Genital Warts (HPV Infection) Causes, Symptoms, Treatment

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Genital Warts Eradication System Summary


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Results of the Pap Smear

About fifty million Pap tests are performed each year in the United States. With a laboratory screening test as effective and inexpensive as the Pap smear, it is hard to understand why not all women have Pap smears at regular intervals from one to three years. One of the most important aspects of the Pap test is that it detects not only cancer but also precancerous conditions. Thus, by alerting a woman and her physician to the need to continue close surveillance and to initiate appropriate treatment, this test can prevent cancer. It is one of the most successful screening devices in medical history. Unfortunately, it is not foolproof, and sometimes a Pap smear misses detecting a cervical cancer. The procedure for performing a Pap test is described in Chapter 2. Originally Pap smears were graded according to five classes designated by Roman numerals. Classes I and II meant benign cells, Class III indicated moderate or severe dysplasia, Class IV suggested carcinoma in situ (see below),...

HPV Infection and Malignant Transformation

Not all invasive SCC subtypes have the same association with HPV infection. In a recent review of 200 cases, Cubilla et al. reported a preferential association of basaloid and warty-basaloid SCC subtypes with HPV infection in approximately 80 of cases, while no HPV was detected in verrucous, mixed verrucous-papillary, pseudohyperplas-tic, and pseudoglandular SCCs.30 Lower rates of HPV DNA were detected in usual type (24 ), sarcomatoid (17 ), mixed (19 ), and papillary NOS (15 ) carcinomas. A significant association between HPV status and histological grade was also reported in this study, with 6 , 21 , and 53 of grade 1-3 tumors, being HPV positive, respectively (P < 0.0001).30 This is in keeping with previous studies showing HPV DNA associated with higher grade and more aggressive penile tumors,1 and would suggest a detrimental prognostic effect of HPV-positive status. This would seem logical given its increased association with a basaloid subtype. However, no other study has been...

Human Papillomavirus Vaccine

Although most human papillomavirus (HPV) infections spontaneously resolve, high-risk HPV types are found in 99 of cervical cancers with types 16 and 18, accounting for about 70 of cervical cancers worldwide. HPV is also believed to account for 90 of anal cancers 40 of vulvar, vaginal, or penile cancers and 12 of oral and pharyngeal cancers. Types 6 and 11 HPV account for 90 of genital warts and laryngeal papillomatosis. The bivalent HPV (types 16, 18) vaccine (Cervarix) and the quadrivalent HPV (types 6, 11, 16, 18) vaccine (Gardasil) are licensed for use in U.S. females age 10 to 25 and 9 to 26 years, respectively. Both are recommended for routine vaccination at age 11 or 12 years and are ideally given before onset of sexual intercourse. The bivalent HPV vaccine is given in a 3-dose series at time 0, 1, and 6 months and the quadrivalent HPV vaccine in a 3-dose series at time 0, 2, and 6 months, with the third dose following the first dose by at least 24 weeks (CDC Pink Book, 2009,...

Human Papillomavirus

Human papillomavirus (HPV) may cause symptomatic genital warts, although most patients do not manifest them. HPV types 6 and 11 cause most visible warts (CDC, 2006). Certain HPV types are associated with genital squamous neopla-sia. Patients with penile plaques suspicious for warts can be examined by placing an acetic acid solution on the plaque and looking for an acetowhite change. Untreated warts will regress, remain stable, or spread. Symptomatic relief is the main treatment goal. Treatment options include podofilox 0.5 , imiquimod (1 , 5 ), topical interferon, cryotherapy, office-based chemical treatments (acetic acid), or surgery (Buck, 2007 CDC, 2006,).

Squamous cell papilloma

This is not an uncommon lesion of the oral mucosa and may arise at virtually any site, but more commonly on palate, buccal mucosa or lips. It is a benign neoplasm of epithelial tissue and most squamous cell papillomata present as pedunculated (stalked attachment) lesions with characteristic white, hyperkeratinised, crenated surfaces, which can be likened to a cauliflower (Fig. 32.6). They are normally small, usually less than 0.5 cm in diameter. Treatment is simply excision at the base of the stalk Fig. 32.6 A squamous cell papilloma of the soft palate. Fig. 32.6 A squamous cell papilloma of the soft palate.

Differential Diagnosis Genital Wart Scrotum

Condylomata Acuminata Man

Sexually transmitted diseases are common. Of every 100 outpatient visits to a venereal disease clinic, 25 of men have gonorrhea, 25 have nongonococcal urethritis, 4 have venereal warts, 3.5 have herpes, 1.7 have syphilis, and 0.1 have chancroid. The incidence of both gonococcal and nongonococcal urethritis has increased dramatically since the early 1980s. On college campuses, 85 of urethritis is nongonococcal in origin. Condylomata acuminata (see Figs. 18-15, 18-21, and 18-40) Human papillomavirus (HPV) infection of the genital tract is one of the most common sexually transmitted diseases among young adults and is the cause of venereal warts. In the United States, it is estimated that 20 million people have genital HPV infections at any one time, with 5.5 million acquiring it annually. Risk factors associated with HPV infection include younger age, belonging to an ethnic minority, alcohol consumption, and a high frequency of anal or vaginal sexual encounters. The annual cost burden in...

Choroid Plexus Papillomas

A choroid plexus papilloma is an unusual tumor that arises from choroid plexus cells within the cerebral ventricles. The normal function of the choroid plexus is to produce cerebrospinal fluid (CSF). These highly vascular tumors are usually identified in infants and children, are most often found within the lateral ventricles, and can produce hydrocephalus or ventriculomegaly from ventricular obstruction or overproduction of CSF.22 Imaging studies show a contrast-enhanced mass with irregular borders within a cerebral ventricle. Arterial supply to these tumors is derived from choroidal arteries, the same arteries that supply the normal choroid plexus. Thus the most common choroid plexus papilloma, which arises within the lateral ventricle, may be fed by the anterior choroidal artery (an important branch of the distal internal carotid artery) or by the lateral posterior choroidal artery (a branch of the posterior cerebral artery.) If the tumor is sufficiently large and vascular and the...

HPV Infection and Penile Cancer

Much of our understanding of how HPV infection may lead to premalignant lesions and invasive tumors is based on studies of carcinogenesis in cervical cancer. However, while almost 100 of cervical SCCs are related to sexually transmitted HPV infection, rates of HPV in penile cancer are reported between 30 to 100 .1-6 The reasons for this wide range include geographical variations and different cultural attitudes towards sex between the reporting centers, as well as technical differences in the methodology used for HPV detection. A recent systematic review of established PCR techniques has found HPV DNA in approximately 50 of all penile SCCs.7 In this respect, penile tumors are more similar to vulval carcinomas, which also share a similar pathogenesis and histology.5,8 The human papilloma virus exerts its tumorigenic effect via expression of the viral oncogenes E6 and E7.9 E6 interacts with p53, while E7 interacts with retinoblastoma (RB) to block the activity of these tumor suppressor...

