Common summarized scenario at clinic (most present like this almost identically ) ; Patient A- a young late teens-early 20s storms in and looks at me not knowing where to start. ‘I have itchy , smelly velvety things growing on my privates and my mum shouldn’t know about this ; figure out what to write at the insurance forms because she will find out.’ It clicks to me immediately this is definitely HPV Genital Warts . I calm her down , take a detailed history and request to review then I’ll advise further . The are indeed warts . I take a further focused history including sexual partners , HIV history etc. You can imagine the shock on the early 20s girl when you tell her that you needed to screen for HIV among other tests first then we embark on a treatment plan . How do you lie about warts in the insurance forms ? Is it even legal ? You can call malaria a febrile illness but what do you ‘baptize’ warts now that the treatment is very particular, very expensive and longterm ? The cost of treatment cannot be handled by a student’s pocket money . How do you maneuver that the mother knows that the girl is innocent and working hard in school and possibly a virgin ? Mother is well connected and will get the insurance alerts in detail . You shock her further that when she gets to age 25, she needs timely cervical cancer screenings done. She looks at you bewildered - cancer ? She also wonders if she should avoid sex with her Brayo and for how long ? Could Brayo be responsible for this ? What if he is the shedder of the virus ?
2nd scenario ; Patient B- A young beautiful pregnant lady walks in . (This is hypothetical covering how most present and worry about). Let’s say 28year old , first pregnancy , freshly into a ‘come-we-stay’ arrangement . Storms in very angry because the fiancé refuses to take responsibility for the itchy velvety lesions in her private parts. She wants you to confirm that indeed this is from John and he needs to be called to come in for checks ; he must be cheating according to her. She also worries because she has googled that pregnant women with warts are not allowed to ‘push’ and caesarean section is recommended . She looks at you with teary eyes ‘see what John has done , imagine a C/S because he probably cheated.’ You calm her down and shock her that ‘there is a chance that this is not from John , could be a sub-clinical infection from way back ; maybe an ex-boyfriend , provoked by the changes of pregnancy ‘. She looks at you very shocked and wonders if you know John and have plans with him to protect him . You shock her further that even if it’s from John , there are no tests to test men for HPV , they are mostly carriers of the virus.
Genital Warts also known as CONDYLOMA ACUMINATA are non-cancerous lesions that can appear in the genital areas of both male and female but are more prevalent in the females who carry about 70% of the burden clinically . They are caused by the Human Papilloma Virus (HPV) variant 6 and 11 . Warts can appear in other parts of the body including inner thighs, anus and mouth and main mode of transmission is sexual ; with a high rise in homosexuality in Kenya, we expect to see more male clients . Transmission can also occur via contact to infected formites such as towels (Watu wa AirBnB are we together?). Heterosexual male rarely exhibit symptoms and are mainly silent carriers . Sadly there is no test to test men unless the few ones with lesions on penis, pubic region or anus etc .
So why college students ? These are young girls, late teens to early 20s. Potentially exposed to multiple strains of HPV by their potentially highly sexually active college boyfriends or by themselves being highly sexually active - or a frequent change in boyfriends with a higher turnover than your average busy working-class Mary. HPV spreads fast , almost like a family-tree with a potential build up on multiple variants in one individual - you sleep with Alex who has variant 6,11, 45, 31 then sleep with Joseph who got variant 16,18 ,33, 72 etc from Jane and you end up with total variants 6,11,45,31,16,18,33,72 and the build up continues . Some of these variants such as HPV 16,18, 31,33 are responsible for future cervical cancer in 10-15 years or less if the body doesn’t clear the virus . The more risky the sexual behavior is , the more risk of low immunity and HPV persistent in the body . But college students use condoms so why the high virus load ? Condoms are not 100% protective against HPV virus - this is a virus that is contagious through touch;skin-to-skin - the condom only covers the penis shaft upto 3/4 , what about the other penile skin and the testicles and inner thing ; any shedding virus in these areas will definitely transmit the virus to the female during the act of intercourse . Oral sex leads to susceptibility to oral warts . Persistence of HPV 6 and 11 leads to clinical manifestation of warts which are raised , velvety , lesions that can be itchy and that can grow very fast and become fungating(rotting away) especially in immunocompromised individuals . Any new HIV infection in an individual or non-adherence to ARVs compromises immunity leading to fresh symptoms and manifestation of warts . Take note that not all patients with warts have HIV (actually most of them are HIV negative) but being one of the opportunistic infections for HIV, HIV screening is mandatory at first contact with a doctor and 3 months later.
Why pregnant females ? In pregnancy , immunity goes down significantly due to pregnancy changes and there is increased blood supply especially in the pelvic and genital organs. These two factors increase activity of a dormant past asymptomatic HPV virus leading to symptoms . This dormant infection could have been ‘hiding’ for years; maybe from a prior exposure from a different partner . Due to increased blood flow and skin sensitivity in pregnancy , the warts become larger, very friable and itchy during pregnancy. What’s the rumor about C/S in women with warts? Well, in my earlier training as younger doctor , the practise was to take all mothers with warts for planned caesarean sections. This is to minimize HPV transmission to the baby which may cause symptoms to the newborns eyes - conjunctiva , mouth and genitalia . The riskier transmission is to baby’s respiratory system leading to respiratory pappilomatosis which are basically HPV lesions in the trachea and lungs ; this is however very rare 1 in 200 newborns in mothers with warts but can potentially be deadly . Some
Warts can be so large as to block the birth canal all together leading to bleeding and tears during birth . The current practice now is to try and manage the lesions as much as possible before delivery and give the mother the autonomy to consent for vaginal birth of the lesions are treated or significantly reduced but they must understand that infection to the baby can occur and can potentially be deadly .
