Tiny bump

[improv]

Dear Dr. Handsfield,

Thank you so much in advance!  

I am a 38 year old male, and I first saw 2 very small warts on the shaft of my penis in March of 2007.  They were visually diagnosed as hpv in June 2007, and I got them removed on July 9, 2007.  I had no success with disclosure soon after that.  Unable to deal with further rejection, I decided to hunker down and wait 6 months.

In December 2007 a tiny bump grew on the base of my penis.  I went to the dermatologist and he said it was a wart and was about to cryo, but I said I wanted it biopsied.  He did – and it turned out it was karatosis.  So I was free, and after January 9, I started dating again.

In May of this year – 10 months after the first removal – I saw a really tiny bump that looked exactly the same as the one in December, in the same place. I was in Israel then and I had an American doctor there view it twice, and he said it was not hpv, to live my life and not to worry about it.  But it didn’t go away on its own, and so I had my old dermatologist check it near the end of June this year.  He viewed it as hpv.  I asked for a biopsy and he said it was condyloma and it was removed.

So a year later I feel I am back in the same boat.

1). Is it possible that there was a misdiagnosis for condyloma this June?  Is it possible that it was actually karatosis again, as it was in December?

2). If it was condyloma, do you suggest the 6 month disclosure idea again, or perhaps a shorter amount of time?

3). Are hpv 6 and 11 actually benign skin conditions, as they do not progress to cancer?  

4).  Does the fact the gw’s were tiny and would certainly not be noticed if I didn’t say anything have any impact on saying something to a future partner, in your opinion?  

5). I have seen two tiny whiteheads under my scrotum recently – does that sound like hpv too?

6). I date women generally over the age of 26 – can I confidently recommend they take gardasil?

[improv]

Dear Dr.,

I have been pondering what you wrote for a day or so.  I understand you feel there is some grey area and that is certainly not easy to deal with.  However, I wanted to ask about the excisional biopsy I had on the bump.  You wrote that there should be no chance of recurring and I should be cured.  Does that mean there is slim to no chance of transmitting it?  If I do decide to say I had something - which is what I've done in the past - how could I frame it?  "I had hpv in the past, like most people, but it is now gone and I am cured?"

Thank you

[Edward W Hook, MD]

Dr. Handsfield and I share the forum.  On this occasion you got me.  FYI, we have never disagreed on our answers to patients although our verbal styles do vary.  

You are asking some of the toughest questions we deal with.  As you know, HPV is the most common of all STDs.  Most people acquire HPV soon after starting to have sex and repeatedly acquire them from then on (there are over 100 types of HPV).  IN most persons the HPV is of no real consequence, resolving without therapy after 8-10 months in about 90% of persons.  The rest also typically ressolve although in a very small proportion of persons they can persist and progress to cause Pap smear abnormalities in women, or even cancer.  Complications of this sort (cancer) are far less common in men but do occur.  As far as prevention of HPV is concerned, the vaccine is a great step forward, preventing most genital warts (casued by types 6 and 11, both of which are in the vaccine) and many Pap smear abnormalities and cancers.  Condoms also work to prevent ALL types of HPV infection.  

So, what's a person to do regarding disclosure of this extraordinarily common STD to sex partners?   I wish I could say that there is no reason to disclose but the fact is that HPV is transmissable.  This is a fact.  An intermediate action is to use condoms.  Is this a rationalization, perhaps.  Bottom line, this is a choice you must make.  At the same time, I do not make non-disclosure a big deal, as I do for problems like gonorrhea, chlamydia, etc.  No on to your questions:

1.  There are lots of reasons for small bumps, etc to appear on the genitals.  While visual diagnosis can be wrong as much as 25% of the time, it is hard to argue with biopsy results.  
2.  See above.  In addition however, I would point out the with excisional biopsy the lesion is gone, thus there should be no chance of recurring.  If the biopsy was complete, you should be cured.
3.  HPV 6 and 11 cause virtually all warts and these rarely cause other complications.  They are however, as you know, an STD.
4.  This is a rhetorical question.  You know, thus you have to decide.  (same sort of thinking applies to what if all the lights are out and your partner couldn't inspect you)
5.  Warts do not have white centers.  What you describe sounds more like a benign cyst.
6.  I personally believe that the HPV vaccine is good for all sexually active women. The reason it is recommended for younger women and not those over 26 is because that is when most infections occur.  The vaccine however works fine in all women and in fact, the manufacturer is planning to apply for liscensure for older women.

I realize I have not given you straight forward questions to some of your questions.  These are questions you must answer for yourself.  I could not fault you for choosing to take other precautions and moving forward.  Disclosure however is the "high road".  Hope this helps.  EWH