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Laser Therapy of Human Papilloma Virus Associated Genital Warts
Med. Laser Appl. 16: 244–247 (2001) © Urban & Fischer Verlag http://www.urbanfischer.de/journals/lasermed
Short Communication
Laser Therapy of Human Papilloma Virus Associated Genital Warts UTE MÜLLER, CARSTEN M. PHILIPP, and H.-PETER BERLIEN Laserklinik, Klinikum Neukölln, eine Einrichtung der Vivantes GmbH, Berlin, Germany Submitted: June 2001 · Accepted: July 2001
Summary Introduction: Condylomata acuminata are caused by the Human Papilloma Virus Types 6 and 11. This sexually transferred disease is one of the most widespread diseases in the world and its incidence is growing. Many different treatments exist, but the results are not satisfactory because of the high relapse rate. Patients and methods: During the past five years we treated 437 patients with genital warts with either a CO2 laser or a Nd:YAG laser, depending on the localisation. A detailed examination preceded every treatment. In cases where the lesions could not be clearly recognised as condomylata, we carried out an ALA-D-Light diagnosis and took biopsies. Results: We treated 280 males and 157 females. 80% of the males and 30% of the females suffered from intraanal lesions. Three males and one female had deep internal urethral lesions and 22% of all patients displayed genital warts at the urethral ostium. 12% of the women had portio lesions and in 4% of the females and in three men we detected dysplasias using the ALA-D-Light diagnosis system. The total relapse rate was of 7%. Discussion: The widespread nature and high infection rate of genital warts together with their possible complications make a reliable and adequate treatment essential. Because of the many phenotypes of condylomata, diseases like dysplasias have to be excluded. Summary: The use of lasers in the treatment of genital warts has helped to reduce the rate of relapse. Appropriate and discriminatory diagnostics prior to treatment lead to better results. Patient’s acceptance is high because they often can be treated as outpatients, suffer only minor inconvenience and good cosmetic results are achieved.
Key words HPV, Condylomata acuminata, ALA-D-Light fluorescence diagnosis, CO2-laser, Nd:YAG-laser
Introduction Within the last years a clear increase in the incidence of sexually transmitted diseases can be discerned. The Human Papilloma Virus, responsible for genital warts, causes one of the most widespread diseases in the world. Human papilloma viruses are known to invade the squamous epithelium of the entire lower female genital tract as well as the male
genitalia. Infections can be either clinical, subclinical or latent. About 60% of the sexually active population are affected by a virus infection at some point of their life. About 1% of these will suffer from genital warts (3). The infection generally occurs during the sexual act when the virus finds its way through the basal membrane via microlesions, but smear infections are also known, as is contamination during parturition. 1615-1615/01/16/03-244 $ 15.00/0
Laser Therapy of Human Papilloma Virus associated Genital Warts
The warts appear after a latency of six months or more. We even know of a seventy year old patient who had had no sexual contact for twenty years before the histologically established appearance of these lesions. The main risk factors include an early beginning to the sexual life and frequent changes in sexual partners. Congenital or acquired immunodeficiency can also favour the appearance of warts. A latent infection can become manifest during pregnancy. Some children are also affected. In a period of five years, we saw 6 patients aged from five to nine with external genital warts. In such cases, sexual assault must – as far as possible – be ruled out. To date, about one hundred and twenty types of human papilloma virus are known. Genital warts are caused by types six and eleven, though in patients with a reduced immune status, other types can also be identified. In contrast to – amongst others – types 16 and 18, type 6 and 11 do not lead to malignant degeneration, but the high rate of infections and possible complications like bleeding and fistulisation make an adequate treatment necessary. External genital warts are the easiest to recognize. Bleaching with acetic acid can be helpful, but can also lead to false negative results. Nearly all anogenital regions including the perineum and the skin of the thigh can be affected. Intraanal lesions do not normally cross the linea dentate, with the exception of patients with aquired immune deficiency syndrome. Here we found tumorlike lesions above this line. Perioral, intraoral, preauricular and internal nose warts are all rare, in contrast to the internal vaginal and portio localisations we often see in young women. The phenotype of the warts can vary from that of singular lesions to large flat areas and tumor like lesions. They often are symptomless, though patients sometimes report of itching, burning, bleeding, pain, dyspareunia, ulceration or secondary infection and fistulisation. The therapeutic stragegies are diverse. Independent of the method of treatment, the frequency of relapse as found in the literature varies from between 0 and 65%. The large variation may be due to differences in the extensiveness, localisation and frequency of follow up examinations involved.
