Human Papillomavirus (eBook)

Human Papillomavirus History and Epidemiology 14
Human Papillomavirus History and Epidemiology 15
1.1 Introduction 15
1.2 Historical Perspective 17
1.3 Epidemiology 18
1.4 HPV in Women 20
1.4.1 Risk Factors 20
1.5 HPV in Men 21
1.5.1 Risk Factors 23
1.6 HPV Transmission Modes 24
1.6.1 HPV Transmission in Children 24
1.6.2 Considerations Regarding Unusual Transmission Routes 26
1.6.2.1 Transmission from CO 2 Plume 26
1.7 Prevention 26
1.7.1 Condoms 26
1.7.2 Vaccines 26
1.7.3 Antiviral Microbicides 27
References 27
Laboratory Methods for Detection of Human Papillomavirus Infection 34
2.1 Introduction 34
2.2 HPV DNA Methods 35
2.3 HPV RNA Methods 37
2.4 Serological Assays 38
2.5 Detecting HPV Infection in Men 39
References 39
Human Papillomavirus and Urological - Associated Diseases 42
Human Papillomavirus and External Genital Lesions 43
3.1 Introduction 43
3.2 Overview 44
3.3 Clinical Manifestations 45
3.3.1 Subclinical Infection 45
3.3.1.1 Presentation 45
3.3.1.2 Symptoms 45
3.3.2 Clinical Disease 45
Condyloma Acuminatum (Anogenital Warts) 45
3.3.2.1 Presentation 45
Expert Advice 46
3.3.2.2 Multifocality 47
3.3.2.3 Symptoms 50
3.3.3 HPV-Related Flat Penile Lesions 50
3.3.3.1 Presentation 51
3.3.3.2 Symptoms 51
Expert Advice 55
3.4 Differential Diagnosis 52
3.4.1 Benign Penile Pearly Papules (Hirsutoid Papillomas) (Fig. 3.20 ) 52
3.4.2 Fibroepithelial Polyps (Fig. 3.22 ) 52
3.4.3 Prominent Sebaceous Glands (Ectopic Sebaceous Glands, Fordyce Spots) (Fig. 3.23 ) 53
3.4.4 Sebaceous Glands (Fig. 3.24 ) 53
3.4.5 Seborrheic Keratoses (Fig. 3.25a, b ) 53
3.4.6 Angiokeratoma (Fordyce Angiokeratoma) (Fig. 3.26a–c ) 53
3.4.7 Verrucous Epidermal Nevi and Pigmented Nevi (Fig. 3.27.a–d ) 54
3.4.8 Molluscum Contagiosum (Fig. 3.28.a, b ) 55
3.4.9 Lichen Nitidus 55
3.4.10 Syphilitic Condylomata Lata (Fig. 3.29.a, b ) 56
3.5 Detection Methods 57
3.5.1 Clinical Diagnosis 57
3.5.1.1 Physical Examination 57
Expert Advice 57
3.5.1.2 Acetic Acid Solution Test (Acetowhite Test) 57
Expert Advice 58
How to Perform the Acetowhite Test 58
3.5.2 Laboratory Diagnosis 58
3.5.2.1 Cytology 58
3.5.2.2 Histological Techniques 59
Expert Advice 59
When to Recommend Lesion Biopsy and ­His­tological Evaluation 59
3.5.2.3 Culture 60
3.5.2.4 Serological Testing 60
3.5.2.5 Molecular Tests 60
Expert Advice 60
Expert AdvicePictures or schematic representations of HPV-associated lesions recorded at each visit are a useful tool for eval 62
Home-Applied Therapy 62
Physician-Applied Therapy 62
Expert AdviceThe treatment method should be changed if: Improvement is not documented after three ­physician-administered t 62
3.6 Treatment 62
3.6.1 Antimitotic Therapy 63
3.6.1.1 Podophyllin 63
Mechanism of Action 64
How to Use 64
Important 64
Indications 64
Advantages 64
Disadvantages 64
Adverse Effects 64
Local 64
Systemic 64
Combination Therapy 65
Podophyllin 25% Used in Combination with Cryotherapy 65
3.6.1.2 Podophyllotoxin (Podofilox Solution 0.5% Condylox Gel and Solution 0.5%)65
Mechanism of Action 65
How to Use 65
Podophyllotoxin 0.5% Solution or Gel 65