How are warts treated ? For the larger ones , we aim for excision ( cutting the off ) using a few medical techniques e.g cautery ( use of heat), cold knife(usual surgical blade excision) or clinical procedures that break off the warts such as cryotherapy(freezing technique) and use of laser . This can be done the office or in theatre depending on how big the procedure is- I collaborate with the dermatologist for trickier small multiple lesions . Thereafter there is application of immune modifying creams that burn off small lesions and prevent recurrence. For smaller lesions we go straight for the creams without requiring excision .Such creams include Imiquimod(Aldara) which are applied on alternative days for weeks till a week after complete cessation of lesions. Cream for 3 days( a week’s dose) costs about 30 dollars - Kshs. 4000 ; per month totals to about 14000 to 15,000 shillings . The creams burn and can affect sorrounding skin and mucosa - advice is to apply some Vaseline on normal skin around the lesion then apply the aldara . These creams also interfere with integrity of condoms and make vagina mucosa so friable and sensitive so sexual contact should be avoided while on treatment . So I tell my girls to avoid Brayo till they are fully recovered and done with treatment; some worry that Brayo will leave - I ask them to choose their battles . There are other creams and treatment formulations such as podophyllotoxin which are not readily available in our Kenyan market. I once had a student who was on Aldara only and wondered how she was going to afford till around 12 weeks ; she couldn’t dare inform her parents about her struggle with warts .
One day , about 5 years ago , I participated in total removal of a patients pubic area(vulva) leaving only the urethra and clitoris because the lesions were very very big completely obliterating any normal skin - this is called a total simple vulvectomy - removing all labia and approximating skin from the edges .
In pregnancy , Aldara is very toxic to pregnancy . Some lesions clear on their own as immunity build up but for the larger ones , excision is recommended . Otherwise we mostly treat symptoms such as itchness , pain etc using lidocaine creams(numbing creams) , sit baths etc and hope that the body clears the infection or we cut off the lesions . Our hands are usually tied in pregnancy due to potential toxicity to pregnancy of the known treatments for warts . Lesions that block the birth canal or distort the vagina significantly risking a bleed lead to automatic caesarean section .
Sadly even after best treatment , warts can recur so long term follow-up is recommended . I always advise my patients to eat well , avoid stress and avoid risky sexual behavior to help in boosting immunity hence enhancing quicker recovery and reduction in recurrences. Is college academic stress , junky diet , social stress a contributing factor in us seeing these lesions more in college students ?
Recurrent lesions must always be biopsied for histology to rule out the rare incidence of concurrent cancer in these lesions .
We believe that once exposed to the HPV that causes warts could mean possible concurrent exposure to the HPV that causes cervical cancer. Generally in the population , all sexually actively women must be screened for cervical cancer lesions from age 25 every three years and annually if HIV positive . We only test high risk HPV variants at age 30 and above to give the body time to clear the exposure so that we only focus on persistent infection . THE RULE CANNOT BE IGNORED ESPECIALLY IN THOSE WHO HAVE HAD HPV WARTS hence more risk for possible multiple HPV types exposure . So dear Njeri, when was the last time you had a pap-smear or VIA for screening done ? (VIA is a cheaper screening modality that gives instant results and being embraced widely).
Warts are associated with a lot of stigma but let’s remember that most people have been at risk of the symptoms if we look back deep into our histories and that of our partners . Just because you never got caught doesn’t mean that you were never exposed to HPV 6 & 11; you are only lucky that your body cleared it before you could ever notice it . So don’t judge a sister with warts ✅.
One prevention modality is HPV vaccination of our children( both boys and girls but mostly girls) before they ever begin sexual life ; best age is age 9-14 or older if they are yet to be sexually active. This way we protect them against not only warts but also future cervical cancer. The vaccine is available for free in all government vaccination clinics ; the rule for 9-14 years is more of a budgetary policy issue but in essence all persons who have never been sexually exposed are eligible for the vaccine.
Let us also maintain faithfulness in our relationships and marriages . Please men kindly protect us ; you are carriers and spreaders and hardly ever face the wrath of the stigmatizing symptoms of HPV. Sadly there are not tests to test you . How unfair !!! Let us also vaccinate our boys to protect their future girlfriends and wives .
College girls , abstinence seems like an old fashioned boring terminology but it protects you against so much including HIV, cervical cancer , STIs, possible tubal infertility , unwarranted pregnancies etc . The boys have nothing much to lose . Let us also embrace and open up to our mothers, aunties , sisters, spiritual-mothers Gyanecologists etc for guidance and advice.
No comments:
Post a Comment