245
Laser Treatment The majority of our patients came to us with a history of many different treatments, and had suffered from warts for months or even years. The lesions were often very extensive. Consequently, almost none of our cases corresponded to early disease. Before treatment, we performed a detailed examination including a proctoscopy and a vaginoscopy. We used equipment with modern optics to help detect small lesions, because these were considered to be a possible reason for the high relapse tendency. In the case of an involvement of the urethral ostium, a urethroscopy was obligatory. In all cases where the lesions were not easily identifiable as harmless warts, we performed a 5-ALA enhanced fluorescence diagnosis (D-LIGHT) to detect dysplastic tissue. We selectively biopsied all conspicuous fluorescent areas. Depending on the histological result, we then planned the subsequent procedure together with our partners from our interdisciplinary tumor conference. The CO2-laser (wavelength 10600 nm) has been used therapeutically for over thirty-five years. We use it on keratinised squamous epithelium. Depending on the situation, we perform either a vaporisation or excision. Most warts can be completely dealt with by vaporisation, lasing in a continuous wave mode. The applied power lies between 10 and 20 watts, depending on the size and thickness of the lesion. Large lesions are excised with the CO2-laser. The laser allows an exact delineation between the tissue layers, so the risk of destroying deeper tissue and inducing scars is rare (4). Owing to smoke production, an efficient smoke outlet is necessary. Because a modest carbonisation occurs, the wounds are closed and the risk of an infection is low. Patients don’t suffer from pain and the wounds will generally heal within 10 days (Fig. 1a,b). In cases with an extensive manifestation at the prepuce, a circumcision with the CO2-laser is also carried out. In this way, a phimosis during wound healing can be avoided and the risk of a relapse reduced (Fig. 2a,b). We use the Nd:YAG-laser with a wavelength of 1064 nm since 1985 for the treatment of condylomata localized on non keratinised squamous epithelium and mucous membranes (1, 2). The handpiece can be
246
UTE MUELLER et al.
Fig. 3. Nd:YAG-laser intraanal non contact coagulation.
a
b
Fig. 1. CO2-laser treatment of condylomata located at squamous epithelium, a) prior, b) after CO2-laser vaporisation.
a
Fig. 2. Disseminated lesions at the prepuce, a) prior, b) 7 days after CO2-laser circumcision.
b
Fig. 4. Nd:YAG-laser intraanal contact vaporization.
replaced by a bare fiber. The bare fiber with a 600 nm core diameter is flexible, precise and can be employed in endoscopic equipment. This allows to treat lesions in localisations generally difficult to reach. The endoscope’s capability of image magnification allows the efficient detection of all lesions. Internal urethral lesions are treated by in situ contact coagulation using 8 W/0.5 s pulses with a freshly broken bare fiber in contact with the warts. It is a method that avoids damaging normal tissue in situations where the lumina are small. Small single or disseminated cervical portio warts are treated using the contact coagulation method either way but using 5 W/0.5 s with regard to the air environvent (1, 2). The non contact coagulation method is performed intraanally and intravaginally. Larger cauliflower condylomata are coagulated using the non-contact method with the bare fiber until a blanching is visible with 10–30 W and pulse lengths between 0.5s and cw depending on size (Fig. 3). In some situations a contact vaporisation with a preblackened fiber is advisable (1, 2). In this case we use 25 W (in air) or 35 W (in aequous solutions) with pulse lengths of 0.2 s (Fig. 4). For laser parameters see also table 1.
Table 1. Nd:YAG-laser parameters for HPV-treatment. Bare fiber 600µm core
Aim
Surrounding
Application
Power (W)
Time (s)
Fresh broken fiber
in situ coagulation of larger lesions in situ coagulation of small lesions in situ coagulation of small lesions
air/water air water
non contact contact contact
10–30 5 8
0.5 – cw 0.5 0.5
Preblackened fiber
contact vaporisation
air water
contact contact
25 35
0.2 0.2
Laser Therapy of Human Papilloma Virus associated Genital Warts
Results Since the founding of the Laser Clinic in 1996, we have treated 437 patients with condylomata, 280 males and 157 females. 80% of the males and 30% of the females suffered from intraanal lesions. Three males and one female had deep internal urethral lesions and in 22% of all patients we could find condylomata at the urethral ostium. 12% of the women showed portio lesions. The overall recurrence rate was 7%. The minimum follow up time is one year. In 4% of the women and in three men we detected a dysplasia.