Indications 65
Advantages 65
Disadvantages 65
3.6.1.3 5-Fluorouracil Cream (Efudex®) 65
Mechanism of Action 65
How to Use 66
5-FU Cream 66
Important 66
Indications 66
Advantages 66
Disadvantages 66
Side Effects 66
3.6.2 Destructive Therapy 67
3.6.2.1 Surgical Excision/Electrosurgery 67
Surgical Technique 67
Important 67
Expert Advice 67
Important 67
Indications 67
Advantages 67
Disadvantages 67
Adverse Effects 67
Expert Advice 67
3.6.2.2 Cryotherapy 67
Mechanism of Action 67
How to Use 68
Indications 68
Advantages 68
Disadvantages 68
Adverse Effects 68
Combination Therapies 68
Cryotherapy + Podophyllotoxin 68
3.6.2.3 CO 2 Laser 68
Mechanism of Action 68
Laser Technique 68
Power Settings 68
Indications 70
Advantages 70
Disadvantages 70
Adverse Effects 70
Combination Therapy 70
3.6.2.4 Photodynamic Therapy 70
Mechanism of Action 70
How to Use (Chen et al., 2007) 70
Indications 70
Advantages 71
Disadvantages 71
Adverse Effects 71
3.6.3 Immunotherapy 71
3.6.3.1 Interferons (INF- a ) 71
Mechanism of Action 71
Indications 71
3.6.3.2 Intralesional Injection of -INF- a 71
How to UseIntralesional INF Injection INF- a -n3 (Alferon N injection available in 1-ml vials). 0.05 ml per lesion admini71
Advantages 71
Disadvantages 71
Side Effects 71
Local 71
Systemic 72
Combination Treatment 72
3.6.3.3 Topical INF Ointment 72
3.6.3.4 Imiquimod 5% Cream (Aldara®) 72
Mechanism of Action 72
How to UseImiquimod cream comes in single-use packets. Open packets with unused cream should be discarded.A thin layer of imi 72
Indications 72
Advantages 72
Disadvantages 72
Adverse Effects 73
Local 73
Systemic 73
Expert Advice 73
Combination Treatment 73
How to Use 73
3.6.3.5 Bacille Calmette-Guérin 73
Advantages 73
Disadvantages 73
Adverse Effects 73
Combination Treatment 73
3.7 Other Treatment Modalities 73
3.7.1 Chemical Destruction 73
3.7.1.1 Trichloroacetic Acid 73
How to Use 74
TCA in a Solution Concentration of 60–90% 74
Indications 74
Advantages 74
Disadvantages 74
Adverse Effects 74
3.7.2 Novel Therapies 74
3.7.2.1 Cidofovir 74
How to Use 74
Indications 74
Advantages 74
Disadvantages 75
Adverse Effects 75
Combination Treatment 75
3.7.2.2 Veregen™ (Sinecatechins 15% Ointment) 76
Mechanism of Action 76
How to Use 76
Important 76
Indications 76
Advantages 76
Disadvantages 76
Adverse Effects 76
Expert Advice 76
Asymptomatic Patients 76
Symptomatic Patients with Predominance of Balanoposthitis Symptoms 76
Symptomatic Patients with Predominance of Flat Visible Lesions 76
3.8 Management of Latent and Subclinical HPV Infection 76
3.9 Circumcision and HPV 77
3.10 Follow-Up 77
3.11 Prevention 77
References 77
Anchor 14 45
Anchor 16 45
Human Papillomavirus-Associated Lesions of the Urinary Tract 82
4.1 Introduction 82
4.2 Overview 82
4.3 Clinical Manifestations 83
4.3.1 Symptoms 83
4.3.1.1 Less Frequent 83
4.3.1.2 Atypical Occurrence 83
4.3.2 Presentation 83
4.3.2.1 Lesion Base 85
4.4 Differential Diagnosis 85
4.5 Detection Methods 85
4.5.1 Clinical Diagnosis 85
4.5.1.1 Physical Examination of the Meatus and Fossa Navicularis 85
Expert Advice 85