Human Papilloma Virus HPV Infection

HPV infection occurs in 15-85 of cases of SCC penis. HPV-16 and 18 are the most frequently detected types. Specifically, HPV-16 is present in 25-95 of cases and HPV-18 in the remaining 5-75 of the cases. Rarely, other HPV types are detected in penile cancer.37 In contrast to the established role of HPV as a risk factor, little is known about its prognostic significance in penile SCC. In 1992 Wiener et al. documented no significant difference in survival between patients with HPV-positive and those with HPV-negative tumors.38 Bezerra et al. in 2001 hypothesized that the presence of HPV DNA in the primary tumor could have a prognostic impact. Their study showed node metastases in 73.8 of HPV-negative and 26.2 of HPV-positive tumors, but such a difference was not statistically significant (p 0.38). They also failed to observe significant survival differences between the two groups of patients.10 Similar results were reported by Lopes et al. in a series of 82 patients who had undergone...

HPV Vaccination

The second scenario focuses on what effect a vaccine against HPV could have. There is a clear rationale in vaccinating young females to prevent cervical cancer. Vaccinating males has been suggested to reduce the total HPV burden in the population as a whole 2 often described as the herd effect. It is attractive to consider vaccinating both males and females to prevent HPV-related malignancies. In particular, cost-effectiveness analysis favors male vaccination in the circumstance of poor uptake by females. It is estimated that the cost of investigating and treating HPV in males between age 15 and 24 is 2.9 billion per annum.23 This is the same direct medical costs as for HIV, whereas genital herpes costs one-tenth of this and hepatitis B only 5.8 million. HPV is implicated in up to 90 of early penile cancer. This scenario goes to the extreme position of how much a national program of vaccinating all males aged up to 22 years, from the year 2012, would impact on the incidence of penile...

Effectiveness of Early Detection and Intervention

Early detection of cervical cancer is effective at decreasing morbidity and mortality because survival depends on the stage at diagnosis. More than 90 of women with local disease survive 5 years, but only 13 of women with distant disease at diagnosis survive 5 years (Hartman et al., 2002). Introduction of a screening program with Pap tests has consistently reduced morbidity and mortality across populations. Increased detection of low-grade lesions and false positives are the primary potential sources of harm. Harms include increased evaluations, including repeated Pap tests and biopsies psychological distress for the women with diagnosed low-grade lesions that may not be clinically important and potential adverse effects from unnecessary treatment.

Chromosomal Aberrations

Whole genome studies on penile cancer are scarce. DNA ploidy studies suggest the frequency of DNA aneuploidy to be correlated with histological type of invasive squamous cell carcinoma of the penis37,38 and patients with DNA diploid cancer to have a better survival rate than patients with aneuploid cancer.39 Preliminary analysis suggests that patients with a high DNA index may be at increased risk of disease progression and metastatic involvement.38,40 Karyotype analysis has been reported in a very small set of penile cancers (n 4), of which three of the four presented with a variety of cytogenetic anomalies.41-43 The tumors with cytogenetic abnormalities seem to have a more aggressive component, though clearly further data linking chromosomal abnormalities to biological behavior and outcome are necessary to state this firmly. In a comparative genomic hybridization study of 26 cases,44 DNA copy number alterations were present in 23 cases (89 ). The CGH analysis using metaphase spreads...

Diagnosis and Treatment

You should be certain that you receive notification about the report on your Pap smear. If you receive a report of an abnormal finding on a Pap smear, or if your doctor observes anything abnormal in the internal examination, it means you need a biopsy to obtain further information. If you are diagnosed with ASCUS, we recommend having the Pap smear repeated. If there is any indication of inflammation, it's a good idea to treat the cervical or vaginal infection before the smear is repeated. In women who are menopausal and are not receiving hormone replacement therapy, before repeating the Pap smear we recommend treatment for several weeks with estrogen, using a vaginal insert or cream or sys If two or more Pap smears identify ASCUS, or if a woman with ASCUS has other risk factors for cervical cancer (for example, HIV, HPV, multiple sexual partners), we recommend colposcopy. Colposcopy is also recommended for women with ASCUS who have any other laboratory or clinical findings that...

Hysterectomy and Other Treatment Options

Cryosurgery may also be used for the treatment of cervical dyspla-sia and carcinoma in situ. In this procedure liquid nitrogen is used to create a cold surface on an instrument that is applied directly to the cervix and causes destruction by freezing of the abnormal cervical areas. The main disadvantage of this method is that no cervical tissue is available for pathologic evaluation to determine whether the entire area of abnormality has been destroyed by freezing. Thus, follow-up with repeat Pap smears is critical. After treatment of CIN, we recommend Pap smears at three-month intervals. After one year, if all Pap smears are negative, an annual Pap smear is sufficient for continued monitoring.

Health Promotion Activities and Information for

A history and directed physical examination should be performed to detect conditions associated with increased maternal and perinatal morbidity and mortality. The first prenatal examination provides an opportunity for cervical cancer screening with a Papanicolaou (Pap) test in women who have not been screened recently. However, Pap tests performed in pregnant women may be less reliable. Risk factors should then identify other testing that might be done at this time, including blood glucose, sickle cell screening, Tay-Sachs screening, and surveillance for other infectious diseases. Routine fetal heart auscultation, urinalysis, and assessment of maternal weight, blood pressure, and fundal height generally are recommended, although the supportive evidence varies (Kirkham et al., 2005). Women should be offered ABO and Rh blood typing and screening for anemia during the first prenatal visit. Genetic counseling and testing should be offered to couples with a family history of genetic...

Treatment of Premalignant Penile Lesions

Circumcision is an essential part of the management of premalignant conditions. As well as removing the lesion if confined solely to the prepuce, it also prevents persistence of an environment suited to HPV infection, chronic inflammation, and progression to invasive disease. It also facilitates follow-up and clinical examination, which is essential with minimally invasive approaches. When performing the

The Preoperative Evaluation

Amining your breasts, checking your abdomen for any enlargements of the internal abdominal organs or pelvic organs. If you haven't had a mammogram and Pap smear in the past year, you may need to get these done, and your doctor may also request blood counts and blood chemistries as well as an electrocardiogram. Sometimes the preoperative evaluation will identify a condition that may take precedence in treatment before the hysterectomy. An example is a suspicious breast lump. Any finding like this needs thorough evaluation because treatment of a malignancy of another organ almost certainly will take priority over an elective hysterectomy. Likewise, if there is an abnormal Pap smear, follow-up studies should be done before surgery, unless the reason for the hysterectomy is cervical cancer. The Pap smear helps determine if there is a cervical abnormality, which might change the surgical approach or procedure. On rare occasions, even with adequate screening, cervical cancer remains...

