Cryo Corner Perianal and Anal Condylomata Acuminata JOHN J. O’CONNOR, M.D., F.A.C.S., F.I.C.S.
INTRODUCTION
lesions of the perianal and anal region are condylomata acuminata. Caused by a sexu ally transmitted DNA-containing virus, the warts gen erally appear within three months of exposure, but the incubation period is variable. While warts seem to be a common manifestation of anal sexual practice, it does not imply that all such lesions are a consequence of such eroticism.1 Once present, the growths are un sightly, annoying, often pruritic, and subject to macera tion and secondary infection. Dermatologists, sur geons, gynecologists and proctologists are all familiar with the many frustrations that result from unsuccess ful attempts at therapy. The disease was known to the ancient Greeks and Romans who described the lesions by the word “acuminate” (pointed) to describe their gross appear ance. These so-called venereal warts vary widely in shape, size, and color. In my experience, the lesions are usually multiple. They appear white, pink, or at times light gray, either as scattered, small individual lesions or as a luxuriant growth of closely agminated or coalescent lesions that may obscure the entire perianal region and anal orifice. The warts may extend beyond the anorectal junction and onto the lower few cen timeters of rectal mucosa. Twenty-one different methods of treatment were de scribed by Swerdlow and Salvati,2 attesting to the fact that there is no panacea. It is the purpose of this report to describe a management by cryotherapy that I have found useful for condylomata acuminata. T
he
m ost
com m on
CLINICAL PROTOCOL
Initially, history is taken, specifically inquiry regarding other possible venereal diseases. Physical examination, Dr. O’Connor is Assistant Clinical Professor o f Surgery, Depart ment o f Surgery, George Washington University School o f Medi cine, Washington, D.C. Address reprint requests to Dr. John J. O’Connor, 916-19th Street N.W ., Washington, D.C. 20006.
276
J. Dermatol. Surg. Oncol. 5:4 April 1979
besides inspection of the perineal and perianal region, includes digital palpation of the anus and anoscopy with a disposable plastic anoscope. Groins are pal pated for adenopathy and the genitals are examined for lesions or discharge. A smear is prepared of any ure thral, vaginal or anal discharge and sent for culture and microscopic examination. In all cases, a serologic test for syphilis is ordered. Treatment does not begin until the laboratory data is back and indicates no evidence of venereal disease. Prior to therapy, the patient is told the lesions will be treated cryotherapeutically by spray technique, and that it may take two to six visits. The patient is further informed that recurrence is common, especially if there is further exposure to the virus. No anesthesia is used in the spray technique. Two cryogens have been used interchangeably, liquid nitro gen and liquid nitrous oxide. The instruments used are the Brymill LN2 spray, Tower LN2 spray, Krymed spray unit, and a Gynetech unit that I have modified by connecting to a siphon nitrous oxide cylinder, then at taching a plastic case over the delivery device after removing the probe. The patient is usually placed in the left lateral position. An assistant separates the but tocks and stands to the left of the operator. The area to be treated is sprayed by one of two methods. If the lesions are small but widely dispersed, a fine jet of cryogen is directed on the wart and a small margin of normal tissue until a layer of frost appears and then continuously for 30 seconds. For a large conglomera tion of lesions that encircle the anus, it is wise to frac tionate and restrict freezing to a single quadrant per treatment session. No attempt is made to protect the surrounding skin with Vaseline® or other ointment. Figures 1 and 2 show a type of lesion that can be treated at once and the result one may expect to obtain from cryosurgery. This case required four visits and eight weeks to heal completely, all done on an out patient basis. Intra-anal condylomata are treated in the same way
O ’C O N N O R
FIGURE 1. Clinical appearance o f a mass o f acuminate warts before treatment by cryotherapy. The photo is by spotlight.
FIGURE 2. Clinical appearance o f the acuminate warts pic tured in Fig. I after cryotherapy.
ex c e p t th a t a 28 mm Welch Allen lighted an o sc o p e is used to visualize the an u s beyond the de n ta te line.
fection w as not enc o u n te re d . All patients w ere advised to tak e sitz b a th s tw ice daily and to use Betadine® as a perineal w ash in e a c h sitz bath. All patients w ere free o f c o nd y lom ata at the time o f their last visits. T w o h u n d re d an d tw enty-six patients had to be tre a te d for rec u rre n c es, but m ost confessed to re e x p o su re to wartbearing individuals o r resum p tio n o f an orectal sexual practice. T here were so m ew h at m ore re c u rre n c es in patients tre a te d with nitrous oxide.
COMMENT Though it is well k now n th a t no m ethod o f treatm en t cu res all c a se s o f c o n d y lo m a ta , c ry o th e ra p y do es p ro duce a c c e p ta b le results. Since 1973, 936 patients with perianal and anal c o n d y lo m a ta have been seen for a total o f 2,246 c ry o th e ra p y sessions, this a v e ra g e s 2.4 visits p e r patient, i.e ., m ost patients re q u ired tw o or th ree tre a tm e n ts. T w o-thirds o f the p atients w ere tre a te d with liquid nitrogen and one-third by nitrous oxide. Freezing tim es w ere not varied for either. De spite the necro sis that o cc u rs, se c o n d a ry bacterial in
REFERENCES 1. 2.
M arino , M. N o r th A m . S w e rd lo w , Dis. C o lon
W ., a n d M ancini, H . W. A nal ero tic ism . S urg. Clin. 5 8 :5 13-5 18, 1978. D. B ., a n d S alv ati, E . P. C o n d y lo m a a c u m in a tu m . R e c tu m 14:226-228, 1971.
