ESSM Newsletter # 37

10 / 20

10 ESSMToday
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