Evidence Based Screening Guidelines

Immunizations are an important part of well-woman care. All patients benefit from disease prevention, and women are often caregivers for children or elderly persons, who are at higher risk from vaccine-preventable illnesses. Vaccines recommended by the U.S. Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) include tetanus diphtheria pertussis (Tdap), herpes zoster, and influenza for adults over age 50 and human papillomavirus vaccine for women 26 and younger.

Endocervical Curettage

Endocervical curettage frequently precedes external cervical biopsies so as not to cross-contaminate the specimens. Endo-cervical lesions can require much more extensive and invasive treatment. Endocervical sampling is done if the cause for the abnormal Pap smear is not identified or if an ectocervical lesion extends into the cervical canal. An endocervical curette is placed into the cervix with the sharp edge against the wall of the canal. The curette is then drawn back and forth against the cervical canal in a 360-degree sampling twice around. The sample removed can be retrieved with an endocervical brush and sent for pathologic assessment separate from any other specimens. Endocervical curettage is contraindicated in pregnant patients. (See Tuggy Video Colposcopy.)

Cervical Polyp Removal

Cervical polyps are generally benign, asymptomatic, and noted most often during a routine gynecologic examination. Most polyps arise from the endocervical mucosa, and most occur in perimenopausal women age 30 to 50. For their removal, the patient is placed in the dorsal lithotomy position and a speculum inserted vaginally. A Pap smear should be obtained and the base of the polyp identified to prevent inadvertent removal of a prolapsed endometrial polyp. The polyp is then grasped as close to its base as possible with a ring forceps and twisted. This twisting motion will dislodge the polyp, which should be sent for pathologic assessment. Hemostasis is obtained with Monsel's solution or silver nitrate sticks if direct pressure is not sufficient. (See Tuggy Video Polyp Removal.)

Elizabeth R Unger and Suzanne D Vernon 1 Introduction

The clinical utility of human papillomavirus (HPV) testing continues to be the focus of much debate. The clear epidemiologic link of HPV infection with the development of cervical intraepithelial neoplasia and invasive cervical cancers (1) leads to widespread expectation that testing for HPV could improve cervical cancer screening or aid in the triage of patients with abnormal cytology. The results of clinical trials of HPV testing are contradictory (2), and widespread implementation of HPV testing is currently not recommended. However, HPV testing is important in epidemiologic studies of cervical and anogenital disease, and a large National Cancer Institute trial is currently evaluating HPV as an adjunct to cytology in cervical cancer screening.

Interpretation of L1 Consensus PCR Assay

All samples, except the water blank (contamination control), should amplify the 286-bp region of P-globin and the DNA product of that size should be visible in each lane. The HPV positive control should amplify the 450-bp HPV consensus product, and the negative control (human placental DNA) should not produce any product. If the positive and negative controls give the expected results, the assay may interpreted. Test samples that amplify p-globin and have no HPV product visible are considered HPV negative. Those with an HPV product are considered HPV positive, whether or not P-globin is amplified. Test samples failing to amplify both p-globin and HPV cannot be interpreted. These samples require further optimization or purification as described in Notes 3-6. Figure 4 is a photograph of an EtBr-stained gel and shows the results of an HPV consensus and P-globin PCR. Fig. 4. EtBr gel. Ten microliters of each PCR product is analyzed by gel electrophoresis. The MY09 MY11 products are in the...

Structural Insights into CDK Substrate Selection

Members of the Cyclin D family are unique amongst the cyclins in containing an LXCXE motif (where X is any amino acid) N-terminal to the first putative cyclin box fold. This short motif is common to a number of proteins that can associate with the product of the retinoblastoma gene, RB. The structure of the A B pocket region of pRB in complex with an LXCXE-containing peptide derived from the human papilloma virus pRB-binding protein E7 has provided a model for how pRB might interact with cyclin D via this sequence.36 The 'A' and 'B' sequences of the pRB pocket encode a tightly associated tandem duplication of the cyclin box fold and the LXCXE motif binds in an extended conformation to the fold encoded by the 'B' pocket.

Primary Tumor Related Prognostic Factors

Histological subtype, local extension, grading, lymphatic and or venous embolization, and perineural invasion within the primary tumor are the most important predictors of lymph node involvement in patients with penile cancer9,11. More controversial is the role of growth pattern, tumor thickness, and presence of HPV infection.

Viruses And Other Infectious Agents

The infectious theory of prostate cancer was fashionable twenty years ago, but most contemporary books do not even mention it. The neglect of this line of research is surprising, since approximately 15 percent of all cancers worldwide are caused by infectious agents. For example, Helicobacter pylori bacteria is associated with stomach cancer, hepatitis B virus with liver cancer, human papillomavirus with cervical cancer, Epstein-Barr virus with nasopharyngeal cancer, and human T-lymphocyte virus with some leukemias and lymphomas. Prostate cancer is also a type of cancer that increases in incidence in individuals whose immune system is suppressed this correlation is consistent with an infectious process. Furthermore, when biopsies of prostatic tissue are examined under the microscope, inflammation is frequently present, consistent with infection. For all these reasons, infectious agents should be seriously considered as possible causes of prostate cancer. Drawing the most attention as...

Patterns of Recurrence

Of regional recurrence, and all distant recurrences were detected within the first 2 years, respectively (see Fig. 14.1 and Table 14.1).1 Consequently, follow-up should be intense during the first 2 years after surgery. A maximal follow-up of 5 years seems reasonable to detect the majority of recurrences. Similar to other types of solid tumors, a second primary tumor could develop because the remaining epithelium of the glans of the penis remains at risk for developing a malignancy or because of prolonged exposure to an etiological factor (i.e. HPV infection) when penile-preserving surgery has been performed.

Impact of Specific Prevention Strategies on Disease Incidence

Fig. 16.3 Projected increase in incidence of penile cancer in the UK by the year 2050. This model can then be applied in the following two interventional scenarios, circumcision and HPV vaccination Fig. 16.3 Projected increase in incidence of penile cancer in the UK by the year 2050. This model can then be applied in the following two interventional scenarios, circumcision and HPV vaccination

Cervix Uteri and Ovary

Women who smoke cigarettes have four times the risk of cervical cancer as nonsmokers. Even women who smoke only 100 cigarettes during their lifetime more than double their risk of cervical cancer. The risk from smoking is greater in women younger than 30 than in those older than 30 (Slattery et al., 1989). Constituents from cigarette smoke, including mutagens and the carcinogen (NNK), have been detected in the cervical mucus of smokers at levels 40 to 50 times those in serum. Smoking is a risk factor for cervical intraepithelial neoplasia (CIN) and cervical cancer among women who test positive as well as negative for human papillomavirus (HPV). The relative risks for CIN and cervical cancer are two to four times greater for current and former smokers compared with never-smokers (US Surgeon General, 2004). Although the risk of some types of ovarian cancer has been shown to be as much as three times greater in women who smoke cigarettes (Qian et al., 1989 Tworoger et al., 2008), the...

