Condylomata acuminata within perianal fistulae tracts: report of two cases

Genital human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI); more than 130 types of HPV have been identified from which more than 40 types affect the lower genital tract and approximately 15 are considered oncogenic. ¹ Condylomata acuminata (anogenital warts) affect around 5.5 million Americans each year and are estimated to have a prevalence of ∼20 million. ² Perianal HPV infection has a wide range of clinical presentations, from asymptomatic warts to invasive cancer. ³ Herein we present two cases of condylomata acuminata, hidden within fistulae tracts; in the first case resulting in recurrence after prior surgical treatment and in the second resulting in a malignant-like tumour. To our knowledge no similar cases have been reported.

A 52-year-old man was admitted to our department due to recurrence of condylomata acuminata, for which he was treated surgically in the past. He had no medical history. His laboratory examinations were within normal range. After informed consent, he was examined and found negative for hepatitis B, C and HIV infections. An operation was scheduled. The patient was placed in lithotomy position under general anaesthesia. An excision and cauterisation of the condylomata were performed, while three superficial fistulae were discovered, which were dealt by fistulotomy. The fistulae tract was found to be fully occupied by warts (Figure 1). The tract was cauterised using diathermy. The patient was discharged the following day and failed to attend at follow-up. OPEN IN VIEWER

The second case concerns a 60-year-old HIV-positive man on antiretroviral therapy (Atripla); he was referred to us due to a 5 × 5 cm anal mass, occupying 12 to 6 o’clock. Two fistulae openings were noticed upon the tumour. Malignancy was suspected and biopsies were taken. The pathology, surprisingly, showed condylomata. The lithotomy position was employed in this patient and after exploration of the fistulae via a probe, fistulotomies were performed; the tracts, as well as the entire tumour were found to be filled with warts (Figure 2). The warts were cauterised and the mass excised with preservation of the sphincter mechanism. The patient was discharged the following day. Six months postoperatively he is free of recurrence. OPEN IN VIEWER

Condylomata acuminata is the most common anorectal infection in men who have sex with men (MSM). ⁴ However, it can also occur in heterosexual men and women; although the most usual route of transmission is through sexual intercourse, non-sexual transmission can also occur. ⁵ The actual prevalence of anal HPV infection depends on the sum of multiple risk factors such as smoking, multiple sexual partners and the presence of other STIs. It is considered to range between 5 and 15% in women and somewhat lower in men. ⁶ It is worth mentioning that HPV infection has a very high prevalence among HIV-positive patients (85–93% in homosexual men and 46% in IV drug users). ⁷ HIV-positive patients have also a higher incidence of perianal fistulas which tend to be complex. ⁸

HPV types are characterised as ‘low-risk’ (6, 11, 42, 43, 44), which are primarily associated with genital warts and respiratory papillomatosis, or as ‘high-risk’ types (16, 18, 31, 33, 35, 39, 45, 51, 52), which are associated with low-grade and high-grade squamous intraepithelial lesions (LSIL and HSIL) and invasive cancer. ³ Infection by multiple HPV types is common and carries an increased risk for anal squamous intraepithelial lesions (SIL, also known as anal intraepithelial neoplasia or AIN) and progression to HSIL over time.

Patients usually complain of a perianal growth, pruritus ani, discharge, odour, bleeding and tenesmus. Physical examination can reveal the classic cauliflower-like lesion; anoscopy is essential because the disease extends internally in more than 75% of patients. ³ Tests for other STIs may be taken from the penis, anus, throat, and vagina and the polymerase chain reaction technique can be used to detect HPV DNA with high sensitivity.

Many methods of treating condylomata acuminata have been described; they can generally be categorised into regional (podophyllin, trichloracetic acid, 5-FU, bleomycin, etc), immunotherapeutic (interferon, imiquimod) and ablative (electrocoagulation, laser therapy, cryotherapy and excision). We prefer a combination of surgical excision and electrocoagulation, which is considered the gold standard in terms of efficacy and recurrence. Often more than one session is required to completely treat the lesions (staged treatment) and much care is taken to protect the sphincter mechanism. Surgical excision has the obvious advantage of the pathological examination of the specimen as well.

Recurrence is a major problem following condylomata treatment and is reported to range from 4.6 to 70% depending on the treatment modality. ⁹ The problem of recurrence is multifaceted residual disease and self-inoculation; immunocompromised patients and the nature of the disease itself (viral) are only a few of the problems that have to be dealt.

It is worth mentioning the use of the quadrivalent human papillomavirus vaccine (qHPV) to prevent anogenital warts in males; currently it is Food and Drug Administration approved for the use in males 9–26 years of age. A recently published cohort study of 313 MSM, aged 26 years and older concluded that qHPV vaccination reduces the risk of anal condyloma development. ¹⁰ Although this study has its limitations, the results are very promising.

Condylomata acuminata require treatment as early as possible. The follow-up must be vigilant, because of the tendency to relapse. Although the genital and anal regions are the commonest sights of appearance, unusual loci, such as fistulae tracts, can be a reason for repeated recurrences.