Volume 111, Issue s32

Human papillomavirus (HPV) infection has been thoroughly demonstrated as a major factor in the pathogenesis of cervical cancer, but HPV's role in penile cancer has not been demonstrated as convincingly. The author reviews several major investigations from the past 35 years and finds that men with certain risk factors (eg, intact foreskin, history of sexual encounters outside marriage, and history of first intercourse at a younger age) place their current female sex partners at greater risk for cervical carcinoma caused by transmission of HPV infection. A brief description of HPV prevention and treatment options is also provided.

The unkeratinized epithelium of the inner human foreskin is thought to be more susceptible to human papillomavirus (HPV) entry than the rest of the penis. However, studies exploring a potential association between male circumcision and HPV infection have produced conflicting results. The present review stratifies the evidence based on methods of sampling and detection of HPV infection, HPV type, and the stage of infection. This approach reveals that circumcision reduces the risk of HPV infection in a stage- and type-specific manner. There is no consistent association of HPV acquisition with circumcision status, indicating that circumcised men may be no more protected from initial HPV infection than their uncircumcised peers. Circumcision is not protective against nononcogenic types of HPV, but is associated with a reduced prevalence and persistence of oncogenic HPV infections. Circumcised men are also less susceptible to multiple infections. These findings indicate that circumcision modulates HPV persistence rather than acquisition. Through promoting HPV infection clearance, male circumcision could be an important adjunct to education, condom use, and vaccination in reducing the global burden of HPV morbidity and mortality.

Even though the incidence of anal cancer among men who have sex with men (MSM) is higher than the incidence of cervical cancer among women, few MSM are identified as high-risk patients in primary care or have received vaccination for human papillomavirus (HPV), the most common sexually transmitted infection worldwide, with 6.2 million new infections each year. The authors review the current literature on diagnosis and basic management of genital, oral, and anal HPV infection. Early diagnosis and treatment of patients with HPV infection is important because this infection causes patients substantial distress even in its benign manifestations. It has also been implicated in a host of cancers, including oral, cervical, penile, and anal cancers and is an independent risk factor for the development of human immunodeficiency virus infection. The incidence of HPV infection drops in women older than 30 years but remains high for MSM in all age ranges. For all of these reasons, physicians should routinely assess the sexual practices of all male patients, especially MSM, and educate them on the HPV infection risks, diagnosis, and treatment options. Physicians can have a significant impact in the primary prevention of HPV by routinely offering HPV vaccination to male patients younger than 26 years.

Despite the morbidity associated with anogenital condylomas and the mortality associated with anal, penile, and cervical carcinoma as a direct consequence of human papillomavirus (HPV), the US Centers for Disease Control and Prevention currently does not recommend routine screening for HPV in immuno competent men. However, findings of emerging research focusing on the high-risk populations of men who have sex with men and men who test positive for human immunodeficiency virus, in whom HPV infection is pervasive and persistent, suggest that these populations may benefit from screening. Therefore, HPV screening, including anal cytology, should be considered for these men in settings where appropriate follow-up, including high-resolution anoscopy, is available.

More than 100 types of human papillomavirus (HPV), of which more than 40 are transmitted sexually, affect men and women. The worldwide prevalence of cervical HPV infection is approximately 10%. The most common HPV types worldwide are 16 and 18, which are the main causative viruses for cervical cancer and are both preventable by vaccination. Two HPV vaccines are currently approved in the United States: the quadrivalent HPV recombinant vaccine in males and females and the bivalent HPV recombinant vaccine in females. The Advisory Committee on Immunization Practices does not recommend routine use of the quadrivalent vaccine in males. The vaccines have been demonstrated to be highly effective in preventing cervical dysplasia, vulvar cancer, and genital warts related to HPV types 6, 11, 16, and 18; they are most effective, however, in vaccinees who have never been infected with HPV. Based on a review of the literature, the authors argue that it may be appropriate to routinely vaccinate both males and females to prevent the spread of HPV types 6, 11, 16, and 18.

The association between human papillomavirus (HPV) and anal cancer and the similarities between the “transitional zones” within the cervix and anus have raised questions regarding the medical biology of anal cancer. In recent years, increased rates of HPV infection and anal cancer among men have encouraged the medical community to search for causes and ways to identify the less insidious precursor, anal intraepithelial neoplasia. The “alphabet soup” terminology describing anal cytologic findings obtained by Papanicolaou (Pap) tests and the anal histologic findings obtained from biopsy specimens need to be better understood as distinct entities. Risk factors for the development of anal cancer have been identified and should be discussed with patients—especially those infected with human immunodeficiency virus—who have a much higher than normal risk of anal cancer. The anal Pap test has been used by the Northwest Pennsylvania Rural AIDS Alliance to detect potential precursors to cancer and degrees of anal dyplasia in patients with HIV infection. The Alliance has been instrumental in creating guidelines for anal Pap testing and encouraging other medical professionals and clinics to do the same, and these guidelines are provided herein.