Para - And Intraurethral Penile Tumor - Like Condilomatosis

Abstract

Condyloma acuminata represents an epidermal manifestation, associated with the epidermotropic human papillomavirus (HPV). They have been reported as the most common sexually transmitted disease, with prevalence exceeding 50%, increased up to 4 times, within the last two decades, as the most common side of affection are the penis, vulva, vagina, cervix, perineum, and perianal area, with increased prevalence in young, sexually active individuals. Increased attention should be focused on lesions, caused by types, with moderate (33, 35, 39, 40, 43, 45, 51-56, 58) or high risk potential (types 16, 18) for malignant transformation, leading to further development of cancers of anus, vagina, vulva and penis, as well as cancers of the head and neck. A provident of coexistence of many of these types in the same patient could be seen in approximately 10-15% of patients, as the lack of adequate information on the oncogenic potential of many other types complicated the treatment and the further outcome. Although the variety of treatment options, genital condylomata acuminata still show high recurrent rate to destructive topical regiments, because of the activation of the viruses at some point, which emphasise the importance of virus- eradication, instead only of the topical destruction of the lesions. Despite decreasing the recurrent rate, the most important goal of immunisation is the reduction of the incidence of HPV-associated squamous cell carcinomas using either the quadrivalent (Silgard/Gardasil) or the bivalent (Cervarix) HPV (human papillomavirus) vaccine. We present a patient with periurethral condylomata acuminate, who refused performing of a biopsy for determining the virus type, as we want to emphasize the importance of the virus - treatment in all cases of genital warts, instead only of topical destruction of the lesions, not only because of the recurrence incidence rate, but also because of the well - known oncogenic potential of some HPV - types, as well as the unknown potential of various underestimated types, in contrast.

Introduction

Condyloma acuminata represents an epidermal manifestation, associated with the epidermotropic human papillomavirus (HPV) [1]. HPV is most often acquired via sexual transmission in sexually active individuals, vertical transmission or extragenital contact in younger patients, rarely in children [2]. They have been reported as the most common sexually transmitted disease, with prevalence exceeding 50%, increased up to 4 times, within the last two decades [2]. The most common site affected are the penis, vulva, vagina, cervix, perineum, and perianal area, with increased prevalence in young, sexually active individuals [1,2]. Uncommon, but also reported sides of invasion are oropharynx, larynx, and trachea [2]. Up to 90% of the genital warts are related to HPV 6 and 11 types, with no neoplastic potential [2]. Increased attention should be focused on lesions, caused by types, with moderate (33, 35, 39, 40, 43, 45, 51-56, 58) or high risk potential (types 16, 18) for malignant transformation, leading to further development of cancers of anus, vagina, vulva and penis, as well as cancers of the head and neck [1][3]. A provident of coexistence of many of these types in the same patient could be seen in approximately 10-15% of patients, as the lack of adequate information on the oncogenic potential of many other types complicated the treatment and the further outcome [3].

Case Report

A 26-year-old Caucasian, otherwise healthy male patient presented with 6 - months history of papillomatous lesions, affecting his glans penis and orificium urethrae was reported. No accompanying diseases, neither medication was reported. Patient-reported brave heterosexual behaviour and promiscuity. The papillomatous lesion was observed within the clinical examination, located on gland penis, exclusively affecting the paraurethral area, measuring approximately 3 cm in diameter (Fig. 1).

Figure 1.

a, b Papillomatous lesion, located on gland penis, affecting orificium urethrae in a 26-year-old male patient

HPV - DNA testing with PCR for high-risk HPV viruses was not performed, because of the patient’s refusal for biopsy. Paraclinical examinations did not reveal any abnormalities. HIV, HBsAg, anti -HBC and TPHA test were negative. The diagnosis of condylomata acuminata was made.

Topical treatment with imiquimod 5% was initiated. Subsequent laser therapy with pulsed dye laser was planned for a total resolution of the symptoms if such was not achieved with topical treatment. A vaccination with anti - HPV vaccine was also planned for the later stage for prevention of further relapses.

Discussion

Conventional treatment options for condylomata acuminata vary between chemical (podophyllotoxin) and physical destruction methods, which are painful and less effective, with high recurrence rates [1]. Intraurethral fluorouracil and lidocaine instillation have also been reported with a variable degree of effectiveness [1]. The use of immunotherapies is preferred recently, including topical application of imiquimod 5% cream, cimetidine and intralesional or systemic interferon [4].

Laser therapy has also been applied with satisfactory therapeutic response in otherwise resistant or recurrent lesions [4]. Application of a Pulsed dye laser-therapy is reported as a safe, effective, satisfactory and less traumatic compared to other options for treatment of genital warts [4]. Ultrasonic surgical aspiration, electrocautery fulguration and cryosurgery have been also used successfully [1][4].

Although various treatment options, genital condylomata acuminata still show high recurrent rate to topical destructive treatment options, because of the activation of the viruses at some point, which emphasize the importance of virus- eradication, instead only of the topical destruction of the lesions [3]. Despite decreasing the recurrent rate, the most important goal of immunization is the reduction of the incidence of HPV-associated squamous cell carcinomas using either the quadrivalent (Silgard/Gardasil) or the bivalent (Cervarix) HPV (human papillomavirus) vaccine [3].

We present a patient with periurethral and intraurethral condylomata acuminate, which refused performing of a biopsy for determining the virus type, as we want to emphasize the important of the virus- treatment in all cases of genital warts, instead only of topical destruction of the lesions, not only because of the recurrence incidence, but also because of the well-known oncogenic potential of some HPV-types, but also the unknown potential of various underestimated types, in contrast.