Inspect the Penis and Scrotum

Penis Syphilis

Pearly penile papules are very common around the coronal sulcus and have no racial predilection. They are thought to be embryonic remnants of a copulative prehensile organ. These fine papules are small, asymptomatic lesions that develop after puberty in 10 to 15 of men. They are skin colored, filiform in shape, and arranged in rows at the junction of the glans penis and sulcus coronarius they are more common in uncircumcised men. They should not be confused with condylomata acuminata. Figure 18-12 shows pearly penile papules. Venereal warts, or condylomata acuminata, may be found near the meatus, on the glans, in the perineum, at the anus, and on the shaft of the penis. Condylomata acuminata are the characteristic lesions of human papillomavirus (HPV) infection. Typically, these papules have a verrucous surface resembling cauliflower. They are highly contagious, with transmission occurring in 30 to 60 of patients after a single exposure. Figure 18-15 shows a patient with condylomata...

Pathology of Head and Neck Tumors

Squamous Cell Carcinoma The Tongue

Squamous papilloma is a solitary papillary lesion of the squamous epithelium which has a white, frondlike gross appearance. Microscopically, it consists of multiple papillae of benign, stratified squamous cells arranged around central fibrovascular cores. They usually occur in adults. Although a viral etiology is suspected, human papillomavirus (HPV) types 6 and or 11 have been detected in only some of the cases. Juvenile laryngeal papillomatosis are his-tologically similar to squamous papilloma but occur in children and are characteristically multiple. They tend to recur and sometimes can be florid enough to cause asphyxiation. Sometimes the recurrences cease at puberty. Squamous cell carcinoma may follow radiation therapy for treatment ofjuvenile papillomatosis (Figure 2-1). Schneiderian papillomas arise in the sinonasal region and may be fungiform (exophytic), inverted (endophytic) or oncocytic (Figure 2-2). The role of HPV in their development is controversial. The patients are...

If I Have a Baby Boy Should He Be Circumcised

I hoped that the controversy was settled. But in recent years it has been revived. Today there are some medical supporters of routine circumcision who believe that it will decrease, at least to a small degree, the risk of venereal diseases In adulthood such as herpes, genital warts, rnonillia infections, syphilis, gonorrhea, chancroid, and perhaps AIDS. But many other physicians are unconvinced, Including myself.

Immunohistochemical Features

FIGURE 26-1 Noncontrast computed tomography (CT) (A) and precontrast and postcontrast T1-weighted axial magnetic resonance images (B and C) in a 21-year-old male with hydrocephalus and a choroid plexus papilloma in the fourth ventricle. CT shows the calcifications within the mass that are inconspicuous on magnetic resonance imaging. The papilloma demonstrates homogeneous enhancement after contrast administration. FIGURE 26-2 Eleven-year-old female with hydrocephalus and a choroid plexus papilloma in the atrium of the left lateral ventricle. T1-weighted sagittal (A) and T2-weighted axial magnetic resonance (MR) images (B) show a T1 isointense, T2 hyperintense mass with central flow voids and necrosis. There is intense enhancement on the postcontrast T1-weighted axial image (C). Collapsed image from a three-dimensional time-of-flight MR angiogram (D) demonstrates an enlarged left posterior choroidal artery supplying the mass. FIGURE 26-2 Eleven-year-old female with hydrocephalus and a...

Malignant Epithelial Tumors with Clear Cell Features 3461 Clear Cell Carcinoma

Penile Cancer

Clear cell carcinomas of the penis are rare tumors of probably sweat gland origin characterized by the presence of neoplastic cells with intracytoplasmic prominent PAS-positive material.19 Tumors preferentially affect the foreskin inner mucosa and are consistently HPV positive, mainly genotype 16. Clear cell carcinomas are composed of solid proliferations of clear cells, sometimes with geographical areas of necrosis. Histology is of a high-grade tumor with evident nuclear atypias. Extensive vascular invasion and a high metastatic rate are common findings. This unusual variant of penile cancer should be distinguished from penile SCC showing clear-cell features, urothelial clear cell carcinomas, and sebaceous carcinomas. Caution should be taken for not confusing glycogenated clear cells with koilocytes and with true neoplastic clear cells. Glycogenated clear cells can be found in usual and other well-differentiated keratinizing SCC variants but changes are focal and usually not...

Clinicopathologic Correlations

Rectovaginal Examination

Although the pelvic examination can reveal many cancers of the female reproductive system, including advanced uterine cancers, it is not very effective in detecting early uterine cancer. The Pap test can reveal some early endometrial cancers, but most cases are not detected by this test. In contrast, the Pap test is very effective in revealing early cancers of the cervix. For this reason, the American Cancer Society recommends the following 1. All women should begin screening for cervical cancer about 3 years after they begin having vaginal intercourse or at age 21 years, whichever occurs first. Screening should be performed every year with the regular Pap test or every 2 years with the newer liquid-based Pap test. 2. Beginning at age 30 years, women who have had three normal Pap test results in a row may undergo screening every 2 to 3 years with either the conventional or liquid-based Pap test. Women who have certain risk factors such as DES exposure before birth, HIV infection, or a...

Single Strand Conformation Polymorphism Analysis of Mutations in Exons 48 of the TP53 Gene

72 polymorphism (CGCArg or CCCPro) were found to be overrepresented among patients who smoke and also among those affected at a younger age (21), and an excess of Arg Arg homozygotes was found in nonsmoking patients with lung cancers (22). p53Arg allele displays several differences in comparison to p53Pro. For instance, it is more susceptible to degradation by human papilloma virus (HPV) E6 protein (23,24). There are indications that this translates to higher susceptibility to HPV-associated cervical cancer (23,25), although studies contradicting these findings also exist (26-30). 23. Storey, A., Thomas, M., Kalita, A., Harwood, C., Gardiol, D., Mantovani, F., Breuer, J., Leigh, I. M., Matlashewski, G., and Banks, L. (1998) Role of a p53 polymorphism in the development of human papillomavirus-associated cancer. Nature 393, 229-234. 30. Minaguchi, T., Kanamori, Y., Matsushima, M., Yoshikawa, H., Taketani, Y., and Nakamura, Y. (1998) No evidence of correlation between polymorphism at...

Histology Light Microscopy

Papillary ependymomas may be superficially difficult to distinguish from choroids plexus papilloma. Although the fronds of a choroids plexus papilloma consist of fingers of fibrosis tissue lined by a single layer of ependymal cells, the fronds of a papillary ependymoma contain ependymal cells sandwiched between the ependymal-coated surface.

Penile Cancer and Its Precursor Lesions 141 Penile Cancer and Adjacent Lesions

Penile cancers are thought to arise from the progression of precursor lesions and can be subdivided into HPV-positive and HPV-negative cases. The HPV prevalence differs significantly by histological subtype. Similar to vulvar and head and neck carcinomas, squamous cell carcinoma of the basaloid and warty type display the strongest association with hrHPV (ranging from 66 to 100 ) and their etiological relationship with hrHPV infection is most plausible.4 19,32,33 The remaining penile squamous cell carcinomas demonstrate about 30 positivity for hrHPV DNA.4,7,17,18,34,35 Verrucous penile carcinoma seems to have a weaker association with HPV positivity, showing a prevalence of 22.4 .19 Despite the similarities between penile and vulvar cancer including the presence of HPV (mainly HPV-16) and their precursor lesions, the clear bimodal age distribution that is found for vulvar cancer is not clearly seen for penile cancer.36 Cubilla et al. observed a lower age for patients (average age 55...

