What are the treatment options for genital warts in males?

Treatment of Genital Warts in Males

For males with genital warts, treatment should be guided by patient preference between self-applied therapies (podofilox 0.5% or imiquimod 5% cream) and provider-administered options (cryotherapy, TCA/BCA, or surgical removal), with the understanding that no single treatment is superior and all have comparable efficacy. 1, 2

Understanding Treatment Goals and Limitations

• The primary goal is removal of visible symptomatic warts, not eradication of HPV infection, which persists in adjacent tissue regardless of treatment modality 1
• Treatment does not affect the natural history of HPV infection or reduce the risk of cervical/genital cancer development 1
• Whether treatment reduces viral transmission remains unclear, though some evidence suggests it may reduce infectivity 1
• Untreated warts may spontaneously resolve (20-30% within 3 months), remain unchanged, or increase in size/number 1
• Most patients respond within 3 months of therapy, with typical clearance rates ranging from 22-94% across all modalities 1

Patient-Applied Treatment Options

Podofilox 0.5% Solution or Gel

• Apply with cotton swab (solution) or finger (gel) to visible warts twice daily for 3 days, followed by 4 days off therapy 1
• Repeat cycle up to 4 cycles as necessary 1
• Total wart area treated must not exceed 10 cm², and total volume limited to 0.5 mL per day 1, 2
• Provider should demonstrate proper application technique at initial visit 1
• Relatively inexpensive, easy to use, and safe, with mild to moderate pain or local irritation as common side effects 1, 2
• Contraindicated in pregnancy 1

Imiquimod 5% Cream

• Apply once daily at bedtime, three times per week for up to 16 weeks 1, 3
• Wash treatment area with mild soap and water 6-10 hours after application 1, 3
• Works as immune enhancer stimulating interferon and cytokine production 1, 2
• Important caveat for males: Complete clearance rates are significantly lower in men (approximately 35%) compared to women (approximately 67%) 4, 5
• More frequent application (daily or multiple times daily) does not improve clearance rates and increases adverse effects 4
• Common local reactions include erythema (58% in males), erosion (30%), excoriation/flaking (26%), itching (22%), and burning (9%) 3
• May weaken condoms and vaginal diaphragms 1, 3
• Contraindicated in pregnancy 1, 3
• Uncircumcised males should retract foreskin and clean area daily during treatment 3

Sinecatechins 15% Ointment

• Apply three times daily (0.5-cm strand to each wart) until complete clearance, but not longer than 16 weeks 1, 2
• Green tea extract with catechins as active ingredient 1, 2
• May weaken condoms and diaphragms 2
• Not recommended for HIV-infected or immunocompromised persons 2
• Contraindicated in pregnancy 1

Provider-Administered Treatment Options

Cryotherapy with Liquid Nitrogen or Cryoprobe

• Most commonly used provider-administered treatment with 63-88% efficacy 2, 6
• Repeat applications every 1-2 weeks as necessary 1, 2
• Destroys warts by thermal-induced cytolysis 2
• Does not require anesthesia and does not result in scarring if performed properly 2
• Relatively inexpensive with cost per successful treatment approximately $200-300 7

Trichloroacetic Acid (TCA) or Bichloroacetic Acid (BCA) 80-90%

• Apply directly to warts, allowing to dry until white "frosting" develops 1
• Can be neutralized with soap or sodium bicarbonate if pain is intense 1, 2
• Repeat weekly as necessary 1, 2
• Can be used in pregnancy, unlike other topical agents 2, 6
• Destroys warts by chemical coagulation of proteins 2

Podophyllin Resin 10-25% in Compound Tincture of Benzoin

• Provider applies to warts only, limiting application to ≤0.5 mL or ≤10 cm² per session 1, 2
• Wash off thoroughly in 1-4 hours 1
• Repeat weekly as necessary 1
• Contraindicated in pregnancy due to systemic toxicity risk 1, 2

Surgical Removal

• Options include tangential scissor excision, tangential shave excision, curettage, or electrosurgery 1
• Efficacy of 93% with 29% recurrence rate 1
• Useful for extensive warts or patients who have not responded to other regimens 1
• Cost per successful treatment approximately $200-300 7

Treatment Selection Algorithm

For Small Number of Warts (<10 warts, <1 cm² total area):

• First-line for patient preference of home treatment: Podofilox 0.5% (most cost-effective) or imiquimod 5% cream 2, 8, 7
• First-line for provider-administered: Cryotherapy (most convenient and effective) 2, 8
• Warts on moist surfaces/intertriginous areas respond better to topical treatments 1
• Warts on drier surfaces respond better to cryotherapy or surgical methods 1

For Extensive or Refractory Disease:

• Surgical excision, electrodesiccation, or CO₂ laser therapy 1, 8
• Consider referral to specialist 1

When to Change Treatment

• Change treatment modality if no substantial improvement after 3 provider-administered treatments 1, 2
• Change if warts have not completely cleared after 6 provider-administered treatments 1
• For patient-applied therapy, reassess after 8 weeks if no improvement 6
• Avoid overtreatment by evaluating risk-benefit ratio throughout therapy 1

Critical Warnings and Complications

Common Complications:

• Persistent hypopigmentation or hyperpigmentation occurs commonly with all ablative modalities and imiquimod 1
• Depressed or hypertrophic scars are uncommon but can occur, especially with insufficient healing time between treatments 1

Rare but Serious Complications:

• Disabling chronic pain syndromes (vulvodynia, hyperesthesia of treatment site) 1
• For anal warts: painful defecation or fistulas 1
• Systemic effects with podophyllin resin (avoid exceeding dose limits) 1

Special Considerations for Males:

• Uncircumcised males treating warts under foreskin must retract foreskin and clean area daily 3
• Males have significantly lower complete clearance rates with imiquimod (35%) compared to females (67%), though the approved three-times-weekly regimen remains optimal 4, 5
• Intra-anal warts are seen predominantly in patients with receptive anal intercourse history and are distinct from perianal warts 1

Follow-Up and Monitoring

• Follow-up visits not required for patient-applied therapy, but recommended after several weeks to assess response and address concerns 1, 6
• Recurrence rates are high (typically at least 25% within 3 months) with all treatment modalities 1
• New warts may develop during therapy as treatment does not cure HPV infection 3
• Sexual contact should be avoided while imiquimod cream is on the skin 3