Discussion The incidence of condylomata as a sexually transferred disease is on the rise. This disease can lead to serious problems, so an effective treatment appears very necessary. The large number of treatments offered and the high rates of relapse indicate that this virus associated disease is not easy to eradicate. The patients with dysplasia show how important a detailed endoscopic examination and the 5-ALA-fluorescence diagnosis (D-LIGHT) can be. The selective laser treatment represents an effective method that in many cases can be performed as an ambulatory procedure. The cosmetic results are good, most patients don’t suffer from pain after treatment and the relapse rate is low.
Die Laserbehandlung der HPV-assoziierten Genitalwarzen Genitalwarzen werden durch die HP-Virustypen 6 und 11 hervorgerufen und am häufigsten durch Geschlechtsverkehr übertragen. Sie zählen zu einer der verbreitetsten Erkrankungen weltweit und zeigen eine zunehmende Inzidenz. Es existieren unterschiedliche Behandlungsmethoden, und die Ergebnisse sind wegen der hohen Rezidivraten nach wie vor nicht befriedigend.
247
Wir haben innerhalb der letzten 5 Jahre 437 Patienten mit Condylomata – abhängig von Ausdehnung und Lokalisation – mit dem CO2-Laser bzw. dem Nd:YAG-Laser behandelt Jeder Behandlung ging eine exakte Diagnostik voraus. In Fällen, in denen die Condylome nicht eindeutig als solche zu erkennen waren, haben wir eine 5-ALA-Fluoreszenzdiagnostik (D-LIGHT) vorangestellt und gezielte Biopsien entnommen. Wir haben 280 Männer und 157 Frauen behandelt. 80% der männlichen und 30% der weiblichen Patienten zeigten einen intraanalen Befall. Befunde in der Urethra haben wir bei 3 Männern und einer Frau gefunden. Insgesamt 22% aller Patienten litten unter einem Befall des orificium urethrae. 12% der Frauen hatten auch Portiobefunde und 4% der Frauen sowie 3 Männer zeigten dysplastische Veränderungen. Die Rezidivrate lag nach Laserbehandlung bei insgesamt 7%. Die weite Verbreitung und das hohe Ansteckungsrisiko der Erkrankung sowie die möglichen Komplikationen erfordern eine konsequente und differenzierte Vorgehensweise. Alle nicht eindeutig als Condylome zu identifizierenden Befunde müssen einer Diagnose zugeführt werden, um Dysplasien nicht zu übersehen. Die Einführung der Laserbehandlung hat die Rezidivrate reduziert. Die vorausgehende Diagnostik erlaubt ein differenziertes Vorgehen und führt zu besseren Ergebnissen. Die Akzeptanz bei den Patienten ist hoch, sie können oft ambulant behandelt werden, sind wenig beeinträchtigt und die kosmetischen Resultate sind gut.