Examination Vagina By Finger

Frog Leg Position

Pap Smear Studies have revealed that liquid-based testing can slightly improve detection of cancers, greatly improve detection of precancerous conditions, and reduce the number of tests that need to be repeated. This method is, however, more expensive than a usual Pap smear. The liquid-based Pap test has a higher sensitivity and lower specificity than conventional Pap tests more false-positive results are obtained with this type of Pap test. Women with positive test results must receive a full diagnostic work-up to distinguish the true-positive results from the false-positive results. According to the National Cervical Cancer Coalition, in the United States today, approximately 90 of all Pap tests are performed with the liquid-based technology. Although liquid-based Pap smears demonstrate distinct advantages in slide quality and *Named for George N. Papanicolaou, the physician who developed this screening technique. When properly performed, the Pap test can accurately diagnose...

Characteristics of HPVRelated Precursor Lesions

Intraepithelial Lesion Penis

Lesions, may progress to penile cancer.26,44,45 Progression into penile cancer is more common in EQ, occurring in approximately 30 of the cases.26 It is unclear whether there is a differential outcome for either HPV-positive or negative cases of Bowen's disease or EQ. described above, FPL are predominantly found at the mucosal site of the penis. Histological evaluation of FPL generally shows mild changes such as squamous hyperplasia or low-grade PIN. High-grade PIN is uncommon, being present in about 5 of the cases. FPL are found in about 50-70 of the male sexual partners of women with CIN versus about 10-20 in men who do not have a partner with CIN.40,50-53 In young male populations, not selected on the basis of a prevalent CIN lesion in the partner, prevalences of up to 36 have been reported.54,55 These data indicate that FPL have a much higher prevalence compared to Bowen's disease, EQ, or BP. Besides the association with HPV, it is important to realize that, in cases of HPV...

Squamous cell carcinoma of the nail apparatus has a good prognosis compared with other sites

Trauma, chronic infection and chronic radiation exposure are possible aetiological factors human papillomavirus (HPV) has been incriminated in some cases. Two reported cases had associated congenital ectodermal dysplasia. Most lesions occur on the fingers, particularly the thumbs and index fingers (Figure 5.31). The presenting symptoms include pain, swelling, inflammation, elevation of the nail, ulceration, a tumour 'mass', ingrowing of the nail, 'pyogenic granuloma' and bleeding. Bone involvement is a rare, very late sign. The duration of symptoms before diagnosis is greater than 12 months in over half the cases. Only in one published case (with ectodermal dysplasia) has the condition led to death, from rapid generalized metastases.

Primary Care of SUD Patients

Chlamydia, herpes, syphilis, human papillomavirus) are more common in SUD patients than in the general population, and patients should be screened routinely. Other infections common in IV drug users include skin abscesses, cellulitis, infectious endocarditis, and pneumonia.

Category C Severely Symptomatic

Initial laboratory studies should include CD4+ CD8+ counts (absolute cell counts and percentages) and, if possible, HIV-1 RNA levels. CBC with differential count, electrolyte and liver function panel, hepatitis screen, reactive protein reagin (RPR) or VDRL, anti-toxoplasma IgG antibodies purified protein derivative (PPD) with anergy panel, and chest x-ray should also be obtained. Ophthalmological, dental, and gynecological examinations (including a PAP smear, chlamydia and gonorrhea studies) should be pursued. The stage of HIV-1 infection will then determine follow-up, prophylaxis, and therapeutic strategies.

Patient care and monitoring

Monitoring for T. vaginalis is generally not required. genital warts Genital warts, caused by the human papillomavirus (HPV), are regularly encountered in primary care. Responsible for various visible, keratotic, and nonkeratotic manifestations, HPV has nearly 120 noted strains, some of which have been linked to squam- Affecting over 20 million Americans, HPV is one of the most common STIs in the United States, with a prevalence of approximately 15 . Furthermore, among adolescent and college-aged women, HPV may be the most common STL4,20 The frequency of cervicovaginal HPV infection among sexually-active women has been observed at 43 , with the greatest incidence noticed in men with three or more sex partners and women whose most recent regular sexual partner had two or more lifetime partners.

HPVIndependent Penile Carcinogenesis

Of non-HPV associated penile cancers.15,26 Another plausible mechanism by which the p16INK4a cyclin D Rb pathway can be disrupted during penile carcinogenesis in the absence of hrHPV is overexpression of the polycomb group (PcG) gene BMI-1, which targets the CDKN2A locus (which encodes both p16INK4a and p14ARF). Overexpression of BMI-1 has been reported in 10 of hrHPV-negative cases.15 Mechanisms by which the p14ARF MDM2 p53 pathway becomes inactivated in non-HPV-associated penile cancers include somatic mutations of the p53 gene. An inverse relation between the presence of mutations of the p53 gene or p53 stabilization, a feature of mutated, inactive p53, and HPV presence has been reported for penile carcinoma,26,30-32 although there is some contradictory evidence regarding the relation between p53 expression and HPV infection.29 Another mechanism by which the p14ARF MDM2 p53 pathway can be disrupted during penile carcinogenesis in the absence of hrHPV is overexpression of the MDM2...

HPVMediated Penile Carcinogenesis

HPV is a family of epitheliotropic, small double-stranded DNA viruses of approximately 8,000 bp. Sexual transmission is the most common route for viral infection, although oral and vertical transmission are also possible.10 Epidemiologic research has classified 15 genotypes of HPV as high-risk, based on their association with cervical cancer, i.e., HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82, and three types as probably high-risk, i.e., HPV 26, 53, and 66.11 Recent literature reviews of data available for Europe, North America, South America, and Asia, reported an overall HPV prevalence in penile carcinomas of approximately 47 .3,8 The contribution of the different HPV types among HPV-positive penile cancers varies as follows HPV-16 (60.23 ), HPV-18 (13.35 ), HPV-6 11 (8.13 ), HPV-31 (1.16 ), HPV-45 (1.16 ), HPV-33 (0.97 ), HPV-52 (0.58 ), other types (2.47 ).3 Based on similar prevalences of HPV (mainly HPV-16) and their precursor lesions,2 etiological...

