HPV & Anal Warts

Case Study:

“My partner and I have been together for 7 years and recently have mutually decided to open our relationship. This all stemmed from him not enjoying bottoming at all. Trust me – we’ve tried and it’s a definite no-go. However, he is super supportive of allowing me the versatile experience I so desire. We are both on PrEP and get routine checks every three months. Recently, I have met a group of guys that are so in tune with my needs and provide me with amazing and tantalizing experiences. I use protection on and off, I must admit, because the raw sensation just does it for me. I was at the gym the other day, feeling around while showering, when I noticed a few bumps that were not evident the weeks prior. When I got home, I was able to explore more thoroughly and found there were clusters in my anal region and looked like they were entering inside the actual hole. Naturally, I freaked out and ran over to my primary doctor for a professional opinion. These lesions wound up being anal warts, caused by the human papilloma virus (HPV). I was sent to Dr. Goldstein in NY for a complete evaluation, both inside and out, along with risk assessment and education. During the exam, Dr. Goldstein performed a full pap smear and HPV testing, along with both an external and internal exam. It was then determined that I needed to undergo a procedure using sedation and local anesthesia at a surgery center in Midtown to get rid of them. It was definitely not a pleasant post-operative experience, but it needed to be done and I am so happy Dr. Goldstein was the one doing it. I am finally back to bottoming and now have a new understanding of HPV as well. I made sure everyone in my group, along with my partner, got fully checked out. It was not a blame game, but more about making sure everyone had a clean slate moving forward. Dr. Goldstein also determined I did not have the high risk strains of HPV, so getting the vaccine – even though I am over the age of 26 – was beneficial and my partner got it as well. Now I get checked every 3 months for the first year to make sure nothing has returned. So far so good.”

What is HPV?

Human papillomavirus (HPV) is the most common sexually transmitted infection. The virus enters the body through a cut, abrasion, or small tear in the outer layer of your skin, and is transferred primarily by sexual intercourse and skin-to-skin contact. It can easily be transferred to others even if you are asymptomatic, although treatment and monitoring may help. It is the cause of nearly all anal cancers and their precursors HGSIL and LGSIL, however only a fraction of anal HPV infections develop into cancer.

What are the symptoms of HPV?

Symptoms may include warts on the anus, genitals, surrounding skin, and/or face. The warts may cause itching, bleeding, discharge, mucus production, lumps, pain, and/or constipation. Although many people with HPV do not develop symptoms, one can still infect others through sexual contact and/or develop anal dysplasia. For this reason, it is imperative to get tested annually and monitor accordingly.

How is HPV diagnosed?

Human Papilloma Virus is diagnosed via cytological testing (HPV sub-typing and anal pap smear), along with an exam known as an HRA (High Resolution Anoscopy). A plastic instrument called an anoscope is used to look at the anal canal with a special microscope called a colposcope.

The anal pap smear examines cells that constitute the outer layer of anal tissue, known as squamous cells, and determines the level of infection that you may have. Positive pap smears are classified into 3 diagnostic categories: ASCUS, LGSIL, and HGSIL.

  • ASCUS. Atypical Squamous Cells of Unknown Significance is a diagnosis in which cells were found that were not normal, but also not identifiable. This can be caused by dysplasia, but it can also be caused by inflammation or other factors like hemorrhoids and fissures.
  • LGSIL. Low Grade Squamous Intraepithilial Lesion, also known as mild dysplasia, is a diagnosis that can present with warts or lesions. It is not considered pre-cancerous, but can turn into HGSIL over time.
  • HGSIL. High Grade Squamous Intraepithilial Lesion is a diagnosis in which there is precancerous change to the skin of the anal canal or perianal area. This is not cancer, and only a small fraction of these diagnoses progress into cancer.


The HRA is the best technique for detecting precancerous lesions, anal cancer, and dysplasia (a pre-cancerous condition which occurs when the lining of the anal canal undergoes abnormal changes). If an abnormal area is seen, then a very small piece of anal tissue may be biopsied to check for signs of cancer or dysplasia. Biopsies positive for dysplasia are classified into Anal Intraepithelial Neoplasia (AIN) levels 1-3, with AIN3 considered carcinoma in-situ.

Utilizing a combination of cytological testing, HRA, and/or biopsy results allows for risk stratification and the development of a comprehensive treatment algorithm.

How can an HPV doctor help?

While there is no cure for HPV, the infection may clear on its own. If it does not, and treatment is needed, there are many options that an HPV doctor can help with. Treatment focuses on wart removal and anal cancer prevention. Warts can be approached with topical creams, acids, infrared coagulation, and/or electrocautery. The best course of action is dependent on the extent and location of the disease. Clients that present with only mild to moderate external disease may be given topical therapy such as Aldara for 8-16 weeks; if persisting or extensive disease is present, then an operation is warranted for eradication. If internal disease is present, it is generally treated by cauterization in an operating room under anesthetic sedation for maximized comfort. Recurrence rates can be as high as 30%, and since most recurrences are external we will prescribe topical treatment once surgery has healed.

Clients that show a positive anal pap smear result of either ASCUS or LGSIL without wart disease are usually monitored with follow-up retesting within 3-6 months after the initial consultation. If the result continues to remain abnormal, a complete HRA with mapping (a technique in which multiple pieces of tissue are biopsied in a clockwise fashion in order to pinpoint exactly where disease is present) is performed to look for any precancerous changes. Clients that have an HGSIL diagnosis or lesions present must be mapped and treated surgically.

Once mapping has been completed and the biopsies evaluated, treatment can be tailored to the region of disease. AIN 1 can be seen in HPV/warts, fissures, hemorrhoids, and other localized inflammatory issues. Most AIN 1 reverts to normal on its own, and should be continually monitored to check for signs of progression. AIN 2-3 is considered dysplastic and requires the use of cautery for eradication. Since this disease is contained to the superficial layer of the skin/mucosa, removal allows for new healthy cells to form.

After your initial diagnosis and/or treatment, Dr. Evan Goldstein, our HPV specialist, will continue to monitor the anal canal to check for signs of disease regression or progression. Our standard monitoring schedule begins with a follow-up visit after 1 month, followed by subsequent appointments 3, 6, & 12 months later. From then on, you will continue to be seen annually.

In terms of prevention, there is a vaccine called Gardasil that protects against the HPV strains that are most likely to cause genital warts and cancer, and is recommended for all patients under the age of 26. If you are 26 or over and HPV-negative for one or more of the strains that Gardasil protects against, it may be useful to receive the vaccine. For recurrent wart disease that has been difficult to control with treatment, obtaining the vaccine may prove beneficial due to it’s immune-boosting capabilities.

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Dr. Evan Goldstein, D.O.

Dr. Evan Goldstein, D.O.

Dr. Evan Goldstein is the founder and President of Bespoke Surgical, a surgical practice for modern males based in New York and Los Angeles. He received his medical doctorate from the University of Medicine and Dentistry School of Osteopathic Medicine in 2002. Receiving the highest osteopathic education was pivotal in shaping his holistic whole-life approach towards his practice of private surgical care.

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