1. Anal Condyloma acuminata treated with plasma argon coagulation Coordinator : Dr. Adrian Catinean, MD,PhD Authors : Morar Andreea,Neag Alexandra General Medicine, 4 th year UMF “Iuliu Hatieganu” Cluj Napoca

2. What is condyloma acuminata? Condylomata acuminata “condylomas” are benign anogenital warts caused by human papillomavirus (HPV), genotypes 6 and 11 being found in >90% of cases. The term condyloma acuminatum (condyloma = knuckle, acuminatum= pointed) was originally used to emphasize the difference between anogenital warts, which are usually protuberant, and the flatter syphilitic lesions, condylomata lata. Condyloma acuminata was a well-known disease from ancient Roman and Hellenic ages. The ancients knew both is venereal origin and that perianal condylomata were common among men who have sex with men.

3. Condyloma acuminata Clinical types External warts Single,multiple papules or plaque Flat,verrucous, pedunculated Reddish or brown smooth raised papules Dome-shaped lesions on keratinazed skin Internal warts Affects mucous membranes Discomfort,pain, bleeding, difficult intercourse

4. HPV infection HPV is the most common sexually transmitted infection (STI). HPV is so common that nearly all sexually active men and women get it at some point in their lives. About 40 out of 150 known HPV genotypes have been associated with genitoanal lesions and they have been divided into low-risk (LR) and high-risk (HR). Low risk types HPV-6 and HPV-11 mostly lead to genital warts. are generally non-oncogenic Low risk types HPV-6 and HPV-11 mostly lead to genital warts. are generally non-oncogenic High risk types HPV-16 and -18 account for 70% of ano- genital cancer cases. High risk types HPV-16 and -18 account for 70% of ano- genital cancer cases.

5. Case report A 27 year old man that presented with repeated rectal bleeding, itching and soreness after defecation. Coproparazitologic examination was negative An anoscopy with a rigid transparent rectoscope was performed and showed lesions localised on the mucoasa in the internal half of the rectal canal.

7. What can it be ? - anal squamous cell carcinoma -anal intraepithelial neoplasia - unsually located condyloma accuminata

8. Diagnosis Histological result from the biopsy showed scuamous epithelium partially acantosis with multiple koilocytes (markers for HPV infection) but without dysplasia and keratinization. He was diagnosed with condyloma acuminata lesions on the anal mucosa, in proximity to the hemorrhoidal vessels caused by HPV-6 infection.

9. Course of treatment Current therapies for condyloma acuminata: Because of the mucosal localization and the proximity to the hemorrhoidal vessels we decided that the best approach would be plasma argon coagulation. Surgical excision Ablation by cryotherapy, electrocautery, or lasers Plasma argon coagulation Imiquimod

10. What is plasma argon coagulation ?? Argon plasma coagulation (APC) it uses argon gas to deliver plasma of evenly distributed thermal energy to a field of tissue adjacent to the probe. This ionized gas or plasma then seeks a ground in the nearest tissue, delivering the thermal energy with a depth of penetration of roughly 2 to 3 mm, significantly reducing the risk of thrombosis. By delivering energy to all tissue near the probe tip, APC can be used to treat a lesion around a fold and not clearly in view or a lesion that cannot be positioned directly in front of the endoscope. The theoretical advantages of APC include: its ease of application speedy treatment of multiple lesions in the case of angiodysplasias or wide areas safety due to reduced depth of penetration lower cost compared to laser

11. First APC session

12. Second APC session after 1 month

13. Follow-up 3 months after treatment

14. Prognostic Although treatments can get rid of the warts, none get rid of the virus. Because the virus is still present in the body, warts often come back after treatment. Anal condyloma has also been shown to be associated with anal cancer, even if genital warts are caused by non-oncogenic HPV. It is recomanded a 6 months anoscopy for relapse control.

15. HPV infection in men is under diagnosed Since HPV usually causes no symptoms, most men can get HPV—and pass it on—without realizing it. Even men with only one lifetime sex partner can get HPV. Factors associated with higher risk in men: lifetime numbers of sexual partners number of recent sexual partners uncircumcised same sex encounters no screening HPV test for men

16. Prevention How to reduce the risk of HPV transmission : The benefits of vaccinated men may be divided into 2 categories: abstinence from genital contact lifetime mutual monogamy condom use, but is not fully protective vaccine reduction of HPV-associated disease burden in boys and men prevention of HPV transmission to women

17. Conclusions HPV infection is frequent in men although is under diagnosed. Even if the HPV infection is not cured, condylomas acuminata can be kept under control. Plasma argon coagulation seems a safe and effective treatment for anal condylomas. Using this method anogenital warts can be removed in layers in a controlled manner, preventing thrombosis. Furthermore we can notice the excellent quality of cicatrization and the complete lack of incidents during or after the treatment.

18. Bibliography Rook’s textbook of dermatology (8 th edition) Human Papillomavirus-Related Disease in Men: Not Just a Women’s Issue - Joel M. Palefsky, MD, CM, FRCP(C), J Adolesc Health. 2010 April European course on HPV associated pathology:guidelines for primary care physicians for the diagnosis and management of anogenital warts - G von Krogh, C J N Lacey, G Gross, R Barrasso, A Schneider, Sex Transm Inf 2000 Successful Treatment of Anal and Perianal Condyloma Acuminata with Imiquimod- Chisato Tawada1, Yoko Oshitani1, Masaki Kimura2 and Mariko Seishima1 Genitoanal human papillomavirus infection and associated neoplasias -Gross G, Curr Probl Dermatol 2014 Genital HPV Infection, Centers for Disease Control and Prevention The Role of HPV in Disease and Oncogenesis, Medscape Age-Specific Prevalence of Anal Human Papillomavirus Infection in HIV-Negative Sexually Active Men Who Have Sex with Men: The EXPLORE Study- Peter V. Chin- Hong,1 Eric Vittinghoff,2 Ross D. Cranston,5 Susan Buchbinder,1,2,4 Daniel Cohen,6 Grant Colfax,1,2 Maria Da Costa,1 Teresa Darragh,3 Eileen Hess,10 Franklyn Judson,8 Beryl Koblin,9 Maria Madison,7 and Joel M. Palefsky1