Introduction Molecular Concept of Penile Carcinogenesis

About half of penile cancers are caused by an infection with high-risk (often also referred to as oncogenic) human papillomavirus (hrHPV), mainly type HPV-16. 3-8 The remaining penile cancers arise independent of hrHPV infection. A similar division has also been described for vulvar and head and neck carcinomas.9 Although the molecular routes of disruption differ in multiple ways - particularly related to the early genetic events and the activity of the known viral oncogenes E6 and E7 -common cellular pathways are disrupted at initial and later stages during penile carcinogenesis in both virus and nonvirus-induced modes. Penile cancers are likely to be initiated by interference with the cellular p14ARF MDM2 p53 and or p16INK4a cyclin D Rb pathways, either by viral (i.e., HPV) or nonviral (i.e., mutation, gene promoter hypermethylation, etc.) mechanisms. This may lead to uncontrolled cell division and reduced apoptosis, and may trigger a state of chromosomal instability that further...

Surgical Treatment

The limited maxillectomy is most frequently performed with either resection of the medial wall or the floor of the maxillary sinus. Medial maxillec-tomy is appropriate for limited, low-grade tumors of the medial wall of the maxillary sinus, nasal cavity, and ethmoid sinus, such as inverted papilloma. The entire medial maxillary wall, lamina papyracea and ethmoid sinus are removed in this procedure (Figures 11-6 and 11-7). The infraorbital nerve is preserved, along with the majority of the anterior maxillary wall, orbital floor, and entire lateral maxillary wall and floor. The fragile nature of the ethmoid air cells, lamina papyracea, and lateral nasal wall makes the en bloc removal of an entire medial maxillec-tomy specimen challenging.52

Patient Centered Approach to the Well Woman Examination

The well-woman examination is an opportunity for the family physician to promote health, prevent disease, and strengthen the physician-female patient relationship. Although women have traditionally been advised to see their doctors for an annual examination, which includes a Papanicolaou smear, new screening guidelines have widened the scope of the visit and deemphasized the Pap smear (which may not be needed on an annual basis). Building a trusting relationship is important because women may be more likely to volunteer sensitive problems with a physician they trust. In addition, some women may have had previous negative experiences with pelvic examinations.

William Harvey 15781657

Early detection by physical examination. It has been estimated that noninvasive cervical cancer (carcinoma in situ) is about four times more common than invasive cervical cancer. In the United States, the widespread use of the Papanicolaou (Pap) test has decreased the incidence and mortality rate by 40 since the mid-1970s. Most invasive cervical carcinomas are found in women who have not had regular Pap tests. In 2007, there were 11,150 new cases of invasive cervical cancer diagnosed, and 3670 women died from this disease. The death rate continues to decline by about 2 per year. An American woman has a 0.78 lifetime risk (1 per 128) for development of cervical cancer and a 0.27 risk of dying from the disease. The 5-year relative survival rate for the earliest stage of invasive cervical cancer is 92 , and the overall (all cases considered together) 5-year survival rate is 71 . Of the many risk factors that have been evaluated, young age at first sexual intercourse, multiple sexual...

Penile Intraepithelial Neoplasia PIN

Processes related to co-infection with other HPV subtypes. A small series looking at HPV subtypes in eight patients with EQ found co-infection with HPV-8 in all cases, while no co-infection was detected in control patients with Bowen's disease.17 The effect of this co-infection on the invasiveness of EQ remains unclear. At present, there is no clear evidence linking aggressiveness of PIN based on the HPV types involved. In fact no study has clearly identified any difference in the transformation rate of PIN lesions based on the presence or absence of HPV infection, and more research into this field is required.


The positive effect of circumcision is mainly explained by preventing conditions such as poor penile hygiene, smegma retention, and phimosis, which have been reported as risk factors for penile cancer.71011 Phimosis (or narrowness of the opening of the foreskin) leads invariably to retention of the normally desquamated epidermal cells and urinary products (smegma) resulting in conditions of chronic irritation with or without bacterial inflammation of the prepuce and the glans. The frequency of phimosis in men with penile carcinoma is between 44 and 85 and in case-control studies a 65-fold increased relative risk for penile cancer was recorded among males with phimosis.1011 When performing statistical analyses after exclusion of phimosis as a risk factor, the presence of a foreskin did not increase the risk of penile cancer.11 Although carcinogenesis has been attributed to chronic inflammation due to the irritating effects of smegma, to date a carcinogenic agent has not been identified...

Health Maintenance

Ask patients whether they have regular doctors and routine medical checkups. When was their last dental examination Do they get their eyes checked periodically Are they aware of their cholesterol levels Do they do anything for exercise If the patient is a woman, does she see a gynecologist regularly Does she perform breast self-examination When were her last mammogram and her last Pap smear obtained If the patient is a man, does he perform routine testicular self-examination

Burden of Disease

The incidence of cervical cancer is decreasing but is still the 10th leading cause of cancer deaths. In the United States an estimated 11,000 new cases of cervical cancer were diagnosed in 2009, and 4070 of these patients will die from this preventable disease (ACS, 2009). Women who have never been screened represent a significant majority of those with diagnosed invasive cervical cancers and deaths caused by cervical cancer. The most important risk factor for this disease is infection with human papillomavirus (HPV). HPV is transmitted sexually, and 90 of squamous cell cervical cancers contain HPV DNA. Other risk factors for cervical cancer include early onset of intercourse, greater number of sexual partners, and cigarette smoking.

Epigenetic Events

HPV-positive patients, though data should be interpreted with care as only 3 HPV-positive patients were included in the study.26 Another study reports methylation status in the promoter region of thrombospondin-1 (TSP-1) and RASSF1A in 46 and 42 of the tumors, respectively. The epigenetic inactivation of TSP-1 and RASSF1A genes was found associated with pathological variables (i.e., unfavorable histological grade, vascular invasion, and shorter overall survival for TSP-1 and T1 tumors for RASF1A). Both methylation markers seemed to be of prognostic significance in penile cancer, yet with opposite roles, i.e., TSP-1 promoter methylation was associated with shorter 5-year disease-free survival and overall survival, while RASSF1A hypermethylation seemed to be associated with a more prolonged-disease free survival.36

What If It Is Cancer

When cancer cells are clearly identified in a Pap smear, the Bethesda Classification System reports them as cancer. Cancer of the cervix usually originates from the squamous cells of the cervix growing from the area of the cervix where the ectocervical tissue (outer tissue covered by squamous mucosa) meets the cervical canal (inner tissue lined by glandular cells). This area is known as the transformation zone. The name is accurate the tissue at this site, the squamous cellular lining, is constantly undergoing changes in form and structure, a phenomenon known as squamous metaplasia (fig. 8.1).


During examination the thumb can be pressed against the internal index finger to determine tenderness, induration, or abscess formation in the perianal tissues in all quadrants. The lubricated anoscope with obturator is introduced fully into the anal canal with gentle, constant pressure. Once fully inserted, the obturator is removed and the anorectal mucosa visualized through 360 degrees during gradual withdrawal. Adequate lighting is essential. Valsalva maneuver may distend vascular lesions for ease in visibility. Anal Pap smears can be obtained if warranted for anorectal cancer concerns and biopsies performed using a Kevorkian or Tischler biopsy forceps. Hemostasis is obtained using silver nitrate sticks. (See Tuggy Video Anoscopy.)