Expert AdviceUrethral malformations (hypospadias and epispadias) (Fig. 4.12a – c ) and anatomic variance (Fig. 4.13 ) should 85
How to Perform Meatoscopy Using theOtoscope 86
Expert AdviceThin (1992) recommends that meatoscopy should be performed on all patients with meatal warts to correctly asses 86
Expert Advice 85
4.5.2 Laboratory Diagnosis 86
4.5.2.1 Brushing Cytology 86
4.5.2.2 Biopsy and Histopathological Evaluation 87
Histopathological Findings 87
Biopsy Indications If lesion appearance is equivocal or atypical To rule out malignancy, particularly in immunocompromis 87
4.5.2.3 Molecular Tests 88
Urethral Meatus/Fossa Navicularis (Fig. 4.19 ) 88
Can HPV Detection Be Improved by Adding Urethral Samples? 88
Urine/Semen 88
4.5.2.4 Urethroscopy 89
Urethroscopy – When to Perform 89
Expert Advice 91
4.5.2.5 Image Diagnosis 91
Antegrade and Retrograde Urethrography 91
Ultrasonography and Computed Tomography 91
Pelvic US and CT Can Be Performed 91
4.6 Treatment (Table 4.1 ) 91
Expert AdvicePictures or a schematic representation of lesions at each visit is a useful tool for evaluating treatment respons 91
4.6.1 Medical Therapies 91
4.6.1.1 Cytotoxic Agents 91
Podophyllotoxin 91
Expert Advice 93
How to Use 93
Advantages 93
Disadvantages 93
Adverse Effects 93
Podophyllin 93
Expert Advice 93
How to Use 93
Advantages 93
Disadvantages 93
Adverse Effects 93
5-Fluorouracil Cream (Efudex®) 93
Advantages 93
Disadvantages 94
How to Use 94
Important 94
Expert Advice 94
4.6.1.2 Immune-Response Modifiers 94
Imiquimod (Aldara®) 94
Expert Advice 94
How to Use 94
Advantages 94
Disadvantages 94
Adverse Effects 94
4.6.2 Surgical Therapies 95
4.6.2.1 Excision 95
Indications 95
Advantages 95
Disadvantages 95
Complications 95
Expert Advice 95
4.6.2.2 Endoscopic Electrosurgical Techniques 95
Advantages 95
Disadvantages 95
Complications 96
4.6.2.3 Cryotherapy 96
How to Use 96
Advantages 96
Disadvantages 96
Adverse Effects 96
4.6.2.4 CO 2 Laser Vaporization 96
Indications 96
CO 2 Laser TechniqueSee Chap. 10 . Carbon dioxide (CO 2 ) laser is coupled to the operating microscope for enhanced v 96
Expert Advice 97
Important 97
Advantages 97
Disadvantages 97
Complications 97
4.6.2.5 Neodymium:YAG Laser/Holmium:YAG Laser 97
Mechanism of Action 97
Indications 98
Technique 98
Advantages 98
Disadvantages 98
Complications 98
Expert Advice 98
4.6.2.6 Transurethral Resection of HPV-Related Lesions of the Urethra and Bladder 98
Indications 98
Complications 98
4.6.2.7 5-Aminolaevulinic Acid Photodynamic Therapy 98
Mechanism of Action 98
Advantages 99
Adverse Effects 99
How to Use (Chen et al., 2007) 99
ALA Solution Preparation 99
4.6.3 Treatment Failures – What to do? 99
4.6.3.1 Immune-Response Modifiers 99
Bacille Calmette-Guérin 99
How to Use (Bohle et al., 1998) 99
BCG Preparation 99
Advantages 99
Disadvantages 99
Adverse Effects 99
Interferon 100
How to Use (Levine et al., 1996) 100
Interferon 100
Advantages 100
Disadvantages 100
4.7 Follow-Up 100
4.8 Prevention 100
4.9 The Role of HPV in Urethral, Bladder, Renal, and Prostate Cancer Development 100
4.9.1 Urethral Cancer 100
4.9.2 Bladder Cancer 101