J. Dermatol. Surg. Oncol. 5:4 April 1979
277
INTRODUCTION
lesions of the perianal and anal region are condylomata acuminata. Caused by a sexu ally transmitted DNA-containing virus, the warts gen erally appear within three months of exposure, but the incubation period is variable. While warts seem to be a common manifestation of anal sexual practice, it does not imply that all such lesions are a consequence of such eroticism.1 Once present, the growths are un sightly, annoying, often pruritic, and subject to macera tion and secondary infection. Dermatologists, sur geons, gynecologists and proctologists are all familiar with the many frustrations that result from unsuccess ful attempts at therapy. The disease was known to the ancient Greeks and Romans who described the lesions by the word “acuminate” (pointed) to describe their gross appear ance. These so-called venereal warts vary widely in shape, size, and color. In my experience, the lesions are usually multiple. They appear white, pink, or at times light gray, either as scattered, small individual lesions or as a luxuriant growth of closely agminated or coalescent lesions that may obscure the entire perianal region and anal orifice. The warts may extend beyond the anorectal junction and onto the lower few cen timeters of rectal mucosa. Twenty-one different methods of treatment were de scribed by Swerdlow and Salvati,2 attesting to the fact that there is no panacea. It is the purpose of this report to describe a management by cryotherapy that I have found useful for condylomata acuminata. T
he
m ost
com m on
CLINICAL PROTOCOL
Initially, history is taken, specifically inquiry regarding other possible venereal diseases. Physical examination, Dr. O’Connor is Assistant Clinical Professor o f Surgery, Depart ment o f Surgery, George Washington University School o f Medi cine, Washington, D.C. Address reprint requests to Dr. John J. O’Connor, 916-19th Street N.W ., Washington, D.C. 20006.
276
J. Dermatol. Surg. Oncol. 5:4 April 1979
besides inspection of the perineal and perianal region, includes digital palpation of the anus and anoscopy with a disposable plastic anoscope. Groins are pal pated for adenopathy and the genitals are examined for lesions or discharge. A smear is prepared of any ure thral, vaginal or anal discharge and sent for culture and microscopic examination. In all cases, a serologic test for syphilis is ordered. Treatment does not begin until the laboratory data is back and indicates no evidence of venereal disease. Prior to therapy, the patient is told the lesions will be treated cryotherapeutically by spray technique, and that it may take two to six visits. The patient is further informed that recurrence is common, especially if there is further exposure to the virus. No anesthesia is used in the spray technique. Two cryogens have been used interchangeably, liquid nitro gen and liquid nitrous oxide. The instruments used are the Brymill LN2 spray, Tower LN2 spray, Krymed spray unit, and a Gynetech unit that I have modified by connecting to a siphon nitrous oxide cylinder, then at taching a plastic case over the delivery device after removing the probe. The patient is usually placed in the left lateral position. An assistant separates the but tocks and stands to the left of the operator. The area to be treated is sprayed by one of two methods. If the lesions are small but widely dispersed, a fine jet of cryogen is directed on the wart and a small margin of normal tissue until a layer of frost appears and then continuously for 30 seconds. For a large conglomera tion of lesions that encircle the anus, it is wise to frac tionate and restrict freezing to a single quadrant per treatment session. No attempt is made to protect the surrounding skin with Vaseline® or other ointment. Figures 1 and 2 show a type of lesion that can be treated at once and the result one may expect to obtain from cryosurgery. This case required four visits and eight weeks to heal completely, all done on an out patient basis. Intra-anal condylomata are treated in the same way
O ’C O N N O R
FIGURE 1. Clinical appearance o f a mass o f acuminate warts before treatment by cryotherapy. The photo is by spotlight.
FIGURE 2. Clinical appearance o f the acuminate warts pic tured in Fig. I after cryotherapy.
ex c e p t th a t a 28 mm Welch Allen lighted an o sc o p e is used to visualize the an u s beyond the de n ta te line.
fection w as not enc o u n te re d . All patients w ere advised to tak e sitz b a th s tw ice daily and to use Betadine® as a perineal w ash in e a c h sitz bath. All patients w ere free o f c o nd y lom ata at the time o f their last visits. T w o h u n d re d an d tw enty-six patients had to be tre a te d for rec u rre n c es, but m ost confessed to re e x p o su re to wartbearing individuals o r resum p tio n o f an orectal sexual practice. T here were so m ew h at m ore re c u rre n c es in patients tre a te d with nitrous oxide.
COMMENT Though it is well k now n th a t no m ethod o f treatm en t cu res all c a se s o f c o n d y lo m a ta , c ry o th e ra p y do es p ro duce a c c e p ta b le results. Since 1973, 936 patients with perianal and anal c o n d y lo m a ta have been seen for a total o f 2,246 c ry o th e ra p y sessions, this a v e ra g e s 2.4 visits p e r patient, i.e ., m ost patients re q u ired tw o or th ree tre a tm e n ts. T w o-thirds o f the p atients w ere tre a te d with liquid nitrogen and one-third by nitrous oxide. Freezing tim es w ere not varied for either. De spite the necro sis that o cc u rs, se c o n d a ry bacterial in
REFERENCES 1. 2.
M arino , M. N o r th A m . S w e rd lo w , Dis. C o lon
W ., a n d M ancini, H . W. A nal ero tic ism . S urg. Clin. 5 8 :5 13-5 18, 1978. D. B ., a n d S alv ati, E . P. C o n d y lo m a a c u m in a tu m . R e c tu m 14:226-228, 1971.
J. Dermatol. Surg. Oncol. 5:4 April 1979
277
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