Colposcopically directed cervical biopsy and cervical curet-tage is primarily used to investigate abnormal findings on routine pelvic examination or an abnormal Pap smear. Consensus guidelines for the management of cervical intraepi-thelial neoplasia (CIN) have been developed (Wright et al., 2007). Colposcopy requires diligent record keeping and patient communication with follow-up arranged pending pathologic results. Contraindications to colposcopy are current infection and delivery within the preceding 6 weeks. Pregnancy does not preclude colposcopy but may impact the decision to biopsy the cervix or perform endocervi-cal curettage based on increased bleeding and miscarriage risks. A pregnancy test is best performed before a biopsy is contemplated. Patients should receive informed consent and understand the risk and benefits as well as their responsibility to follow up based on exam findings.

Endometrial Biopsy

An endometrial biopsy can be performed to evaluate abnormal uterine bleeding in women who are premenopausal or postmenopausal in conjunction with ultrasound. It can also be used to assess for a short luteal phase in infertility and abnormal or atypical glandular cells seen on Pap smear in women over 40. Women with spontaneous postmenopausal bleeding and an endometrial thickness greater than 5 mm should be further evaluated with an endometrial biopsy (Amann et al., 2006).


Onychomatricoma is a recently described entity, clinically characterized by a thickened, yellow longitudinal nail portion with splinter haemorrhages and a slight overcurvature, consisting of a markedly papillomatous lesion of the matrix covered by normal nail-producing epithelium. Its connective tissue stroma is densely cellular and contains fine collagen fibres. The tumour projections fit into channels in the thickened nail substance that run along the whole length of the nail. After avulsion, the nail substance shows these channels lined with the upper third to half of normal matrix epithelium, exactly as seen on the nail's undersurface after nail avulsion. The exact nature of this lesion is not yet clear however, human papillomavirus has not been demonstrated.

Fibrous overgrowth

Fibrous overgrowths or fibroepithelial polyps are relatively common in the mouth and are usually the result of trauma or frictional irritation. By contrast, fibromas, which are benign neoplasms, are extremely rare. They are most often seen in the cheeks or lips where such irritation from the dentition can be encountered. Sometimes known as polyps, they may be semi-pedunculated or sessile in their attachment and are similar in colour to the surrounding normal tissue unless they have been traumatised frictionally, when they may show a whitened keratinised surface. They do not, however, have the cauliflower hyperkeratotic surface of the papilloma, being smooth-surfaced and hence easily distinguished from the papilloma (Fig. 32.2). Treatment is simple surgical excision. As, histologically, they are simple hyperplasias, there is no requirement to remove a margin of normal tissue nor to extend the excision deeply into the under-

Cervical Cancer

The World Health Organization reports cervical cancer as the second largest cause of female cancer mortality worldwide with 288,000 deaths yearly. Roughly 510,000 cases of cervical cancer are reported each year with approximately 80 of these from developing countries. Human papilloma virus is a cause of cervical cancer with prevalence of approximately 630 million infections in the world.


Some studies have shown the presence of CPTs in trans-genic animals. Large T antigen, the major regulator of late viral gene products of the simian virus 40 (SV-40), when expressed in mice, induces the formation of choroid plexus neoplasms.2 The large T antigen is expressed only in the choroid plexus and appears to interact with the product of the p53 gene.27 More recently, the expression of transgenes of the viral oncoproteins E6 and E7 from human papilloma virus have also been shown to produce tumors in 71 of offspring, of which 26 of the tumors were CPTs.2 ance of choroid plexus tumors. A, Axial T1-weighted MRI showing variegated, frondlike mass in left lateral ventricle supplied by vascular pedicle. The lesion proved to be a choroid plexus papilloma. B, Axial contrast-enhanced MRI of choroid plexus carcinoma (left) showing irregular tumor infiltrating brain parenchyma. After surgery, chemotherapy, and repeat surgery, a gross-total resection has been achieved.


There is also concern about the potential effects of plume or surgical smoke produced by electrosurgery and lasers. Toxic chemicals are produced when tissue is burned. Blood aerosols and viruses such as human papilloma virus in the laser plume are thought to be capable of transmitting disease. A surgeon's mask alone does not provide adequate protection. High-volume aspiration (similar to that on dental units but with special filters) is recommended.


Table 16-13 Treatment of Genital Warts For STIs other than syphilis, expedited partner therapy, the practice of administering medication to diagnosed patients to treat their partner(s), has proved effective in reducing reinfection rates and further spread of infection (CDC, 2006) (SOR B). Human papillomavirus vaccine is effective in reducing the incidence of HPV infection (Sundar et al., 2010) (SOR A). Imiquimod 1 or 5 increases wart clearance compared with placebo in people without HIV infection (Buck, 2010) (SOR A). Podofilox (Condylox) is more effective than placebo at clearing genital warts after 16 weeks (SOR A).

Verruca Warts

Wart Testis

Warts are common growths of skin and mucosa caused by the human papillomavirus (HPV). Currently, more than 100 types of HPV have been identified. Specific HPV types often correlate to the lesion location, morphology, or oncogenic potential. Although most are benign, warts can be disfiguring or can cause significant psychological distress, and some cause cancer. Condylomata acuminata (genital warts) occur on the external genitalia, perineum, perianal, or adjacent intertriginous regions but can also be found on the oral mucosa. These lesions are generally considered sexually transmitted, but it is usually impossible determine when the inoculation Women with condylomata should have annual Papanico-laou tests to evaluate for cervical neoplasia. For both men and women, it is advisable to refrain from sexual activity while genital lesions are present, to prevent transmission. In 2006 the FDA approved an HPV vaccine (Gardasil), recommended for females age 11 to 26 regardless of abnormal Pap...

Grade Description

For example, congenital abnormalities such as Chiari malformations, agenesis of the corpus callosum, anencephaly, aqueductal stenosis, holoprosencephaly, and encephaloceles can be evaluated. Congenital pediatric neoplasms that occur in the first year of life such as choroid plexus papilloma and carcinoma, gliomas, primitive neuroectodermal tumors, and vascular disorders (e.g., the vein of Galen malformation) can be elucidated. Infectious diseases of the brain may result in abnormal intracranial fluid collections, complicating meningitis or encephalitis. US can be useful in providing guidance for needle aspirations of these collections.


