In an adult male with clinically evident genital warts who has not been previously vaccinated, should he receive human papillomavirus vaccination and is routine HPV testing indicated?

HPV Vaccination and Testing in Adult Males with Genital Warts

An adult male with genital warts should receive HPV vaccination if he is age 26 or younger and has not been previously vaccinated, regardless of his current infection status; however, routine HPV testing is not indicated in men.

HPV Vaccination Recommendations

Age-Based Guidelines

The Advisory Committee on Immunization Practices (ACIP) provides clear age-stratified recommendations for males 1:

• Ages 13-21 years: Routine vaccination with quadrivalent (4vHPV) or nonavalent (9vHPV) vaccine is recommended 1
• Ages 22-26 years: Vaccination may be administered (permissive recommendation) 1
• Men who have sex with men (MSM) or HIV-positive males ages 22-26: Routine vaccination is recommended (stronger recommendation than general male population) 1

Vaccination Despite Active Infection

The presence of genital warts does not contraindicate vaccination and should not delay it. The CDC explicitly states that vaccination should be given irrespective of history of genital warts 1. Here's the critical reasoning:

• Genital warts are typically caused by HPV types 6 and 11 1, 2
• The quadrivalent and nonavalent vaccines protect against HPV 6,11,16, and 18 (plus additional oncogenic types in 9vHPV) 1
• While the vaccine provides no therapeutic benefit for existing HPV types with which the patient is already infected 1, it protects against the other vaccine HPV types 1
• Males with genital warts caused by HPV 6/11 remain susceptible to oncogenic types 16 and 18, which cause the majority of HPV-attributable cancers 1

Vaccine Selection

For males, use either quadrivalent (4vHPV) or nonavalent (9vHPV) vaccine 1. The bivalent vaccine (2vHPV) is not recommended for males as it does not protect against HPV 6 and 11, which cause 90% of genital warts 1.

HPV Testing in Males

Clear Guideline: No Routine Testing

The CDC explicitly states that HPV tests should not be used to screen men 1, 3. This recommendation is unequivocal and applies to:

• Asymptomatic men 1
• Male partners of HPV-infected women 1, 3
• Men with visible genital warts 1

Rationale for Not Testing

The evidence supporting this recommendation includes:

• No clinically validated HPV test exists for men 3
• FDA-cleared HPV tests are only approved for cervical specimens, not penile, anal, or oral specimens in routine screening contexts 3
• Within ongoing sexual relationships, both partners are usually already infected by the time one is diagnosed, even if asymptomatic 4, 3
• Testing for low-risk HPV types (6 and 11) that cause genital warts provides no clinical benefit 3
• HPV testing should not be used to determine vaccination eligibility 3

What to Do Instead

Rather than HPV testing, the appropriate clinical approach includes:

• Visual examination for genital warts, which are diagnosed clinically 5
• Screen both partners for other STDs when one has genital warts 1, 4
• Consider biopsy only for atypical lesions, treatment-resistant lesions, or in immunocompromised patients 5

Critical Counseling Points

Transmission Dynamics

Patients must understand that 1, 4:

• Genital warts can be transmitted even when no visible warts are present 1, 4
• Transmission can occur even after warts are treated 1, 4
• Condoms reduce but do not eliminate transmission risk, as HPV infects areas not covered by condoms 1, 4

Partner Notification

• Patients should inform current sexual partners about their diagnosis 1, 4
• Patients should refrain from sexual activity until warts are removed or resolved 1, 4
• A diagnosis of HPV does not indicate sexual infidelity, as the virus can remain dormant and reactivate years after initial infection 4, 3

Natural History

• If untreated, genital warts may spontaneously resolve (20-30% within 3 months), remain unchanged, or grow 4, 5
• Genital warts commonly recur after treatment, especially in the first 3 months 1, 4
• Genital warts are not life-threatening and rarely progress to cancer 1

Common Pitfalls to Avoid

• Do not delay vaccination while waiting for wart treatment or clearance 1
• Do not order HPV testing in male patients, as it provides no clinical utility and is not validated 1, 3
• Do not falsely reassure patients that condoms provide complete protection against HPV transmission 1, 4
• Do not assume that asymptomatic periods mean non-infectiousness 1, 4
• Do not withhold vaccination from men over age 21 who are MSM or HIV-positive, as they have routine (not permissive) recommendations through age 26 1