4.9.3 Prostate Cancer 101
4.9.4 Renal Cancer 102
References 102
Human Papillomavirus and Penile Intraepithelial Neoplasia 106
5.1 Introduction 106
5.2 Terminology 107
What Happened to PIN 2?The categorization of SILs into low- and high-grade depends mainly on the degree of koilocytosis a fou 107
5.2.1 Differentiated PIN 107
5.2.2 Undifferentiated PIN 108
5.3 Overview 108
5.3.1 Natural History of PINs 110
Expert AdviceThe importance of the acetowhite test in the diagnosis and treatment of PIN is paramount. It allows for the exact 110
Expert AdviceAny long-lasting penile lesion that is unresponsive to classic medical treatments should be biopsied and sent for 110
5.3.2 Incidence 110
5.3.3 Risk Factors 111
5.3.4 Differential Diagnosis 111
5.4 Multifocal Intraepithelial Neoplasia (Bowenoid Papulosis) 111
5.4.1 Clinical Manifestations 112
5.4.1.1 Symptoms 112
5.4.1.2 Presentation 112
Expert AdviceBP lesions are less papillomatous than common genital viral condyloma lesions and usually present a smooth-topped 112
5.4.2 Diagnosis 113
5.4.2.1 Histological Findings 113
Expert AdviceThe finding of inclusion-like bodies associated with the presence of innumerous mitoses in metaphase (“star-shape 113
5.4.3 Treatment 113
5.4.3.1 CO 2 Laser 113
Advantages 113
5.4.3.2 5-Fluorouracil Cream 113
5.4.3.3 Imiquimod Cream (Aldara®) 113
Advantages 113
5.4.4 Follow-Up 113
5.5 Bowen’s Disease 114
5.5.1 Risk Factors 114
5.5.2 Clinical Manifestations 114
5.5.2.1 Symptoms 114
5.5.2.2 Presentation 114
5.5.3 Diagnosis 114
5.5.3.1 Histological Findings 114
5.5.4 Treatment 114
5.5.4.1 Surgical Excision and Electrosurgery 114
Indication 114
Advantages 115
5.5.4.2 Cryotherapy 115
Advantages 115
Disadvantages 115
Side Effects 115
5.5.4.3 5-Fluorouracil Cream 115
Indications 115
Side Effects 115
5.5.4.4 Imiquimod Cream (Aldara®) 115
Indication 115
Advantages 115
Disadvantages 115
5.5.4.5 CO 2 Laser 115
Advantages 115
Disadvantages 115
5.5.4.6 Photodynamic Therapy with Methyl Aminolevulinate 115
Indication 115
Advantages 116
Disadvantages 116
Side Effects 116
5.5.4.7 Circumcision 116
Indication 116
5.5.5 Follow-Up 116
5.6 Erythroplasia of Queyrat (Unifocal Intraepithelial Neoplasia) 116
5.6.1 Clinical Manifestations 116
5.6.1.1 Symptoms 116
5.6.1.2 Presentation 116
5.6.2 Differential Diagnosis 116
5.6.3 Diagnosis 116
Expert AdviceEarly biopsy to better define diagnosis is recommended by Porter et al. (2002) . Excisional biopsy can be per 117
5.6.3.1 Histological Findings 117
5.6.4 Treatment 118
5.6.4.1 5-Fluorouracil Cream 118
5.6.4.2 Imiquimod Cream (Aldara) 118
Advantages 118
5.6.4.3 Local Excision 118
Indications 118
5.6.4.4 Circumcision 118
Indication 118
5.6.4.5 CO 2 Laser 118
Advantages 118
Disadvantages 118
5.6.4.6 Nd:YAG Laser 118
Disadvantages 118
5.6.4.7 Photodynamic Therapy with Methyl Aminolevulinate 118
Side Effects 118
5.6.4.8 Total Glans Resurfacing 119
Indications (Hadway et al., 2006) 119
Optional Indication 119
Advantages 119
Disadvantages 119
5.6.5 Follow-Up 119
5.7 Penile Lichen Sclerosus 119
5.7.1 Clinical Manifestations 120
5.7.1.1 Symptoms 120
5.7.1.2 Presentation 120
