HPV and Anal Health

HPV is the human papillomavirus. HPV infections are very common and are spread through intimate skin-to-skin contact. Nearly everyone will get HPV at some point in their lives.
There are over 100 different strains of HPV, but they are generally divided into low-risk and high-risk types.

The low-risk types often never show symptoms but may cause warts on the penis, vagina, or the anus, both outside and inside.

The high-risk types are more commonly associated with pre-cancerous lesions (which often cannot be seen or felt), resulting an increased risk of developing anal cancer. Not everyone with a high-risk HPV strain will develop pre-cancerous lesions, but they are at much higher risk.

HPV mainly affects cells that make up our outside skin. It tends to affect an area called the transformation zone, which is where our outside anal skin meets the inside skin. For most people, this area is approximately one and a half inches inside.

Young, healthy people frequently “clear” HPV infections without any intervention. However, certain risk factors may impact someone’s ability to do so.

Genital warts can appear anywhere from a few weeks to a few months after you are exposed to HPV. The warts might look like small bumps. Sometimes they are fleshy and look like small cauliflowers.

Genital warts can get bigger over time, or they may go away on their own.

Your health care provider can usually tell if you have genital warts by looking at them. You can also develop warts inside your anal canal or around your anus. Sometimes an anoscope is used to look inside your anus to see if you have any internal warts. Anal and genital warts are more commonly caused by low-risk strains of HPV and do not normally lead to anal cancer.

However, if you have warts, you may also have been exposed to high-risk HPV strains and may be at increased risk of developing pre-cancerous lesions.

Anal Dysplasia is a condition that results in abnormal changes in the cells in the lining of the anal canal or the skin around the anal opening. It is associated with past or present infection with HPV.

When these abnormal cells cluster to form a visible pattern, it’s called a lesion. The lesions are classified as low-grade squamous intraepithelial lesions (LSIL) or high-grade squamous intraepithelial lesions (HSIL).

HSIL is a term used to describe precancerous lesions which require closer monitoring and intervention because they have the potential to progress to anal cancer. Not all HSIL progresses to anal cancer, and most of them will not.

Because we do not know which HSIL lesions will progress to anal cancer, the recommendation is to treat them and continue to monitor patients more closely going forward.  HSIL lesions may return even after being treated.

Your primary care provider may perform anal pap smear tests, high-risk HPV tests, and/or the digital anal rectal examination (DARE) to see if you need further evaluation with High Resolution Anoscopy (HRA). If any of these tests are abnormal, HRA is the recommended procedure to screen for possible HSIL. If HSIL is found during the HRA exam, treatment is usually recommended in order to reduce your risk of developing anal cancer.

If you don’t receive primary care with Howard Brown, you can get screened for HPV, anal dysplasia, and other STIs at a Sexual & Reproductive Health Walk-In Clinic near you. Quick and low-cost, no appointment needed.

• People living with HIV
• Men who have sex with men (MSM)
• Individuals with many sex partners or a partner with many sex partners
• Individuals having receptive anal sex
• Individuals with a history of anal warts, genital warts, anal fissures, fistulas, or hemorrhoids
• Individuals with a history of cervical, vaginal, or vulvar dysplasia or cancer
• Individuals who smoke cigarettes
• Organ transplant recipients and other groups with reduced immunity

There is no single treatment for HPV infection. Some people “clear” an HPV infection on their own. They can later be reinfected with HPV again. Dysplasia and warts can be removed in
several ways:

• Burning them with an electric needle (electrocautery) or a laser
• Freezing them with liquid nitrogen
• Cutting them out
• Treating them with chemicals.
• Cream, gel, or solution

Condoms do not totally prevent transmission of HPV but may be helpful. HPV can be transmitted by direct contact with infected areas that aren’t covered by a condom. In 2009,
the vaccine Gardasil was approved to prevent infection with 2 low risk types of HPV, which cause warts, and 7 high-risk types of HPV, which can cause cancer. Talk to your provider to see if you should get the Gardasil vaccine.

A High Resolution Anoscopy (HRA) procedure requires relatively little preparation. A complete bowel preparation is not required but emptying your bowels prior to the procedure may reduce possible discomfort.

Your provider will give you exact preparation instructions, but you should avoid the following for 24 hours prior to your procedure:

• Engaging in anal sex;
• Inserting anything, including medication or other products, into your anus; or
• Using a douche or receiving an enema.

Please immediately call our team to reschedule your appointment if:

• You have engaged in one of the above activities within 24 hours of your planned procedure;
• You are experiencing acute abdominal pain;
• You are experiencing diarrhea (if you do not regularly experience it); or
• You are actively receiving treatment for a sexually transmitted illness (STI).

It is very important that you arrive on-time to your appointment. You should arrive at the clinic 10 to 15 minutes before your scheduled appointment time in order to allow our team to prepare for the procedure and provide care to you in a timely manner.

Sign in with the front desk staff like any other appointment and a member of our Anal Health care team will soon retrieve you and bring you to the exam room. At this time, please let our specialist know if you have any allergies to topical anesthesia (including lidocaine) and/or if you are currently taking any blood thinners.

The appointment will proceed as follows:

1. The provider asks the patient about relevant medical history and discusses details of the procedure.
2. The patient is placed on their left side on the examination chair.
3. The provider conducts a digital exam with a gloved finger and some numbing gel.
4. An anoscope (a small diameter plastic tube) is inserted into the anus.
5. A vinegar-soaked gauze pad is placed inside and the anoscope is removed for a few minutes. Another vinegar-soaked gauze pad will be placed on the outside anal skin.
6. After approximately two minutes, the gauze pads will be removed.
7. The peri-anal skin (the outside of the anus) is examined using a colposcope (a moveable, high-resolution microscope with a light source).
8. The anoscope is reinserted to allow the provider to examine the internal anus and rectum.
9. More vinegar and an iodine solution may be applied with a small swab.
10. If an abnormal-appearing tissue is identified in the peri-anal area, internal anus, or rectum, a small biopsy is taken and sent to a pathology lab for analysis. The tissue sample is very small (approximately the size of a sesame seed) and taking the sample may be painless or feel like a quick pinch. Note: If the abnormal-appearing tissue is on the outside (the peri-anal area), the area will be numbed with lidocaine prior to taking a biopsy.

The High Resolution Anoscopy (HRA) procedure is relatively minor and requires little to no recovery. Our care team will provide you with specific post-procedure instructions at your appointment, but generally speaking:

If the procedure does not result in a biopsy, no aftercare is required. You may experience some discomfort during the procedure, but it should pass very shortly thereafter and not recur. If you do experience continuing or recurring discomfort, please contact our team and we will work to identify the cause.

If the procedure results in one or more biopsy, your anus will need a short period of time to heal, and you may experience minor pain or bleeding following bowel movements. We suggest taking warm baths and/or over-the-counter pain relievers (such as Tylenol or ibuprofen) to soothe discomfort. Additionally, nothing should enter the anus for five to seven days following the procedure.