Schlüsselwörter HPV, Condylomata acuminata, Fluoreszenzdiagnostik, CO2Laser, Nd:YAG-Laser
References 1. BASTERT G, WALLWIENER D (eds): Lasers in Gynecology. Springer Verlag, Berlin 1992 2. BERLIEN H-P, MUELLER G (eds): Angewandte Lasermedizin. ecomed Verlag, Landsberg, Muenchen, Zuerich 1989 3. GROSS GE, BARASSO R (eds): Human Papilloma Virus Infection – A Clinical Atlas. Ullstein Mosby, Berlin 1997 4. KEYE WR JR (ed): Laser Surgery in Gynecology and Obstetrics, 2nd ed. Year Book Medical Publishers, Inc. Chicago 1990
Correspondence address: UTE MÜLLER, Laserklinik, Klinikum Neukölln – Eine Einrichtung der Vivantes GmbH, Rudower Str. 48, D-12351 Berlin, Germany Tel: +49 (0) 30 6004 3831; Fax: +49 (0) 30 6004 3870; e-mail: [email protected], URL:www.knk-berlin.de
Short Communication
Laser Therapy of Human Papilloma Virus Associated Genital Warts UTE MÜLLER, CARSTEN M. PHILIPP, and H.-PETER BERLIEN Laserklinik, Klinikum Neukölln, eine Einrichtung der Vivantes GmbH, Berlin, Germany Submitted: June 2001 · Accepted: July 2001
Summary Introduction: Condylomata acuminata are caused by the Human Papilloma Virus Types 6 and 11. This sexually transferred disease is one of the most widespread diseases in the world and its incidence is growing. Many different treatments exist, but the results are not satisfactory because of the high relapse rate. Patients and methods: During the past five years we treated 437 patients with genital warts with either a CO2 laser or a Nd:YAG laser, depending on the localisation. A detailed examination preceded every treatment. In cases where the lesions could not be clearly recognised as condomylata, we carried out an ALA-D-Light diagnosis and took biopsies. Results: We treated 280 males and 157 females. 80% of the males and 30% of the females suffered from intraanal lesions. Three males and one female had deep internal urethral lesions and 22% of all patients displayed genital warts at the urethral ostium. 12% of the women had portio lesions and in 4% of the females and in three men we detected dysplasias using the ALA-D-Light diagnosis system. The total relapse rate was of 7%. Discussion: The widespread nature and high infection rate of genital warts together with their possible complications make a reliable and adequate treatment essential. Because of the many phenotypes of condylomata, diseases like dysplasias have to be excluded. Summary: The use of lasers in the treatment of genital warts has helped to reduce the rate of relapse. Appropriate and discriminatory diagnostics prior to treatment lead to better results. Patient’s acceptance is high because they often can be treated as outpatients, suffer only minor inconvenience and good cosmetic results are achieved.
Key words HPV, Condylomata acuminata, ALA-D-Light fluorescence diagnosis, CO2-laser, Nd:YAG-laser
Introduction Within the last years a clear increase in the incidence of sexually transmitted diseases can be discerned. The Human Papilloma Virus, responsible for genital warts, causes one of the most widespread diseases in the world. Human papilloma viruses are known to invade the squamous epithelium of the entire lower female genital tract as well as the male
genitalia. Infections can be either clinical, subclinical or latent. About 60% of the sexually active population are affected by a virus infection at some point of their life. About 1% of these will suffer from genital warts (3). The infection generally occurs during the sexual act when the virus finds its way through the basal membrane via microlesions, but smear infections are also known, as is contamination during parturition. 1615-1615/01/16/03-244 $ 15.00/0
Laser Therapy of Human Papilloma Virus associated Genital Warts
The warts appear after a latency of six months or more. We even know of a seventy year old patient who had had no sexual contact for twenty years before the histologically established appearance of these lesions. The main risk factors include an early beginning to the sexual life and frequent changes in sexual partners. Congenital or acquired immunodeficiency can also favour the appearance of warts. A latent infection can become manifest during pregnancy. Some children are also affected. In a period of five years, we saw 6 patients aged from five to nine with external genital warts. In such cases, sexual assault must – as far as possible – be ruled out. To date, about one hundred and twenty types of human papilloma virus are known. Genital warts are caused by types six and eleven, though in patients with a reduced immune status, other types can also be identified. In contrast to – amongst others – types 16 and 18, type 6 and 11 do not lead to malignant degeneration, but the high rate of infections and possible complications like bleeding and fistulisation make an adequate treatment necessary. External genital warts are the easiest to recognize. Bleaching with acetic acid can be helpful, but can also lead to false negative results. Nearly all anogenital regions including the perineum and the skin of the thigh can be affected. Intraanal lesions do not normally cross the linea dentate, with the exception of patients with aquired immune deficiency syndrome. Here we found tumorlike lesions above this line. Perioral, intraoral, preauricular and internal nose warts are all rare, in contrast to the internal vaginal and portio localisations we often see in young women. The phenotype of the warts can vary from that of singular lesions to large flat areas and tumor like lesions. They often are symptomless, though patients sometimes report of itching, burning, bleeding, pain, dyspareunia, ulceration or secondary infection and fistulisation. The therapeutic stragegies are diverse. Independent of the method of treatment, the frequency of relapse as found in the literature varies from between 0 and 65%. The large variation may be due to differences in the extensiveness, localisation and frequency of follow up examinations involved.
