What is HPV?

Human papilloma virus (HPV) infection; It is the most common sexually transmitted viral infection in the world, its incidence is 9-13% in the community, and it is accepted that 630 million people in the world are infected with this virus. It manifests itself most frequently with genital condylomas (warts) in men, and is accused as the causative agent of many cancers in men and women. There are more than 200 types of HPV known, and 15 of the sexually transmitted HPV types are considered carcinogenic-cancer-causing. It is known to cause HPV infection, cervical cancer, penile, tongue, oro-nasopharynx, larynx and tonsil cancers, and it can occur years after being infected with the virus. In today’s studies, it has been shown that the carcinogenic types of human papilloma virus (HPV) are responsible for almost all of the cervical (cervix) cancers. Conversely, if HPV is prevented or treated with a vaccine, the frequency of cervical cancer (cervical cancer) has been greatly reduced. In the analysis and field studies, it has been reported that the probability of sexually active women and men to be infected with HPV throughout their lives is 50%. The patient with genital warts should share this information with his partner and his/her examination control should be ensured. In order to increase awareness and awareness about HPV and to emphasize that it can be prevented by vaccination, March 4 was declared as “World HPV Day” with the participation of the World Papillomavirus Association, the World Cancer Organization (UICC), and many other international associations.

ACTIVE

Human (human) Papilloma Virus (HPV) is a DNA virus that causes the formation of Condyloma (wart-papilloma) in humans. The incubation period for post-contamination HPV infection and wart development varies between 2 weeks and 8 months, mostly between 3 weeks and months for genital warts, and 10 years (10-30 years) for cancer development. There are HPV types and 90% of genital warts are caused by HPV types 6 and 11, which are frequently recurring but low-risk types for cancer development. These types have also been associated with warts of the eyes, nose, mouth, and trachea. HPV types with high risk for cancer are 16,18, 31,33,35,45,52,58 and genital warts caused by these types are not visible.

they are rarely seen, they rarely cause visible genital warts. It has been determined that high-risk HPV types play an important role in the development of various cancers, including cervical, vaginal, vulva, anal, penile and oropharyngeal carcinoma. HPV Types 16, 18, 31, 33, 45, 52 and 58 are reported to be responsible for 90% of this cancer. HPV type 16 has been found to be the most important factor in the etiology of cervical cancer (cervical cancer) all over the world. This is followed by types 18, 45 and 31. In males, precancerous and malignant diseases such as squamous cell penile carcinoma, carcinoma in situ, Bowenoid papillosis (pigmented Bowen’s disease), queyrate erythroplasia (found on the mucosal surface of the glans and foreskin) and Bowen’s disease (usually found in keratinized skin) they are associated with neoplastic lesions .

ROUTE AND TRACK OF CONTACT

There are many risk factors that accelerate the transformation of HPV infection, which is highly contagious, into cancer. The most important ones among these are polygamy and having the first sexual experience at a young age (before the age of 18) and giving birth more than 3 times are seen as risk factors. In addition, the presence of other sexually transmitted diseases (especially chlamydia trichomatis and herpes simplex etc.), smoking and tobacco useConditions in which the immune system is suppressed (such as HIV), malnutrition, and poor personal hygiene are among the risk factors. s in smokers There is a 27% increased risk of developing genital warts compared to non-smokers. Although condoms reduce the risk of transmission, they cannot completely prevent it. Transmission in HPV can be examined under four headings: sexual contact, perinatal (congenital) transmission, contamination from objects and surfaces, and respiratory tract (droplet) contamination.

1- Sexual transmission: HPV is usually spread during vaginal and anal sexual intercourse, as well as oral intercourse. It can be transmitted only by skin-to-skin contact even without sexual intercourse. Genital warts are highly contagious and the risk of HPV transmission to a sexual partner is 64%, and it is known that the rate of transmission from woman to man is significantly higher than the rate of transmission from man to woman. Infection rates in anal and oral intercourse are also very high. It has been found that HPV is the cause of 50-75% of oral-tongue-throat (oropharyngeal) cancers among oral sex head and neck cancers and it is an independent risk factor in this type of cancer.

