Penile warts: an update on their evaluation and management

Abstract

Background: Penile warts are the most common sexually transmitted disease in males. Clinicians should be familiar with the proper evaluation and management of this common condition.

Objective: To provide an update on the current understanding, evaluation, and management of penile warts.

Methods: A PubMed search was completed in Clinical Queries using the key terms 'penile warts' and 'genital warts'. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews.

Results: Penile warts are caused by human papillomavirus (HPV), notably HPV-6 and HPV-11. Penile warts typically present as asymptomatic papules or plaques. Lesions may be filiform, exophytic, papillomatous, verrucous, hyperkeratotic, cerebriform, fungating, or cauliflower-like. Approximately one-third of penile warts regress without treatment and the average duration prior to resolution is approximately 9 months. Active treatment is preferable to watchful observation to speed up clearance of the lesions and to assuage fears of transmission and autoinoculation. Patient-administered therapies include podofilox (0.5%) solution or gel, imiquimod 3.75 or 5% cream, and sinecatechins (polypheron E) 15% ointment. Clinician-administered therapies include podophyllin, cryotherapy, bichloroacetic or trichloroacetic acid, oral cimetidine, surgical excision, electrocautery, and carbon dioxide laser therapy. Patients who do not respond to first-line treatments may respond to other therapies or a combination of treatment modalities. Second-line therapies include topical/intralesional/intravenous cidofovir, topical 5-fluorouracil, and topical ingenol mebutate.

Conclusion: No single treatment has been shown to be consistently superior to other treatment modalities. The choice of the treatment method should depend on the physician's comfort level with the various treatment options, the patient's preference and tolerability of treatment, and the number and severity of lesions. The comparative efficacy, ease of administration, adverse effects, cost, and availability of the treatment modality should also be taken into consideration.

Keywords: bichloroacetic/trichloroacetic acid; cimetidine; cryotherapy; electrocautery; human papillomavirus; imiquimod; laser; podofilox; podophyllin; sinecatechins; surgery.

Figure 1

Penile warts manifesting as small, discrete, soft, smooth, flesh-colored, dome-shaped papules.

Figure 2

Penile warts manifesting as multiple, small, discrete, soft, smooth, flesh-colored, dome-shaped papules in clusters.

Figure 3

Penile warts manifesting as multiple verrucous papules and plaques.

Figure 4

Penile warts that are cauliflower-like.

Figure 5

Penile warts manifesting as papillomas on the penile shaft.

Figure 6

Pearly penile papules presenting as flesh-colored papules circumferentially distributed on the corona of the glans penis.

Figure 7

Fordyce spots presenting as discrete, creamy yellow, smooth papules.

Figure 8

Acrochordons presenting as soft, flesh-colored skin growths with a smooth contour.

Figure 9

Molluscum contagiosum presents as discrete, smooth, dome-shaped, pearly white papules on the penile shaft.

Figure 10

Examination of a molluscum contagiosum lesion under a dermatoscope shows a discrete dome-shaped papule with central umbilication.

Figure 11

Lichen nitidus presenting as multiple discrete, flat-topped, fleshed-colored papules on the penile shaft.

Figure 12

Lichen planus presenting as purple, planar, polygonal papules on the glans penis.

Figure 13

Seborrheic keratosis presenting as a well-demarcated, oval, brown plaque with a ‘stuck on’ warty appearance.

Figure 14

Lymphangioma circumscriptum presenting as clusters of small firm dark-red blisters with warty surface on the distal penis, resembling frog spawn.

Figure 15

Human scabies presenting as erythematous papules, which are intensely pruritic.