Genital warts are not one infection, and the type matters

A man in his late twenties has had three lesions cauterised. They came back. He has two questions and he asks them in this order: is this cancer, and who gave it to me. Both questions have answers, and neither answer is the one he is expecting.

Which virus, and which types#

Genital warts are caused by human papillomavirus, of which there are many types, and they do not all do the same thing.

The multinational HPV in Men study measured which ones turn up in warts. It followed 2,487 men aged 18 to 70, examining them and testing for the virus every six months, and found an incidence of genital warts of 2.35 cases per 1,000 person-years, highest in men aged 18 to 30 at 3.43. Among the men who developed new warts, the types detected were HPV 6 in 43.8 percent, HPV 11 in 10.7 percent and HPV 16 in 9.8 percent. The first two are low-risk types and account for the bulk of visible warts. The third is not: HPV 16 is the type most associated with cancer, and it turned up in about one wart in ten.

So the honest answer to the first question is neither yes nor no. A visible wart is, in the ordinary case, evidence of a low-risk type rather than an oncogenic one, which is why the wart itself is not a cancer and will not become one in the great majority of cases. But a wart does not exclude a high-risk type either, in the lesion or in skin that looks normal beside it, and that is why the assessment is not finished by looking. The public conversation about human papillomavirus is a cancer conversation, and a patient who has read it arrives frightened of the wrong thing and reassured about the wrong thing in turn.

The Korean numbers, and how fast they moved#

A population-level analysis of Health Insurance Review and Assessment Service data covering 2007 to 2018 set out what has happened here. The annual number of men diagnosed with anogenital warts rose from 32,709 to 114,734, a 3.5-fold increase. Prevalence rose 3.34 times, from 132.83 to 443.57 per 100,000.

The costs moved faster than the cases. Related medical expenditure rose roughly 9.76 times over the same twelve years, from about 2.8 million to about 27.2 million US dollars. A second analysis, of treatment method rather than diagnosis, covered 2010 to 2019 and found every modality rising. Surgical removal of anorectal warts rose by more than 250 percent across the decade, and men had surgery four times as often as women. The mean number of sessions was higher in men for both surgical and non-surgical treatment, and most of it happened in primary care institutions rather than hospitals. Where in the country it happened is not random either: a Bayesian spatial analysis of condyloma in Korea found regional clusters and identified the municipal characteristics that went with them.

Why it came back#

Every method of removing a wart removes the wart. None of them removes the infection from the surrounding skin, which looks normal and is not treated. When a lesion reappears six weeks later it is usually not a failure of the procedure and usually not a new exposure; it is virus that was already present in skin that had nothing visible on it.

This is the single most useful thing to say before the first treatment rather than after the third. A patient who has been told that clearance often takes several sessions experiences the second session as expected. A patient who has not been told experiences it as evidence that the treatment did not work, or that something has happened in the meantime that needs explaining to a partner.

The second question#

Who gave it to me is the question I am asked most and can answer least. The same cohort measured the gap between acquiring the virus and seeing anything. Median time from a newly detected infection to the appearance of a wart was 17.1 months. Even among the men whose new infection was HPV 6 or 11 alone — the fastest group — it was 6.2 months. A separate cohort of young men documented the same sequence, warts developing after an infection that had already been detected. Infection can also persist without producing any lesion at all. Between those facts, the appearance of a wart does not date the exposure and cannot be used to work out when or from whom it was acquired.

I say that plainly, because the alternative is a patient constructing a timeline out of nothing and acting on it. The honest statement is that the virus is extremely common, that the lesion tells you nothing about timing, and that the arithmetic people attempt in this situation does not work.

What is left is practical. The lesions are treatable. Recurrence is expected rather than alarming. The types involved are usually not the ones that cause cancer, and establishing that is a test rather than an inspection. And in a country where the diagnosis in men has more than trebled since 2007 and concentrates in men in their twenties, the vaccine conversation is not only a conversation about daughters.