Dear Dr G,

I am a thirty-five-year-old man who has had a healthy sexual relationship with my wife for the last five years.

In reality, I am faced with a dark secret of my past that torments me regularly.

In my late twenties, I was curious about my sexuality and perhaps experimented a bit with my sexual orientation.

After confirming my true heterosexuality, I left that past dark secret behind me.

Unfortunately, I noticed a small flower-like growth arising from my anus recently and went to the doctors.

The doctor told me the growth was an anal wart, and I was shocked to find out it is related to the Human Papillomavirus (HPV), which is essentially a sexually transmitted infection (STI).

The doctor performed some cryotherapy treatment for the warts, which was successful for a while, but they recur regularly.

On the last occasion, the doctor decided to biopsy the wart.

Indeed, he found some precancerous cells he called AIN.

I am terrified and would like to put Dr G on the spot for the issues of my anal warts and the risk of cancer.

I thought HPV was a virus that only affects women. Why is it affecting my anus?

Is it true anal warts only affect men having sex with men? Can they be transmitted any other way?

Are the viruses oncogenic and always cause anal cancers?

What exactly is AIN and anal cancer?

Finally, I have heard about the vaccine. Do you think it is too late for me to have it?

Regards,

Aston

Almost 80 million Americans are infected with HPV, and about 14 million new cases are added each year. Around 1% of sexually active adults live with recurrent genital warts. Genital warts are an infection caused by the transmission of Human Papilloma Virus (HPV) during sexual contact.

Out of the 170 subtypes of HPV, more than 40 are spread through genital and anal contact, and HPV 6 and 11 are commonly linked to anal warts. HPV transmission occurs in both men and women, and the risk factors for cancer include an early age of sexual intercourse, multiple sexual partners, poor hygiene, and smoking.

Nearly all sexually active persons are infected by HPV at some point in their lives, making it the most common sexually transmitted infection globally. Ninety percent of affected individuals demonstrate no symptoms despite the infections, and the virus is thought to resolve spontaneously within two years.

HPV can persist, resulting in either warts or precancerous lesions. Low-risk HPV subtypes like HPV 6 and 11 can result in regular genital warts with low risks of cancer. On the other hand, oncogenic subtypes of the virus such as HPV 16 and 18 can typically affect the cervix, vulva, and vagina in women. The virus is also known to infect the oropharyngeal cavity and anus, risking oropharyngeal and anal cancers in both genders.

Anal warts appear as visible “flower-like” lesions in the anus. In many cases, normal skin tags can be mistakenly diagnosed as anal warts. Scraping the lesion for DNA analysis of the subtype of the virus is the most accurate way of diagnosis. Precancerous detection of AIN (Anal Intraepithelial Neoplasia) is typically associated with high-risk HPV subtypes.

Such precancerous lesions can be treated with minimally invasive modalities such as infrared photocoagulation and laser therapy. Regular follow-up and biopsies are required, as the progression of the lesions to anal cancer makes future treatments complicated.

About 8,300 people are diagnosed with anal cancers every year in the United States, representing about 0.5% of new cancers. Contrary to common belief, anal cancers do not just affect MSM (Men having Sex with Men). In fact, women are affected more often than men, with women above sixty having double the risk of such cancer.

The standard treatment of anal cancer may include radical surgery therapy and chemoradiation. The five-year survival rate of anal cancer in the United States is only 68%, due to late presentations. The most effective way to get protection against HPV is to get vaccinated.

Although the vaccine is supposed to be for both sexually naive boys and girls at the age of 13, protection is also demonstrable up to the age of 45. Other ways to diminish the transmission of HPV include reducing the number of sexual partners and avoiding sexual contact with a partner when the warts are present. HPV vaccines are also advocated for individuals diagnosed with anal warts to enhance immunity against HPV.

The French philosopher Albert Camus, who was the second youngest recipient of the Nobel Prize in Literature, once said: “Autumn is a second spring when every leaf is a flower.”

The existence of genital warts has been documented since ancient Greece, while causation by a virus was only determined in 1907. The curious nature of the transmission of HPV is that it is highly contagious with each sexual contact, but the manifestations may vary from being harmlessly dormant to precariously insidious.

When nearly all sexually active adults are infected with the HPV virus at some point in their sexual lives, it is indeed fair to assume “every visible leaf is a potential flower in the bum!”