ESSM Newsletter # 37

10 ESSM Today Key from Kols: Human papillomavirus infection in males: The time is now! by Tommaso Cai Human papillomavirus (HPV) infection is one of the most common sexually transmitted condi- tions in both genders with important conse- quences on public health. Even if the role of HPV infection in female is well known and there is a common consensus about the link between HPV and female oncological and non-oncological disease, in males the role of HPV infection is not totally understood and taken into account. Men play a key role in the transmission of HPV to women, but little is known about the natural history of HPV infections in males. Moreover, in everyday clinical practice there are a lot of questions without answer: ■ What is the role of HPV infection in males? Is the man only a carrier? ■ How can perform a HPV infection diagnosis in men? What is the role of HPV-positive partner? ■ What we need to do in men who are partner of HPV-positive women? ■ What is the role of HPV vaccination in males? There is an urgent need for upgrading current knowledge among andrologists in terms of HPV prevention, diagnosis and treatment to resolve patients’ doubts. HPV infections in males: Not only a carrier! Data about HPV infection prevalence are not fully clear. The prevalence of HPV in males, in fact, ranges from 1.3 to 72.9 % in the general population. However, a first limitation is due to the fact that the majority of studies conducted so far have been performed on specific male populations, such as homosexuals, human im- munodeficiency virus (HIV)-infected or infertile men. Another bias is due to the fact that genital warts are considered the only HPV infection signs in males. In this sense, the spreading and diffu- sion of HPV non-condilomatas related infection in general population is high. Moreover, several reports demonstrated that HPV infection is often asymptomatic in males, highlighting the high risk of infection diffusion. There are several diseases related to HPV infection in males: ■ Oncological disease Penile, oral, neck and anal cancers Non-oncological disease ■ Genital warts ■ Infertility (in particular when co-infection with other sexually transmitted pathogens, such as Chlamydia trachomatis). The high risk of oncological disease develop- ment after HPV infection exposure is due also to the fact that HPV clearance in males is not fast. Recently, has been demonstrated a low prevalence of high-risk HPV infection clearance in non-vaccinated males, highlighting the need for considering the implementation of male vac- cination programmes, especially against high- risk HPV. The role of HPV vaccination in males will be discussed in deep in the next sections. Diagnosis of HPV infections in males: A real challenge! Even if the HPV infection diagnosis in females is standardised and commonly performed, in males a general consensus is lacking about this issue. The anamnestic evaluation with an accurate analysis of sexual behaviour and number of partners is very important. An accurate evalua- tion of penile, scrotum and perineal area is es- sential. Other instrumental procedures (such as cystoscopy or penoscopy) should be performed only in very selected cases. For research reasons, the use of urine samples for HPV DNA detection in asymptomatic men should be considered. A number of experts demonstrated that non-invasive urine sampling is an accurate method for screening genital HPV infections in both men and women. This aspect is crucial, since such a non-invasive procedure could improve patient compliance and adherence to an extended surveillance protocol. Moreover, the accuracy of the test used for the detection of HPV DNA by PCR in the urine is high, as reported by other authors (sensitivity about 98 % and specificity about 97 %). In everyday clinical practice an accurate exami- nation of genitals and perineum is enough. How- ever, to all men with genital warts the screen- ing for all the other sexual transmitted infection should be offered. Treatment of HPV infections in males: Vaccination program, I suppose! The aims of the HPV infection in males are: ■ eliminate the clinical manifestations of the infection (genital warts, etc.) ■ improve the HPV clearance ■ reduce the risk for new re-infection ■ reduce the HPV diffusion among males and females The local treatment of genital warts can be performed in line with the andrologist skill and armamentarium; from surgical approach to laser ablation. Several authors suggest to use penoscopy during ablation procedures in order to identify the not visible lesions too. However, the gold of the treatment should be the elimina- tion of the virus and the reduction of the new infection risk. In this sense, the role of vaccination in males is imperative. Prophylactic HPV vaccines have been developed to target the commonest high- and low-risk HPV genotypes. Currently available vaccines now in- clude bivalent (targets HPV 16/18), quadrivalent (targets HPV 16/18/6/11) and nonavalent (targets HPV 16/18/6/11/31/33/45/52/58) vaccines. dr. tommaso cai Department of Urology Santa Chiara Regional Hospital Trento, Italy ktommy@libero.it