2- Congenital transmission: HPV can be transmitted from mother to baby during birth and cause warts on the larynx and eyes of the baby. Transplacental transmission can occur from sperm carrying HPV during fertilization and by advancing in the female genital tract.

3- Contamination from surfaces and objects: The transmission of HPV from objects is a controversial issue. No proven case has been reported that HPV is transmitted from surfaces such as toilets and bathrooms. However, it is thought that the objects used during the treatment of genital warts may be infected with HPV. It is recommended to use separate gloves for manual examination. Vaginal ultrasound probes are considered a source and high-level disinfection is recommended.

4) Respiratory transmission: Inhalation/respiratory transmission of HPV is a controversial issue. HPV DNA was detected in the smoke produced by laser and electrocautery treatment. As a result of these observations, it is recommended to use smoke removal systems, masks, gloves, aprons and glasses during the process. Laser (300nm) is more dangerous than electrocautery (70nm) because larger and higher amounts of HPV DNA were obtained in laser vapor than in electrocoagulation vapor.

SYMPTOMS AND SYMPTOMS

HPV is a slow-growing virus and its latent period is 9-12 months. However, in the period of active genital lesions, the contagiousness is quite high. After the virus is taken into the body, it is eliminated by the body’s immune system at a rate of 70% in the first year and 90% in the second year, depending on the type of virus. Especially in high-risk carcinogenic virus types (types 16 and 18) that integrate into human DNA, it may take longer for the virus to be eliminated from the body. In the remaining 10% of the patients, the infection continues, genital warts appear, or in the long term (10-30 years) it causes the development of cancers in various areas. For this reason, it may be possible to detect precancerous lesions in the early period with the pop-smear screening test. If a lesion in the form of a condyloma has emerged, the diagnosis must be confirmed by biopsy and must be typed. Because today it is possible to determine whether the causative agent is the oncogene subtype of HPV.

Genital warts (Condylomas-HPV lesions) can be located generally along the entire penis in men, as well as around the testicles, groin, calves and anus.

Although it is rarer, it can sometimes be encountered in the anus or urinary canal, and even it can reach the bladder by advancing through the urinary canal. . In the transurethral resection material performed in the bladder, many cases have been reported as a pathology result of condyloma-HPV wart. In women, they are usually located around the anus, vulva, vagina, cervix (cervix). Warts are solitary or multiple, in different shapes (flat, flat or raised from the skin in the form of cauliflower), colors (tan, pink, red, white or gray), hard or soft in consistency and sizes, so that cauliflower fills the perineum between the anus and the vagina. They can also be seen as giant masses (genital warts). These lesions usually do not cause itching or pain.

HPV is the cause of 5% of cancers in the world. HPV infections are seen as a definite risk factor for cancer of the penis, anus, rectum, mouth, nasopharynx and larynx in men. Its role in penile cancer has been scientifically proven. Although the role of HPV in other urological cancers has not been proven yet, HPV infection should be kept in mind in patients with prostate cancer and some types of bladder cancer (in cases with squamous bladder cancer, squamous bladder cancer-associated inverted papilloma, chronic urinary tract infection and schistosomiasis). Although there is a relationship between HPV and inverted papilloma, which is a precancerous lesion in the bladder, a strong relationship such as HPV-cervical cancer has not been established between HPV and bladder cancer.

In women, it is the most important etiological reason for the development of cervical cancer (cervix cancer). Studies have shown that almost all of the cervical cancer cases are caused by certain types of HPV. A decrease in the frequency of cervical cancer has been determined by preventing (with vaccination), treating or hygienically preventing the transmission of HPV infections. HPV is a DNA virus and infects cervical cells, causes abnormal and uncontrolled cell proliferation, leading to condyloma-wart formation, these lesions lose control over time and become cancerous.