5.7.2 Diagnosis 120
Expert AdviceBiopsy is recommended in all patients suspected of having LS (Pugliese et al., 2007) however, the biopsy of ch120
5.7.2.1 Histological Findings (Fig. 5.22a, b) 121
5.7.3 Treatment 121
5.7.3.1 Medical 121
Steroids 121
Indication 121
Advantages 121
Side Effects 121
Expert AdviceThe use of potent steroids should be avoided in pediatric and in HPV-infected patients. 121
5.7.3.2 Hormones 121
5.7.3.3 Tacrolimus Topical (Protopic) 122
Advantages 122
Expert AdviceTacrolimus use in anogenital LS may reactivate HPV infection (Bilenchi et al., 2007) . 122
5.7.3.4 Surgical 122
Circumcision 122
Indication 122
Expert AdviceIt is highly recommended to send all tissue removed at circumcision or meatotomy (including in the pediatric popu 122
CO 2 Laser 122
Advantages 122
Meatoplasty 122
Urethral Reconstruction 122
5.7.4 Follow-Up 122
5.8 Penile Horn 122
Expert AdviceMalignant change should be suspected in a rapidly growing penile horn lesion. 123
5.8.2 Pathogenesis 123
5.8.3 Clinical Manifestations 123
5.8.3.1 Symptoms 123
5.8.3.2 Presentation 123
5.8.4 Diagnosis 123
5.8.4.1 Histological Findings 123
5.8.5 Treatment 123
5.8.6 Follow-Up 123
5.9 Genital Paget’s Disease 123
Expert AdvicePatients presenting with EMPD should be systematically evaluated for an underlying carcinoma. 124
5.9.1 Clinical Manifestations 124
5.9.1.1 Symptoms 124
5.9.1.2 Presentation 124
5.9.1.3 Histological Findings (Fig. 5.25) 124
5.9.2 Treatment 124
5.10 Kaposi’s Sarcoma 124
5.10.1 Clinical Manifestations 125
5.10.1.1 Symptoms 125
5.10.1.2 Presentation 125
5.10.1.3 Histological Findings 125
5.10.2 Treatment 125
5.11 PIN Prevention 125
References 125
Human Papillomavirus and Squamous Cell Carcinoma of the Penis 129
6.1 Introduction 129
6.2 Natural History of HPV in Male Subjects 130
6.3 Etiology of Squamous Cell Cancer of the Penis 130
6.4 Molecular Pathogenesis 131
6.4.1 HPV-Mediated Penile Carcinogenesis 133
6.4.2 HPV-Independent Penile Carcinogenesis 133
6.4.3 Common Molecular Events in Penile Carcinogenesis 133
6.5 Prevention of HPV Infection 134
6.5.1 HPV Vaccination 134
6.5.2 Condom Use 134
6.6 HPV as a Prognostic Indicator in Penile Cancer 134
6.7 Conclusion 135
References 135
Human Papillomavirus and Other Anogenital Premalignant Diseases 138
Human Papillomavirus and Anal Intraepithelial Neoplasia 139
7.1 Introduction 139
7.2 Overview 139
7.2.1 Anal HPV Infection and Associated Diseases in Men 140
7.2.2 Anal HPV Infection and Associated Diseases in Women 140
7.3 Clinical Manifestations 142
7.3.1 Symptoms 142
7.4 Differential Diagnosis 142
7.4.1 Benign Conditions 142
7.4.2 Malignant Conditions 143
7.5 Diagnosis 143
7.5.1 Anal Cytology and Histology 143
7.5.2 AIN Grading and Terminology 143
7.5.3 Anal and Perianal Brush Samples for Molecular Tests 144
7.5.4 High-Resolution Anoscopy and Targeted Biopsies 144
How to Perform HRAHRA is an office procedure and anesthesia is not required. A digital rectal examination (DRE) is also perfor 144
7.5.5 Anoscopic Changes Associated with HSIL 146
7.5.6 Cellular Markers 146
