Editors' Message  |   March 2011
Human Papillomavirus: Every Answer Raises More Questions
Author Notes
  • Dr Weaver is a medical advisor for the Hillsborough County Sheriff's Office, Department of Detention Services, in Tampa, Florida. Dr Cymet is the associate vice president for medical education at the American Association of Colleges of Osteopathic Medicine. Dr Cymet is a member of the JAOA's Editorial Board. 
  • Address correspondence to Tyler C. Cymet, DO, Associate Vice President for Medical Education, American Association of Colleges of Osteopathic Medicine, 5550 Friendship Blvd, Suite 310, Chevy Chase, MD 20815-7231.E-mail: 
Article Information
Gastroenterology / Preventive Medicine / Urological Disorders
Editors' Message   |   March 2011
Human Papillomavirus: Every Answer Raises More Questions
The Journal of the American Osteopathic Association, March 2011, Vol. 111, Sii-S2. doi:
The Journal of the American Osteopathic Association, March 2011, Vol. 111, Sii-S2. doi:
Genital human papillomavirus (HPV) is the most common sexually transmitted infection worldwide.1 Because it is so prevalent in men and women, is easily transmitted by skin-to-skin contact, and is often asymptomatic and undetectable, it is difficult to effectively prevent transmission despite our best efforts, including promotion of abstinence, condom use, and circumcision.2 This difficulty is very important because men are often silently transmitting this infection to women; the men are then at risk of developing anogenital or penile cancer, and the women are at risk for cervical cancer or its precursors. Numerous studies have been conducted over the past 3 decades that show how the sexual behavior and practices of men directly impact the health of their female partners, as highlighted in the article by Roberta Wattleworth, DO.3 
As more data about the efficacy and safety of prophylactic vaccination against HPV in men becomes available, it will be critical for the medical profession to understand the impact of HPV on men and women and to be able to weigh that impact against the benefit, risk, and cost of the vaccine in the male population. The ethics behind vaccinating one specific population (ie, men) to protect another population (ie, women) is a discussion for debate. However, offering protection against anogenital condylomas to young males who will become sexually active should not be minimized. As highlighted in the article by Craig A. Dietz, DO, MPH, and Chessa R. Nyberg, PharmD, anogenital condylomas are common in men and often lead to repeated, expensive treatments.4 Meanwhile, Richard A. Ortoski, DO, and Christine S. Kell, PhD, review the epidemiology of anal cancer in men and its precursors and highlight the latest recommendations for HPV screening in this population.5 One of the biggest challenges in screening an at-risk male population for anal HPV is establishing an appropriate referral source for those patients who have abnormal anal cytology and therefore require further evaluation and treatment. 
Studies of the natural history of genital HPV in men have lagged behind those in women for a number of reasons, including unclear methods for screening men for HPV, penile dysplasia, and anal dysplasia. Also, there is a substantially lower incidence of penile cancer in men compared to cervical cancer in women. As reviewed in the article by Cathryn J. Rehmeyer, PhD, some interesting research has been recently published to answer some key questions pertaining to the incidence of genital HPV in men.6 These findings have helped experts sort out some of the controversy around circumcision: although it appears that circumcision is protective in the prevention of penile carcinoma, when the data are carefully evaluated and stratified by potential cofounders, the data do not support circumcision as being protective in the prevention of the acquisition of anogenital HPV, including condylomas.7 
Despite the surge in data recently published, many questions remain about HPV transmission, immune response to natural infection, and incidence in the male population. For example, it is not known if men generate a sufficient immune response from a natural genital HPV infection to protect them from repeat infections with the same HPV type. The threshold for type-specific antibody levels at which a person is protected from future HPV infections is also not known. Vaccination against HPV types 6, 11, 16, and 18 has been demonstrated to be safe when administered to boys and generates a measurable, robust immune response similar to that in girls. 
Data regarding the efficacy of this vaccine in protection against acquisition and persistence of genital HPV, including anogenital condylomas, in men are forthcoming and will provide further guidance regarding recommendations for HPV vaccination in males. 
The article by Kathleen McGinley, DO, and colleagues on HPV testing in men, including a discussion on anal pap smears, is interesting and timely.8 Although physicians are performing this screening test in high-risk populations, the test has not become everyday practice as of yet. The authors' review of the data is valuable and interesting. 
We hope you find the articles in this supplement intellectually stimulating and that they raise questions on the issue of HPV. For every question we think we answer, more arise—it is what makes medicine so much fun to practice. 
 Financial Disclosures: Dr Weaver discloses that she is a speaker for Merck & Co, Inc, in the vaccine division. Dr Cymet has no relevant disclosures to report.
 This supplement is supported by an independent educational grant from Merck & Co, Inc.
Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36(1):6-10.
Jastreboff AM, Cymet T. Role of the human papilloma virus in the development of cervical intraepithelial neoplasia and malignancy. Postgrad Med J. 2002;78(918):225-228.
Wattleworth R. Human papillomavirus infection and the links to penile and cervical cancer. J Am Osteopath Assoc. 2011;111(3 suppl 2):S3-S10.
Dietz CA, Nyberg CR. Genital, oral, and anal human papillomavirus infection in men who have sex with men. J Am Osteopath Assoc. 2011;111(3 suppl 2): S19-S25.
Ortoski RA, Kell CS. Anal cancer and screening guidelines for human papillomavirus in men. J Am Osteopath Assoc. 2011;111(3 suppl 2):S35-S43.
Rehmeyer CJ. Male circumcision and human papillomavirus studies reviewed by infection stage and virus type. J Am Osteopath Assoc. 2011;111(3 suppl 2): S11-S18.
Giuliano AR, Palefsky JM, Goldstone S, et al. Efficacy of Quadrivalent HPV Vaccine against HPV Infection and Disease in Males. N Engl J Med. 2011;364(5):401-411.
McGinley KF, Hey W, Sussman DO, Brown GA. Human papillomavirus testing in men. J Am Osteopath Assoc. 2011;111(3 suppl 2):S26-S28.