Giant Condyloma-War (Buschke Loewenstein Tumor): It is a type of HPV wart that grows slowly but can reach giant sizes and has a chance of becoming cancerous (35-50%). It is generally 3 times more common in men over 50 years of age. It is most commonly seen in the penis and although HPV types 6 and 11 are mostly responsible, HPV type 16,18 is also detected in some cases. Metastasis is not usually seen in cancer cases, but the death rate in 5 years is 20-30%. It is treated by surgical removal, but it recurs in 60% of cases.

A relationship has been found between HPV and male infertility. It has been shown that the presence of HPV affects sperm count, motility and morphology. In addition, it reduces the success of assisted reproductive techniques and increases the possibility of miscarriage in case of pregnancy.

DIAGNOSIS

Physical examination may be sufficient for diagnosis. However, if we are not sure of the diagnosis or if it is resistant to treatment, if the appearance is not typical warts, if there are hard, bleeding and effusive warts, biopsy can be taken to confirm the diagnosis of warts. HPV typing can be done by using biopsy or swab material taken from warts. The swab sample can be taken from the glans penis/coronal sulcus, penile shaft, scrotum, perianal area, turning 360° with dacron swabs moistened with saline, passing over all surfaces of the areas. To sample the urinary tract (urethra), the swab is advanced approximately 2 cm from the urethral opening into the urethra and rotated 360° as it is removed. Cervical smear screening may be appropriate for women older than 30. Oral, nasopharyngeal and anal swab can be taken in suspicious cases. HPV is not cultured and there are no reliable serological methods. Re-infections with the same HPV types are common because sufficient antibodies are not formed after HPV infection.

In the differential diagnosis: It can be confused with some skin diseases, precancerous skin lesions and lesions caused by the sexually transmitted molluscum contagiosum virus. The most confused disease with HPV wart is molluscum contagiosum (MCV). MCV is a DNA virus in the poxvirus group and causes smooth, umbilical-flattened, flesh-colored, 2-5 mm in size papules lesions. The diagnosis can be made by observation and often does not require laboratory examination. The lesions are highly contagious, often transmitted by skin contact, with an incubation period of 2-7 weeks, sometimes up to 6 months. It can be transmitted from bathrooms and pools in children, and through sexual contact in adults. MVC lesions can also regress spontaneously. Cryotherapy, mechanical cleaning with electrocautery, podophylline/podophyllotoxin, 3% cidofir cream, 5% imiquimod can be used in treatment.

TREATMENT

There is no drug that destroys the HPV virus and treatment is aimed at removing the lesions. If HPV warts are not treated, the warts may remain the same, grow or sometimes regress or disappear completely. As the size of the wart increases, the rate of spontaneous disappearance decreases, and especially the lesions over 4 cm disappear spontaneously.

not expected. Early treatment is important to reduce the carcinogenic effect of the infection and to prevent its spread. Recurrence can be seen frequently in the first 3 months after treatment, and the frequency of recurrence in 3-month follow-ups is between 50-60%.

Medical treatment: Locally effective creams such as podophylline, trichloroacetic acid (TCA), 5_fluorouracil, Imiquimod cream (Aldara), sinecatechins (catechine-polyphenol obtained from green tea) are used.

Ablative treatments: The basic and effective treatment is aimed at the destruction of condyloma-wart lesions with surgery or some energy systems. For this purpose, liquid nitrogen-cryotherapy (freezing with liquid nitrogen), electrocautery and laser systems are used. The laser can be applied especially to lesions in the urinary tract or lesions in all other localized areas. Pain, scarring and skin discoloration can be seen as side effects. Surgical resection is recommended if the lesions are widespread or form large masses (genital warts).

Alternative Therapies: Among the alternative therapies recommended today: podophylline resin, interferon (into the lesion), cidofovir (local) and photodynamic therapy. Apart from these, bleomycin, cidofovir, vitamin D3 derivatives, aminolevulinic acid (ALA) (photosensitizer), intradermal PPD can be counted.