Several HPV genotypes have been linked to the development of cervical cancer. HPV vaccine (Gardasil), developed to protect against HPV genotypes 6, 11, 16, and 18, is the first employed to prevent cervical cancer, precancerous genital lesions, and genital warts due to HPV. The CDC recommends the HPV vaccine for all 11- and 12- year-old females. Vaccination is also recommended for females aged 13 through 26 years who have not been previously vaccinated or who have not completed the full series of shots.34

Multiple Sclerosis

The role of viral infections in the initiation and maintenance of MS has been debated for some time. Several viral infections are known to cause demyelination in animals, including visna virus of goats and sheep, canine distemper virus, and Theiler's murine encephalomyelitis virus (TMEV). Viral infections in humans can also cause demyelination (progressive multifocal leukoencephalopathy 'JC papilloma virus , subacute sclerosing panencephalitis 'measles virus , and human T-cell lymphotropic or leukemia

Sinonasal Tumors

Tumors of the external nose are usually related to prolonged exposure to the sun. Basal cell and squamous cell carcinoma are most common (see Chapter 33). Intranasal tumors can be benign or malignant. The most common growth within the nasal cavity is the benign squamous papilloma, caused by the human papillomavirus (HPV). This typically appears as an exophytic lesion within the nose, often at a junction between squamous and respiratory epithelium, and causes irritation and bleeding. Treatment consists of simple excision, and recurrence is uncommon. Malignant degeneration is extremely unlikely. A much more aggressive papillary lesion is an inverted papilloma. These tumors often manifest as unilateral polyps and can cause symptoms of nasal obstruction, bleeding, and sinusitis. These lesions require excision because they can be locally destructive, and malignant degeneration can occur. Endoscopic excision is usually possible, although external approaches are sometimes required.


Recurrent respiratory papillomatosis occurs in all ages but is more common in children. It is the most common benign tumor of the airway and is usually found on the true vocal cords and supraglottic and subglottic areas. The causative agent is human papillomavirus. Symptoms usually begin with hoarseness or aphonia and progress to stridor and dyspnea at a later stage of disease. Treatment is by endoscopic removal using the carbon dioxide laser or pulsed dye laser (PDL), and recurrence is common. It can progress to complete airway obstruction and eventually death. Repeated procedures are required. Interferon has been used for severe cases. The antiviral drug cidofovir has demonstrated efficacy against recurrent respiratory papillomatosis and is considered a promising new adjuvant treatment for this disease. The HPV vaccination program in the female adolescent population may lead to a decreased incidence of pediatric laryn-geal papillomas by reducing the vertical transmission of the...


Sexually transmitted infections (STIs) are usually spread by contact with infected skin or body fluids such as semen, blood, and vaginal secretions. Many STIs are uncomfortable but fairly minor problems, but some, such as HIV infection, are life-threatening. You can take simple steps to protect yourself. If you have sex with someone whom you do not know to be free of infection, use a condom, which gives protection against most STIs (apart from genital warts and pubic lice, which can affect body areas that are not covered by a condom). If you develop an STI, you should avoid sexual activity until you have been treated and are free of infection.

Implantable Devices

It is important to evaluate a patient to determine if she is an appropriate candidate for an implantable contraceptive. Implantable contraceptives are recommended for women with at least one child, in a monogamous relationship, who have no history of pelvic inflammatory disease (PID) and no history or risk of ectopic pregnancy. There are also multiple contraindications to IUD use. Evaluation of the patient is essential because IUDs cannot be used in the following situations (a) pregnancy or suspected pregnancy, (b) anatomically abnormal or distorted uterine cavity, (c) acute PID or history of PID, unless there has been a subsequent intrauterine pregnancy, (d) postpartum endometritis or infected abortion in the past 3 months, (e) known or suspected uterine or cervical neoplasia or unresolved abnormal pap smear, (f) genital bleeding of unknown etiology, (g) untreated acute cervicitis or vaginitis, (h) acute liver disease or liver tumor, (i) woman or her partner has multiple sexual...

Nipple Discharge

The most common types of discharge are serous and bloody. A serous discharge is thin and watery and may appear as a yellowish stain on the patient's garments. This commonly results from an intraductal papilloma in one of the large subareolar ducts. Women taking oral contraceptives may complain of bilateral serous discharge. A serous discharge can also occur in women with breast carcinoma. A bloody discharge is associated with an intraductal papilloma, which is common among pregnant and menstruating women. It may, however, be associated with a malignant intraductal papillary carcinoma. The presence of any nipple discharge is more important than its character because both types of discharge are associated with benign or malignant disease.

Clinical Summary

Sexually transmitted infections diagnosed in a prepubertal child may indicate sexual abuse. Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas, and syphilis are almost always transmitted by intimate sexual contact unless acquired perinatally. Condylomata acuminata (genital warts) and herpes simplex may be transmitted to the prepubertal child through sexual or nonsexual contact. False positive tests are not uncommon in this population with low disease prevalence.

Colloid Cysts

Patients may have weakness in the legs not associated with loss of consciousness, headache that is progressive, or paradoxical lightning headache that is relieved by positional changes of the head. Papilledema may be present on examination. Occasionally, patients with colloid cysts present with symptoms consistent with normal pressure hydrocephalus. Imaging with noncontrast CT demonstrates ventricular obstruction and dilatation with a hyperdense mass in the third ventricle. Coronal MRI usually demonstrates the mass in the anterior third ventricle. These tumors can be confused with basilar aneurysms or choroid plexus papilloma, although these lesions are not as hyperdense on noncontrast neuroradiological studies. Management includes immediate attention to hydrocephalus, often with ventricular drainage. Early surgical intervention is recommended to prevent neurological deterioration. y


Up to 50 of women with trichomoniasis are asymptomatic. Symptomatic women may complain of a yellow-green, malodorous discharge, vaginal burning, and dysuria. On physical examination, hemorrhagic, punctate cervical lesions are pathognomonic but are only present in 2 of cases (French et al., 2004). More common signs are foul-smelling purulent discharge, vaginal tenderness, vulvar erythema and edema. The vaginal pH is usually basic. Office microscopy is first line for diagnosis of trichomoniasis (ACOG, 2006). The sample should be taken from the posterior vault, diluted in 2 drops of saline, and assessed quickly because motility of the protozoa diminishes rapidly (Fig. 25-3). Although microscopy has good specificity (99 ), motile trichomonads are seen in only 50 to 80 of culture-proven cases. Thus, culture is the gold standard. Trichomonads can be reported on a Pap smear, but it is not recommended as a diagnostic test because of the low sensitivity (58 ) (French et al., 2004). In men the...


For cervical cancer in women who have been sexually active and have a cervix, USPSTF recommends screening within 3 years of onset of sexual activity or by age 21, whichever comes first, and screening at least every 3 years. They recommend against the use of routine Pap tests in low-risk women older than 65 years and in women who have had a hysterectomy for benign reasons (USPSTF, 2003). The AAFP (2008) endorses this recommendation. ACOG (2009) recommends starting at age 21 with screening every 2 years, then every 3 years for women over age 30 with three consecutive normal Pap smears. The ACS recommends initiating screening 3 years after a woman becomes sexually active or at age 21, with annual Pap tests (or biannual tests if using liquid-based preparation) until age 30 and then every 2 to 3 years thereafter (Hartman et al., 2002). The USPSTF does not currently have recommendations regarding HPV vaccination. ACOG recommends HPV vaccination of females age 9 to 26 years against HPV. The...