245
Laser Treatment The majority of our patients came to us with a history of many different treatments, and had suffered from warts for months or even years. The lesions were often very extensive. Consequently, almost none of our cases corresponded to early disease. Before treatment, we performed a detailed examination including a proctoscopy and a vaginoscopy. We used equipment with modern optics to help detect small lesions, because these were considered to be a possible reason for the high relapse tendency. In the case of an involvement of the urethral ostium, a urethroscopy was obligatory. In all cases where the lesions were not easily identifiable as harmless warts, we performed a 5-ALA enhanced fluorescence diagnosis (D-LIGHT) to detect dysplastic tissue. We selectively biopsied all conspicuous fluorescent areas. Depending on the histological result, we then planned the subsequent procedure together with our partners from our interdisciplinary tumor conference. The CO2-laser (wavelength 10600 nm) has been used therapeutically for over thirty-five years. We use it on keratinised squamous epithelium. Depending on the situation, we perform either a vaporisation or excision. Most warts can be completely dealt with by vaporisation, lasing in a continuous wave mode. The applied power lies between 10 and 20 watts, depending on the size and thickness of the lesion. Large lesions are excised with the CO2-laser. The laser allows an exact delineation between the tissue layers, so the risk of destroying deeper tissue and inducing scars is rare (4). Owing to smoke production, an efficient smoke outlet is necessary. Because a modest carbonisation occurs, the wounds are closed and the risk of an infection is low. Patients don’t suffer from pain and the wounds will generally heal within 10 days (Fig. 1a,b). In cases with an extensive manifestation at the prepuce, a circumcision with the CO2-laser is also carried out. In this way, a phimosis during wound healing can be avoided and the risk of a relapse reduced (Fig. 2a,b). We use the Nd:YAG-laser with a wavelength of 1064 nm since 1985 for the treatment of condylomata localized on non keratinised squamous epithelium and mucous membranes (1, 2). The handpiece can be
246
UTE MUELLER et al.
Fig. 3. Nd:YAG-laser intraanal non contact coagulation.
a
b
Fig. 1. CO2-laser treatment of condylomata located at squamous epithelium, a) prior, b) after CO2-laser vaporisation.
a
Fig. 2. Disseminated lesions at the prepuce, a) prior, b) 7 days after CO2-laser circumcision.
b
Fig. 4. Nd:YAG-laser intraanal contact vaporization.
replaced by a bare fiber. The bare fiber with a 600 nm core diameter is flexible, precise and can be employed in endoscopic equipment. This allows to treat lesions in localisations generally difficult to reach. The endoscope’s capability of image magnification allows the efficient detection of all lesions. Internal urethral lesions are treated by in situ contact coagulation using 8 W/0.5 s pulses with a freshly broken bare fiber in contact with the warts. It is a method that avoids damaging normal tissue in situations where the lumina are small. Small single or disseminated cervical portio warts are treated using the contact coagulation method either way but using 5 W/0.5 s with regard to the air environvent (1, 2). The non contact coagulation method is performed intraanally and intravaginally. Larger cauliflower condylomata are coagulated using the non-contact method with the bare fiber until a blanching is visible with 10–30 W and pulse lengths between 0.5s and cw depending on size (Fig. 3). In some situations a contact vaporisation with a preblackened fiber is advisable (1, 2). In this case we use 25 W (in air) or 35 W (in aequous solutions) with pulse lengths of 0.2 s (Fig. 4). For laser parameters see also table 1.
Table 1. Nd:YAG-laser parameters for HPV-treatment. Bare fiber 600µm core
Aim
Surrounding
Application
Power (W)
Time (s)
Fresh broken fiber
in situ coagulation of larger lesions in situ coagulation of small lesions in situ coagulation of small lesions
air/water air water
non contact contact contact
10–30 5 8
0.5 – cw 0.5 0.5
Preblackened fiber
contact vaporisation
air water
contact contact
25 35
0.2 0.2
Laser Therapy of Human Papilloma Virus associated Genital Warts
Results Since the founding of the Laser Clinic in 1996, we have treated 437 patients with condylomata, 280 males and 157 females. 80% of the males and 30% of the females suffered from intraanal lesions. Three males and one female had deep internal urethral lesions and in 22% of all patients we could find condylomata at the urethral ostium. 12% of the women showed portio lesions. The overall recurrence rate was 7%. The minimum follow up time is one year. In 4% of the women and in three men we detected a dysplasia.
