HPV in men

What HPV is and what it does in men

Human papillomavirus is not one virus but a family of more than two hundred types. A handful of them infect genital skin, and there they divide into two groups that do very different things:

• Low-risk types, chiefly 6 and 11. They cause genital warts. They are a nuisance, they are contagious and they recur, but they do not cause cancer.
• High-risk types, led by 16 and followed by 18, 31, 33, 45, 52 and 58. They hardly ever cause warts: when they do cause a problem, they do it silently, as flat lesions that can go years without symptoms.

In men, the vast majority of infections are transient: the immune system clears them within one or two years. Only a small fraction persist, and only a fraction of those go on to produce a premalignant lesion.

Genital warts

These are the most visible and the most common manifestation. They appear as soft raised lesions, skin-coloured or slightly paler, with an irregular surface, on the shaft of the penis, the glans, the foreskin, the urinary meatus or the perianal area. There may be one or several, and they can grow in clusters.

• They are treated with medication applied to the lesion or with procedures that remove it: cryotherapy, diathermy, CO₂ laser or excision.
• They recur frequently, in around one in four people, because treatment removes the lesion but not always the virus in the neighbouring tissue. It does not mean the treatment failed.
• Having warts does not mean you also have a high-risk type, nor that you are on your way to a cancer.

Premalignant lesions of the penis

When a high-risk type persists, it can produce penile intraepithelial neoplasia, or PeIN. These are abnormal cells confined to the surface layer of the skin: they are not yet cancer, because they have not crossed the membrane that separates them from the deeper tissue, but they can become cancer if left to evolve.

They usually appear as red, velvety, whitish or pigmented patches on the glans or the foreskin. They are easily mistaken for balanitis, dermatitis or a fungal infection, which is why many are treated with creams for months before being biopsied.

Two different routes to penile cancer

This is the concept that makes sense of everything else, and the one that is almost never explained. Since 2016, and reinforced in the 2022 classification, penile cancer is recognised as having not one origin but two, with different precursor lesions, different patients and different prevention.

Lichen sclerosus: the route nobody mentions

This is a chronic inflammatory condition of the genital skin that hardens and whitens the foreskin and glans, and which over the years narrows it until it produces phimosis. It has nothing to do with HPV or with sexual activity.

It matters because it is the main gateway to the HPV-independent route: a long-standing lichen sclerosus can give rise to differentiated PeIN, and from there to a carcinoma. Untreated lichen sclerosus is a real and modifiable risk factor, and in many cases circumcision is both the definitive treatment and the preventive measure.

Which lesions must be biopsied

If you take away a single sentence from this guide, let it be this one: a penile lesion that has gone weeks without healing is not treated blindly any longer, it is biopsied.

• Any lesion that does not resolve after four to six weeks of appropriate treatment.
• Red, whitish, velvety or pigmented patches that persist.
• Lesions that bleed, ulcerate, harden or grow.
• Warts with an atypical appearance, irregular pigment or an indurated base.
• Any lesion beneath a foreskin that cannot be retracted: what cannot be seen cannot be monitored.
• Areas of lichen sclerosus that change in appearance or thicken.

Penile cancer: why delay is the problem

It is an uncommon tumour, though less uncommon in Mexico and Latin America than in Europe or the United States. It presents as a lesion that will not heal, an ulcer, a lump or a thickening, almost always on the glans or the foreskin.

What determines the outlook is not so much the size of the tumour as whether it has reached the lymph nodes in the groin. And this is where the factor that does depend on the patient comes in: the delay in seeking help. Months often pass between the lesion appearing and the first consultation, almost always out of embarrassment or fear of what will be found.

What actually helps to prevent it

• HPV vaccination. It covers the most frequent high-risk types and also those that cause warts. It is more effective the earlier it is given, ideally before sexual activity begins, but it can also be indicated in adults. It prevents new infections; it does not treat existing ones nor remove an established lesion.
• Circumcision. It reduces the risk of penile cancer, particularly where there is phimosis or lichen sclerosus, and it makes hygiene and skin monitoring easier.
• Stopping smoking. Tobacco is an independent risk factor and is frequently left out of this conversation.
• Treating chronic inflammation. Recurrent balanitis, lichen sclerosus and phimosis are not minor nuisances: they are the ground on which these lesions develop.
• Condoms reduce transmission, though they do not eliminate it, because the virus is also present on skin the condom does not cover.

If your partner has been diagnosed with HPV

This is a frequent reason for consultation and it almost always arrives loaded with recrimination. A few things are worth clarifying:

• There is no way to know who transmitted it or when. The virus can remain dormant for years without any sign, so a recent diagnosis does not indicate recent infidelity.
• There is no treatment that eliminates the virus in someone without lesions. What is treated are the lesions, not the infection.
• The sensible course is an examination of the genital skin and biopsy only of what warrants it.
• Vaccination remains useful even where there has been prior exposure, because it protects against the types not yet acquired.