7.6 Treatment for Anogenital Warts and AIN 146
Expert Advice 147
7.6.1 Topical Treatments 147
Disadvantages 147
7.6.1.2 Trichloroacetic Acid 147
Advantages 147
Disadvantages 147
Adverse Effects 147
7.6.1.3 Imiquimod 5% Cream (Aldara) 147
Advantages 147
Disadvantages 147
Side Effects 148
Local 148
Systemic 148
7.6.1.4 Cidofovir 1% Gel 148
How to Use 149
Advantages 149
Disadvantages 149
Adverse Effects 149
7.6.1.5 Photodynamic Therapy 149
How to Use (Webber and Fromm, 2004) 149
Advantages 149
Adverse Effects 149
7.6.2 Ablative Treatments 149
7.6.2.1 Infrared Coagulation 149
Advantages 149
Disadvantages 149
Adverse Effects 150
7.6.2.2 Surgical Excision 150
Indication 150
Disadvantages 150
Adverse Effects 150
Expert Advice 150
7.6.2.3 Electrocautery 150
Adverse Effects 150
7.6.2.4 CO 2 Laser 150
Disadvantages 150
Adverse Effects 150
Expert Advice 150
7.7 Surveillance 151
7.8 Anal Disease Screening 151
7.9 Prevention of HPV-Related Anal Warts and AIN 151
References 151
Anchor 31 146
Human Papillomavirus and Cervical Intraepithelial Neoplasia 154
8.1 Introduction 154
8.2 Overview 154
8.3 Terminology and Grading of Cervical Dysplastic Lesions 155
8.4 Risk Factors for Cervical Cancer Development 157
8.5 Natural History of Cervical Dysplastic Lesions 157
8.5.1 CIN 2 and 3 157
8.6 Clinical Manifestations 157
8.6.1 Symptoms 157
8.7 Diagnosis 157
8.7.1 Colposcopy with Acetowhite Test 158
8.7.2 Biomarkers 158
8.7.2.1 HPV DNA Testing 158
Expert AdviceHPV DNA testing is not useful in adolescents and should not be used . In addition, Spitzer (2007) recommended 159
8.8 Treatment for HSIL and CIN 160
8.8.1 High-Grade Squamous Intraepithelial Lesions 160
8.8.2 CIN 1 160
8.8.3 CIN 2 and 3 160
8.9 Treatment Modalities 160
8.9.1 Excisional Procedures 160
8.9.1.1 Loop Electrosurgical Excision/Large Loop Excision of the Transformation Zone 160
Advantages 160
Adverse Effects 160
8.9.1.2 Cold-Knife Conization 161
Indications 161
Disadvantages 161
Adverse Effects 161
8.9.2 Ablative Procedures 161
Expert Advice 161
8.9.2.1 Cryotherapy 161
Advantages 161
Disadvantages 161
Adverse Effects 161
8.9.2.2 CO 2 Laser or Nd:YAG Laser 161
Advantages 161
Disadvantages 161
8.10 Post-treatment Follow-Up 161
8.11 Prevention 162
8.12 Screening 163
References 163
Human Papillomavirus Infection and Immunosuppression 165
Human Papillomavirus Infection in HIV-Infected Individuals 166
9.1 Introduction 166
9.2 Overview 167
9.2.1 HPV-HIV Coinfection in Women 167
9.2.2 HPV-HIV Coinfection in Men 167
9.3 HPV Infectious Cycle 168
9.4 Effects of Host Immune Status on the Risk of HPV Infection 169
9.5 Host Immune Evasion Methods of HPV 169
9.6 HPV Infection in Immunosuppressed Individuals 170
9.7 Relationship Between Declining CD4 + Levels, HPV Infection, and Anogenital Cancers 171
9.8 Relationship between HIV/HPV Coinfection and CIN/Cervical Cancer 171
9.8.1 Natural History of CIN in the HIV-Infected Patient 171
9.8.2 Cervical Disease Screening for HIV-Infected Women 172
9.8.3 Treatment Considerations for Anogenital Warts and CIN in ­HIV-Infected Women 172
9.9 Relationship between HIV/HPV Coinfection and AIN/Anal Cancer 172