Discussion The incidence of condylomata as a sexually transferred disease is on the rise. This disease can lead to serious problems, so an effective treatment appears very necessary. The large number of treatments offered and the high rates of relapse indicate that this virus associated disease is not easy to eradicate. The patients with dysplasia show how important a detailed endoscopic examination and the 5-ALA-fluorescence diagnosis (D-LIGHT) can be. The selective laser treatment represents an effective method that in many cases can be performed as an ambulatory procedure. The cosmetic results are good, most patients don’t suffer from pain after treatment and the relapse rate is low.
Die Laserbehandlung der HPV-assoziierten Genitalwarzen Genitalwarzen werden durch die HP-Virustypen 6 und 11 hervorgerufen und am häufigsten durch Geschlechtsverkehr übertragen. Sie zählen zu einer der verbreitetsten Erkrankungen weltweit und zeigen eine zunehmende Inzidenz. Es existieren unterschiedliche Behandlungsmethoden, und die Ergebnisse sind wegen der hohen Rezidivraten nach wie vor nicht befriedigend.
247
Wir haben innerhalb der letzten 5 Jahre 437 Patienten mit Condylomata – abhängig von Ausdehnung und Lokalisation – mit dem CO2-Laser bzw. dem Nd:YAG-Laser behandelt Jeder Behandlung ging eine exakte Diagnostik voraus. In Fällen, in denen die Condylome nicht eindeutig als solche zu erkennen waren, haben wir eine 5-ALA-Fluoreszenzdiagnostik (D-LIGHT) vorangestellt und gezielte Biopsien entnommen. Wir haben 280 Männer und 157 Frauen behandelt. 80% der männlichen und 30% der weiblichen Patienten zeigten einen intraanalen Befall. Befunde in der Urethra haben wir bei 3 Männern und einer Frau gefunden. Insgesamt 22% aller Patienten litten unter einem Befall des orificium urethrae. 12% der Frauen hatten auch Portiobefunde und 4% der Frauen sowie 3 Männer zeigten dysplastische Veränderungen. Die Rezidivrate lag nach Laserbehandlung bei insgesamt 7%. Die weite Verbreitung und das hohe Ansteckungsrisiko der Erkrankung sowie die möglichen Komplikationen erfordern eine konsequente und differenzierte Vorgehensweise. Alle nicht eindeutig als Condylome zu identifizierenden Befunde müssen einer Diagnose zugeführt werden, um Dysplasien nicht zu übersehen. Die Einführung der Laserbehandlung hat die Rezidivrate reduziert. Die vorausgehende Diagnostik erlaubt ein differenziertes Vorgehen und führt zu besseren Ergebnissen. Die Akzeptanz bei den Patienten ist hoch, sie können oft ambulant behandelt werden, sind wenig beeinträchtigt und die kosmetischen Resultate sind gut.
Schlüsselwörter HPV, Condylomata acuminata, Fluoreszenzdiagnostik, CO2Laser, Nd:YAG-Laser
References 1. BASTERT G, WALLWIENER D (eds): Lasers in Gynecology. Springer Verlag, Berlin 1992 2. BERLIEN H-P, MUELLER G (eds): Angewandte Lasermedizin. ecomed Verlag, Landsberg, Muenchen, Zuerich 1989 3. GROSS GE, BARASSO R (eds): Human Papilloma Virus Infection – A Clinical Atlas. Ullstein Mosby, Berlin 1997 4. KEYE WR JR (ed): Laser Surgery in Gynecology and Obstetrics, 2nd ed. Year Book Medical Publishers, Inc. Chicago 1990
Correspondence address: UTE MÜLLER, Laserklinik, Klinikum Neukölln – Eine Einrichtung der Vivantes GmbH, Rudower Str. 48, D-12351 Berlin, Germany Tel: +49 (0) 30 6004 3831; Fax: +49 (0) 30 6004 3870; e-mail: [email protected], URL:www.knk-berlin.de