Combined Treatments: Combined treatments are preferred to reduce the frequency of recurrence or in the treatment of widespread and resistant lesions. Imiquimod cream (Aldara) may be recommended after the wound healing process, first to destroy the lesions by ablation and then to prevent recurrence. In very common and resistant lesions, systemic, local or intralesion alpha interferon therapy can be given.

Treatment of Warts in the Urinary Canal: Although rare, genital warts can be seen in the urinary canal and in the mouth of the urinary canal, especially in patients with hypospadias and congenital anomalies. Therefore, in patients with HPV warts in the mouth or canal of the urinary tract.

Endoscopic examination of the bladder should also be performed. In the treatment of warts in the urinary tract, cryotherapy with liquid nitrogen or endoscopic destruction of the lesions with Laser or electrocautery-transurethral resection is recommended. The use of podophylline and imiquimod is not recommended.

PROTECTION FROM HPV INFECTION

1-USE OF CONSEVATIVES: As with all sexually transmitted diseases, regular use of condoms in polygamous sexuality reduces the risk of infection relatively, but since HPV is highly contagious, it does not completely eliminate the transmission (it provides 70% protection), and it can be transmitted through contact from areas without a condom. As a precaution against all sexually transmitted diseases, including HPV, scrotal condoms that cover the entire groin and genital area have been developed. Effective protection against sexually transmitted diseases can be provided by using a normal penile condom together with this complex scrotal condom. A female condom can also be used as a precaution against HPV. A female condom is a nitrile pouch that fits into a woman’s vagina. Data are limited, but it is known to reduce HPV transmission considerably. Ultimately, the safest way to prevent HPV and other sexually transmitted diseases is to abstain from oral, vaginal, and anal sex, or to have a mutually monogamous sexual relationship with a known uncontaminated partner.

2- Circumcision:Circumcision has been shown to protect against other sexually transmitted diseases, such as high-risk HPV infection and genital herpes.

3- Shaving of the Genital Areas I: Epilation of the genital area, waxing and shaving have been shown to increase the risk of HPV transmission. Scratching the skin with a razor blade facilitates the penetration of HPV into the skin. Therefore, for sexual contact, at least one day should be waited after this area is cleaned of hair. Since shaving the genital area with a razor or waxing while there is a wart may cause the virus to spread and more warts to appear, cleaning of the hairs should be done by other methods while there is a lesion.

4-Quitting Smoking:It is a known fact that the rate of HPV is higher in smokers, it is strongly recommended to quit smoking because genital warts are cleared and they are more likely to recur.

5-HPV VACCINE: The HPV vaccine has brought a new perspective to the prevention of HPV-related cancers. Against almost all HPV types that infect humans

has been developed and the vaccine has started to be used in all countries of the world and in Turkey. It is recommended that the vaccination be done routinely for girls aged 11-12, and it is basically accepted as 13-26 years old for women in the vaccination age group. It can also be done to sexually active women (26 years and older), but it is less effective than those who have not started a sexual life, and it shows the most effective benefit when applied before the first sexual experience. It is not safe during pregnancy, but can be administered during breastfeeding. The use of male HPV vaccine is still a matter of debate, but now quadrivalent and divalent HPV vaccines 11-12. It is recommended to be vaccinated routinely between the ages of 9 and 21 years (it can also be done at a time between 9 and 21 years old). There is no evidence to suggest that the HPV vaccine loses its ability to provide protection over time. The protection of the HPV vaccine does not fade over time, and there is no study showing the contrary. The vaccine is recommended to be administered intramuscularly in three doses, once every three months. There are bivalent and quadrivalent (vaccine developed against bi and four HPV types) vaccines in Turkey.

Vaccine types:

1-Cervarix (bivalent): It is a bivalent vaccine: It provides protection only against HPV 16,18, which is considered a carcinogen.

2-Gardasil 4 (quadrivalent): is a quadrivalent vaccine and provides protection against carcinogenic and frequently recurring HPV 16, 18, 11, 6.

3-Gardasil 9 (9-valent): It is a nine-valent vaccine and provides protection against HPV types 16, 18, 11, 6 and a total of four types, 31,33,45,52 and 58.

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