9.9.1 Natural History of AIN in the HIV-Infected Patient 172
9.9.2 Anal Disease Screening for HIV-Infected Individuals 173
9.9.3 Treatment Considerations for Anogenital Warts and AIN in HIV-Infected Individuals 173
9.9.3.1 Imiquimod 5% 173
9.9.3.2 Cidofovir 1% Gel 173
9.9.3.3 Infrared Coagulation 173
9.9.3.4 Excisional Surgery and Electrocautery 173
9.9.3.5 CO 2 Laser 173
9.9.3.6 Observation ( “ Watch and Wait” Approach) 174
Expert AdviceVisible lesions of the anal and perianal region in HIV-infected individuals should be carefully evaluated, includ 174
9.10 HAART in HPV-Associated Neoplasias 174
9.11 HAART in HPV-Associated Cervical Disease 174
9.12 HAART in HPV-Associated Anal Disease 174
9.13 HAART in HPV-Associated Oral Disease 175
9.14 Surveillance 175
9.15 Considerations Regarding HPV Prophylactic and Therapeutic Vaccines in HIV-Infected Individuals 175
9.15.1 Prophylactic Vaccines 175
9.15.2 Therapeutic Vaccines 176
References 176
Human Papillomavirus - Laser Treatmentand Prevention 181
Human Papillomavirus and CO 2 Laser Treatment 182
10.1 Introduction 182
10.2 Historic Background 182
10.3 CO 2 Laser Components 183
10.4 CO 2 Laser Beam 184
Expert AdviceA dry operative field is required for effective CO 2 laser action. 184
10.4.1 Laser Safety 185
10.4.1.1 Eye Protection 186
10.4.1.2 Laser Plume 186
10.5 CO 2 Laser Indications 187
10.6 Personal Laser Technique 187
10.6.1 Preoperative Care 187
10.6.2 Settings 188
Expert Advice 188
10.6.3 Procedure 189
10.6.3.1 CO 2 Laser Vaporization of Penile Lesions 189
10.6.3.2 CO 2 Laser Vaporization of Scrotal Lesions 190
10.6.3.3 CO 2 Laser Lesion Excision 190
10.6.3.4 CO 2 Laser Vaporization of Urethral Lesions 190
Expert Advice 190
10.6.4 Postoperative Care 190
10.6.5 Complications 192
References 194
Human Papillomavirus Vaccines 195
11.1 Introduction 195
11.2 HPV: An Overview 196
11.3 A Short Introduction to Papillomavirus Biology 197
11.3.1 HPV Life Cycle (see graphic representation of HPV life cycle in Fig. 11.2 ) 197
11.4 Significance of HPV Proteins in the Generation of Prophylactic and Therapeutic HPV Vaccines 197
11.5 Natural History of HPV Antibodies 198
11.5.1 Humoral Responses 198
11.5.2 Cell Immune Responses 200
11.6 Prophylactic HPV Vaccination 200
11.6.1 Gardasil® 204
11.6.1.1 Who Should Receive Gardasil? 204
11.6.1.2 Indications 204
11.6.1.3 How to Administer 204
11.6.1.4 Side Effects 204
11.6.1.5 Cost 204
11.6.2 Cervarix“ 204
11.6.2.1 Who Should Receive Cervarix? 204
11.6.2.2 Indications 204
11.6.2.3 How to Administer 205
11.6.2.4 Side Effects 205
11.6.2.5 Cost 205
11.7 HPV Vaccination: Issues to Be Addressed 205
11.7.1 Duration of Protection 205
11.7.2 HPV Prophylactic Vaccine Cross-Protection 205
11.7.3 Vaccination of HPV-Infected Individuals 205
11.7.4 HPV Vaccines in Developing Countries 206
11.7.5 Condoms vs. HPV Prophylactic Vaccines 207
11.8 Prophylactic HPV Vaccines in Men 207
11.8.1 Nongenital HPV Infections in Men 208
11.8.2 Cost-Effectiveness of Male Vaccination 208
11.9 Therapeutic HPV Vaccination and Future Vaccine Developments 208
References 209
Index 215