Most genital HPV infection is transmitted by skin-to-skin sexual contact usually involving friction or microtrauma to exposed skin
.20 Subclinical infections are common; exophytic or visible condylomas usually appear 1 to 3 months after exposure but can appear much later.
20 There is no standard method to diagnose genital HPV other than visual inspection and clinician experience. Biopsies are usually not necessary, and HPV DNA sampling is usually not available or practical.
3,20 Generally, genital warts are painless, flesh-colored or pale-pink lesions with cauliflower, velvety, or smooth textures (
Figure 1). Single lesions can be present anywhere on the penile shaft, urethra, scrotum, or perineum and can be symmetric on opposing moist surfaces. Individual condylomas may coalesce in large masses around the penis or perineal area, including the anus.
20,21 For confusing or subclinical lesions, a 5% solution of acetic acid (acetowhite test) can be applied to reveal or whiten inconspicuous lesions, but this is a nonspecific technique and its positive and negative predictive values are unknown.
3,21
Lesions can be confused for other conditions, such as pearly penile papules, molluscum contagiosum, or bowenoid papulosis lesions (
Figure 2), and invasive precancerous lesions.
20 Questionable, atypical, or treatment-resistant lesions should be examined with biopsy for definitive diagnosis. Penile carcinoma is rare but is highly associated with the presence of HPV-16 and the state of being uncircumcised.
4 Patients who are MSM with newly diagnosed condylomas should be screened for other sexually transmitted diseases including HIV infection, hepatitis C virus infection, chlamy - dia, and gonorrhea.