How is human papillomavirus (HPV) testing performed in men, and when is it indicated?

HPV Testing in Males: Evidence-Based Approach

Direct Answer

Routine HPV testing is not recommended for men because no FDA-approved or clinically validated test exists for male genital, anal, or oral specimens. 1, 2 The CDC explicitly states that HPV tests should not be used to screen men or partners of women with HPV. 2

---

Why HPV Testing Is Not Performed in Immunocompetent Men

Lack of Validated Testing Methods

• All FDA-cleared HPV DNA tests are designed exclusively for cervical specimens and have not been validated for penile, anal, or oral samples in routine clinical practice. 1
• Research methods exist (PCR-based assays, hybrid capture) but remain investigational and lack clinical validation for male screening. 3, 4

Natural History Makes Testing Unnecessary

• Most HPV infections in men are transient and clear spontaneously without causing disease or symptoms. 1, 2
• Within ongoing sexual relationships, both partners are typically already infected by the time one person is diagnosed, even without visible signs. 2
• The majority of sexually active adults will acquire HPV at some point in their lives. 1

---

What to Do Instead: Clinical Examination

Visual Diagnosis of Genital Warts

• Genital warts—the most common manifestation of HPV in men—should be diagnosed by direct visual clinical examination, not laboratory testing. 1
• High-risk oncogenic HPV types (16,18) rarely produce visible warts, so absence of warts does not exclude infection. 1
• The acetic acid test (acetowhitening) is not sufficiently specific and should not be used as a sole diagnostic criterion for HPV infection in men. 5

Screen for Other STIs

• When genital warts or HPV-related conditions are identified, screen both the patient and sexual partner for other sexually transmitted infections. 1, 2

---

Special Populations Where Screening May Be Considered

Men Who Have Sex with Men (MSM)

• Anal cancer incidence is dramatically elevated in MSM: 80–131 cases per 100,000 person-years in HIV-positive MSM versus 1–2 cases per 100,000 in the general population. 6, 1
• HIV-negative MSM with receptive anal intercourse have an incidence of approximately 14 cases per 100,000 person-years. 6, 1
• Annual digital anorectal examination (DARE) is recommended for MSM with a history of receptive anal intercourse to detect palpable masses. 6, 1

HIV-Positive Men

• HIV-infected men have an anal cancer incidence of 40–60 cases per 100,000 person-years. 6, 1
• Annual anal cytology (anal Pap test) should be considered for all HIV-positive men, regardless of sexual practices. 1, 7
• Critical caveat: Anal cytology should only be performed in settings where high-resolution anoscopy (HRA) is available for follow-up of abnormal results. 1, 7

Other Immunocompromised Men

• Men receiving chronic immunosuppressive therapy (organ transplant recipients, long-term corticosteroid users) should be managed similarly to HIV-positive patients. 1

---

Prevention: The Primary Strategy

HPV Vaccination Recommendations

• All males aged 9–21 years should receive HPV vaccination (strong recommendation based on high-quality evidence). 1
• Males aged 22–26 years should be vaccinated if not previously immunized. 1
• HIV-infected males should receive the three-dose series regardless of age within the 9–26-year range. 1
• Either quadrivalent (4vHPV) or 9-valent (9vHPV) vaccine is appropriate for male patients. 1

Risk Reduction Counseling

• Consistent condom use may reduce HPV transmission risk, though HPV can infect areas not covered by condoms. 1, 2
• Reassure patients that HPV detection does not indicate infidelity: infection can persist for years before detection, and most sexually active adults acquire HPV. 1, 2

---

Common Pitfalls to Avoid

• Do not order HPV testing to screen asymptomatic men—it provides no clinical benefit and is not validated. 2
• Do not use HPV testing to decide whether to vaccinate—vaccination should not be withheld based on presumed prior exposure. 1, 2
• Do not test for low-risk HPV types (6,11)—this provides no clinical benefit. 2
• Do not perform anal cytology without access to high-resolution anoscopy—abnormal results require HRA with biopsy for appropriate management. 1, 7