Symptoms and Diagnosis of HPV

Human papillomavirus (HPV), the most common sexually transmitted virus, infects most sexually active people at least once during their lifetime, and it often causes repeated infections. The Centers for Disease Control and Prevention (CDC) estimates that nearly 14 million Americans become infected annually by the virus, many in their teens and 20s, usually right after a person becomes sexually active.

Scientists have identified more than 150 types of HPV, about 40 of which can infect the genital area, causing genital warts and certain cancers. While most HPVs do not cause cancer, others can cause cervical cancer and cancers of the anus, mouth, penis, throat, vagina and vulva.

How HPV spreads

HPV spreads when an infected person engages in anal, oral or vaginal sex with another person. During these sex acts, HPV can spread without penetration via skin-to-skin genital contact. It can spread even when the infected person has no signs or symptoms of infection.

Sex partners who have been together may both be infected with HPV, often making it impossible to know where the infection started. And it can get interesting because being infected with HPV does not suggest that a person had sex outside the relationship: Symptoms can develop years after having had sex with someone who was infected, even with only one lifetime sex partner. But limiting your number of sex partners does lower your risk for HPV.

Symptoms of HPV

Most HPV infections go undetected because the body's immune system responds to the infection before any visible signs appear. When the immune system cannot control the infection, however, warts may appear or cell changes may occur, which without treatment can become cancerous.

HPV-associated warts include four major types:

• Condylomata acuminate warts: skin-colored, pink or dark-colored with a cauliflower-like appearance
• Flat papule warts: skin-colored with a smooth or slightly raised surface
• Keratotic warts: thick, layered appearance, resembling common warts
• Smooth papule warts: skin-colored with a dome shape

These warts typically appear in areas where friction occurs during sex. For men, areas of friction include external areas such as the penis, the perineum, the scrotum and the perianal region. Men can also develop internal warts in the urethral meatus (urinary opening on the glans penis) or the anal mucosa (lining of the anus). For women, areas of friction include external areas such as the perianal area, the perineum, the vaginal opening and the vulva. Women can also develop internal warts on the anal mucosa, the cervix or the vagina. 

Intra-anal warts may develop after anal intercourse, while perianal warts can develop without anal penetration through other sexual activity or by spread from a nearby genital site.

Many people who have genital warts do not experience symptoms, which include:

• Vulvar warts: burning, itching and difficult or painful intercourse
• Vaginal warts: occasional bleeding, discharge or birth canal obstruction
• Penile warts: itching
• Urethral meatus warts: urinary stream impairment or hematuria (blood in the urine) 
• Perianal and intra-anal warts: pain, itching or bleeding with bowel movements

Diagnosing HPV

Currently, there is no approved test for HPV for men. Healthcare providers may presume that an individual has an HPV infection based on the appearance of external genital warts, but not all warts appear on external surfaces. HPV-associated warts can appear on the internal surfaces of the cervix and the vagina and may only be visible through inspection during a pelvic exam. Women can be tested for cervical cancer, which, according to the Mayo Clinic, actually tests for HPV, which causes cervical cancer.

The American Cancer Society recommends primary HPV testing or combined Pap and HPV testing every five years or a Pap test every three years for women between the ages of 25 and 65. During testing, the healthcare provider performs a pelvic exam using a plastic or metal device called a speculum to expand the vagina. This allows the doctor to inspect the vagina and the cervix and collect cells and mucus from the cervix for testing. This is called a Pap test or Pap smear. The Pap test examines cervical cells for changes that might become cancerous if left untreated, while the HPV test detects the virus that can lead to these cervical cell changes.

Routine screening for HPV or HPV-associated disease is not recommended for anal, penile, mouth and throat cancers, but some healthcare providers offer anal Pap testing to patients with risk factors for anal cancer.

Risks of untreated HPV

An HPV infection can become chronic, and if left untreated it can lead to precancerous lesions that can advance to invasive cervical cancer. Research shows that most cervical cancer can be linked to HPV infection. For those with a normal immune system, it commonly takes 15 to 20 years for cervical cancer to develop; for those with a weakened immune system, it can take five to 10 years. The early detection of precancerous cells by a Pap test is key to stopping the progression to cervical cancer.

Outlook

Although not a cure for HPV infection, the HPV vaccine (Gardasil 9) protects against infection from a variety of HPV types that cause genital warts and HPV-related cancers. CDC guidelines recommend HPV vaccination for males and females at age 11 or 12—it can be given as early as age 9—and for anyone through age 26 who has not already been vaccinated.

What happens if you are diagnosed with HPV?

According to the World Health Organization, most HPV infections resolve on their own without treatment. There is no cure for the virus, so if you develop warts and they do go away, they can reappear in the same region or in other regions. Your healthcare provider may recommend medications that can be repeatedly applied to the warts to eliminate them. If these medications are ineffective, your healthcare provider may suggest conventional or laser surgery, cryotherapy (freezing with liquid nitrogen) or electrocautery (burning with an electric current) to remove the warts.

You should avoid sexual activity until the warts go away or are removed, but keep in mind that even after the warts are gone, you can spread HPV to partners. Condoms can help protect against the spread of HPV if they are used properly, but they will not protect against HPV spread from areas that are not covered by a condom.

If you have an abnormal HPV or Pap test, your doctor may recommend you undergo a colposcopy. During the procedure, your doctor will closely examine the cervix with a magnifying tool and take samples of abnormal areas. Abnormal cells can be removed using a loop electrical excision procedure (removal using a heated wire loop), surgical removal, cryosurgery or a laser before they become cancerous.

HPV is common and widespread, but the HPV vaccine can prevent cancer-causing infections and improve outcomes in cancerous cases.