What are the treatment options for male genital warts?

Treatment of Male Genital Warts

For male genital warts, treatment should be selected based on wart characteristics and patient preference, with either patient-applied options (podofilox 0.5% or imiquimod 5% cream) or provider-administered treatments (cryotherapy, TCA/BCA, or surgical removal) as first-line approaches. 1, 2

Patient-Applied Treatment Options

Podofilox 0.5% Solution or Gel

• Apply twice daily for 3 consecutive days, followed by 4 days off treatment, repeating this weekly cycle for up to 4 cycles 3
• Limit total treatment area to ≤10 cm² of wart tissue and total volume to ≤0.5 mL per day 3, 1
• The healthcare provider should ideally apply the first treatment to demonstrate proper technique and identify which warts to treat 3
• This is relatively inexpensive, easy to use, and safe, with mild to moderate pain or local irritation as common side effects 1, 2
• Contraindicated in pregnancy 3, 1

Imiquimod 5% Cream

• Apply with a finger at bedtime, 3 times per week (not consecutive days) for up to 16 weeks 3, 1, 4, 5
• Wash the treatment area with mild soap and water 6-10 hours after application 3, 4, 5
• Many patients achieve clearance by 8-10 weeks 4, 2
• Works as an immune enhancer stimulating interferon and cytokine production 1, 2
• Important caveat: Males have significantly lower complete clearance rates (33-35%) compared to females (72%) with imiquimod 6, 7
• More frequent application (daily or multiple times daily) does not improve clearance in men and increases local adverse reactions 6
• May weaken condoms and vaginal diaphragms; avoid concurrent use 5
• Contraindicated in pregnancy 3, 4, 5

Sinecatechins 15% Ointment

• Apply 3 times daily until complete clearance of warts, but not longer than 16 weeks 1
• This is a green tea extract with catechins as the active ingredient 1, 2
• May weaken condoms and diaphragms 1
• Not recommended for HIV-infected or immunocompromised persons 1, 2
• Contraindicated in pregnancy 1

Provider-Administered Treatment Options

Cryotherapy with Liquid Nitrogen (Most Common Provider Treatment)

• Repeat applications every 1-2 weeks until warts clear 3, 1
• Efficacy ranges from 63-88% in clinical trials 1, 2
• Destroys warts by thermal-induced cytolysis 3, 1
• Relatively inexpensive, does not require anesthesia, and does not result in scarring if performed properly 1
• Requires substantial training for proper technique, as over- and under-treatment may result in poor efficacy or complications 3
• Pain after application, followed by necrosis and sometimes blistering, is common 3
• Local anesthesia (topical or injected) may facilitate therapy if warts are present in many areas or if the area is large 3

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

• Apply a small amount only to warts and allow to dry until a white "frosting" develops 3
• Can be repeated weekly if necessary 3, 1
• Destroys warts by chemical coagulation of proteins 3, 1
• Can be used in pregnancy, unlike other topical agents 1, 2
• If excess acid is applied, powder the treated area with talc, sodium bicarbonate, or liquid soap to remove unreacted acid 3
• Can be neutralized with soap or sodium bicarbonate if pain is intense 1

Podophyllin Resin 10-25% in Compound Tincture of Benzoin

• Apply a small amount to each wart and allow to air dry 3
• Limit application to ≤0.5 mL or ≤10 cm² per session to avoid systemic toxicity 3, 1, 2
• Should be thoroughly washed off 1-4 hours after application to reduce local irritation 3
• Can be repeated weekly if necessary 3
• Contraindicated in pregnancy 3, 1, 2

Surgical Removal

• Options include tangential scissor excision, tangential shave excision, curettage, or electrosurgery 3
• Appropriate for large warts or when other treatments have failed 3

Alternative Regimens

• Intralesional interferon or laser surgery may be considered 3

Treatment Selection Algorithm

Choose based on the following factors:

• Wart location: Warts on moist surfaces or intertriginous areas respond better to topical treatments than warts on drier surfaces 1, 2
• Number and size: Most patients have <10 warts with a total area of 0.5-1.0 cm² 2
• Patient ability: Patient must be able to identify and reach warts for self-applied treatments 1, 2
• Cost and convenience: Patient preference for self-treatment versus office visits 2

Treatment Monitoring and Modification

• Change treatment modality if there is no substantial improvement after 3 provider-administered treatments or 8 weeks of patient-applied therapy 1, 2
• Do not extend treatment beyond the recommended duration (16 weeks for imiquimod/sinecatechins, 4 cycles for podofilox) 3, 5
• Follow-up after several weeks of patient-applied therapy can assess response and address concerns, though routine follow-up is not required 3, 4, 2

Critical Warnings and Complications

Local Reactions

• Common complications with ablative treatments include persistent hypopigmentation or hyperpigmentation and depressed or hypertrophic scars 1, 2
• Local skin reactions (erythema, erosion, excoriation/flaking, edema) are common with imiquimod, occurring in 58-65% of patients 5
• Rare but serious complications include disabling chronic pain syndromes such as hyperesthesia of the treatment site 2

Systemic Reactions

• Patients may experience flu-like systemic symptoms (malaise, fever, nausea, myalgias, rigors) during treatment with imiquimod, even with normal dosing 5
• Consider interruption of dosing if systemic reactions occur 5

Special Populations

• Uncircumcised males treating warts under the foreskin should retract the foreskin and clean the area daily 5
• Sexual (genital, anal, oral) contact should be avoided while imiquimod cream is on the skin 5

Important Treatment Limitations

• Treatment removes visible warts but does not eradicate HPV infection or affect its natural history 1, 2
• Recurrence rates are high with all treatment modalities 2
• Untreated warts may resolve spontaneously, remain unchanged, or increase in size/number 1, 2
• New warts may develop during therapy, as treatment is not a cure 5
• The effect on future transmission remains unclear 2