible area as it is to have internal lesions. All internal lesions, i.e. in the anal canal and rectum, must be treated in the operating room and neither ointments nor ointments can be used. External lesions can. Let’s start with ointment treatments. The ointments are relatively caustic ointments, mainly ointments based on cycloracetic acid, ointments based on podophyllin resin, which is commercially known as Wartec, and ointments based on Imiquimod. Imiquimod is known as Aldara or Inmunocare. The ointment treatments for condyloma are all very caustic. I want to recommend patients to follow the instructions given to them by their doctor. People think that by putting more ointment they are going to be cured faster, this is absolutely false, this is a long-distance race, it is not a sprint. These are treatments that last approximately one month. Those patients who want to run more than they should, run the risk of generating important chemical burns. In short, you have to follow your doctor’s guidelines, small amounts for a long time.
We can also use liquid nitrogen, i.e. burn by cold, not heat. This is used when the warts are small, are external and are not many, because liquid nitrogen is a very effective treatment but unfortunately frankly annoying for the patient, especially in a genital area and is a very unselective treatment.
Finally, let’s talk about surgical treatment. Surgical treatment is for those internal lesions or when the involvement is very important. That is, massive in the entire perineal area. It is performed in the operating room, always under sedation. Nowadays anesthesia allows patients to be sedated briefly to perform the treatment without harming them. It can be performed with a diathermy scalpel, that is to say, with an electric scalpel, cauterizing the visible lesions or, preferably, and if the surgeon has one, the ideal is to use a CO2 laser. The CO2 laser cauterizes, photovaporizes the lesion, minimizing the thermal damage it causes.
What are the most common questions?
There are many questions that patients ask, that you enter in forums, that you visit, that you try to understand what is happening, what is affecting you. One of the first questions is, can I get condylomata again after treatment? The answer is yes. Viruses are the smallest living structure known and when we treat condylomas, whether external or internal, in the office or in the operating room, we only treat those lesions that are obvious to the naked eye, we cannot see where there might be a virus on the skin that has not yet developed a lesion. That is why it is very important to keep a schedule of check-ups. These are usually done every month or so, to see if new lesions appear and for your surgeon or doctor to decide whether to treat or apply an ointment or cream.
What is infected for life? The answer is no, absolutely not. Condyloma is an opportunistic virus, HPV. That is, it interacts transiently with us. It is not only cured by what your doctor gives you, whether it is an ointment or a surgical treatment, our immune system is also cured. In fact, there are spontaneous remissions. There are patients who, without the need for treatment, eliminate the warts, that is to say, they disappear. In fact, we all know or have had nephews and nieces or people in childhood who have had warts on their hands. Warts on the hands are also a type of HPV. And we all know that there are people who, by adolescence, stopped getting warts without needing to be treated. You are not infected for life, what remains in the blood is the antibody, the immunization against HPV, but the antigen, sooner or later, with treatment, becomes negative.
When can I consider myself cured? This is another thing that torments patients, especially with regard to relationships. When a patient has had visible lesions and has been treated, it is considered what, because medicine is statistical, that six months have to pass since the patient had the last lesion and has not developed a recurrence in this time. Medicine is statistical and there are always cases that are out of this statistic. For example, when it is said that a person can be considered cured after breast cancer after five years, we say this because most patients do not have any more after five years, but there is always a person who develops a satellite lesion after seven years. That is to say, in general terms, it can be considered that after six months a patient can maintain an absolutely normal life in sexual terms with his or her partner or with new partners. Of course he can become infected again if he does not take the necessary precautions, but the lesion or the HPV he had is considered cured.
Another of the questions that patients ask us, and which really frightens them, is: can it really cause anal cancer? The answer is yes, but let’s qualify it. As you know, HPV is closely related to cervical cancer, and generally people extrapolate the clinic and treatment of cervical cancer and condyloma follow-up to anal condylomas. In our specialty, in proctology, things are a little different. HPV can cause anal cancer exceptionally, i.e. very rarely. HPV interacts with the cells of the rectal mucosa and generates a phenomenon known as dysplasia. This dysplasia is an alteration in cell replication. When they divide, they divide, so to speak, disturbed by the presence of the virus. This disturbance, which is known as dysplasia, can be mild, moderate or severe. The next step is carcinoma. This journey, which is known as AIN 1-2-3, Anal Intraepithelial Neoplasia, takes some time, it does not jump from one day to the next and anal cancer appears. That is why patients who are correctly followed up, correctly checked, and for that we use a high-resolution rectoscope, which as we have mentioned is an absolutely painless test that is performed in the office, we can see and follow up once the patient has been treated for their condylomas and so the chances of developing, first a dysplasia and, in the worst case, an anal neoplasia, really remote, that is to say, I want to send a message of tranquility in that sense. It is very, very unlikely that a patient affected by condylomas, properly treated and followed up, will develop dysplasia or, in the worst case, anal neoplasia.
Conclusion
In conclusion, as we have said before, condylomas are a sexually transmitted disease, the most common in our country. It is not a serious disease, it is a heavy disease that conditions the patient for some time, but it is cured, and one does not remain infected for life. It is treated with a series of ointments and, when the lesions are internal, in the operating room, under sedation and if possible with a CO2 laser, which, as we have mentioned, minimizes thermal damage and allows the patient to return to work much sooner.