Excisional Biopsy and/or Laser Ablation of Condyloma
Excision = to cut and remove
Biopsy = to take part of a tissue and have it analyzed
Ablation = to destroy and/or make disappear
Condyloma = a wart-like lesion caused by the human papilloma virus (HPV)
Condyloma acuminata are wart-like lesions caused by a few of the near 80 strains or types of strains of the human papilloma virus (HPV). The strains that cause sexually transmitted warts are distinct from those causing warts on the hands or feet. They are usually transmitted by sexual contact, although some believe that transmission is possible without direct sexual contact. The latency period from contact to growth has not been truly defined. In that regard, it may be possible for weeks, months, and perhaps even years to pass between exposure and development of the lesion(s). The penile shaft is the most common site of condyloma. Thescrotum, perineum (area between the scrotum and anus), perianal region (directly around the anus), and prepubic region (area above the penis) are other common sites. Uncommonly, condyloma can occur in the urethra (tube through which you urinate). In women, condyloma present on the labia minora and majora, as well as within the vagina. Certain strains of HPV are known to cause cervical cancer in women, although there is no established link of HPV to penile cancer in men. When left untreated, the individual lesions may grow in size and spread to other areas.
Over the years, condyloma have been treated in many different ways. All of the therapies are administered with the intent of destroying the individual lesion(s). The virus, however, is usually not destroyed and so recurrence (without repeat exposure) is quite possible.
- Topical Therapy: Medications applied only to the lesions that destroy tissue on contact
- Antiviral Topical Therapy: Medicines applied to the entire general area that attack the virus following penetration into the skin or lesion
- Cryotherapy: Application of liquid nitrogen to freeze and destroy the lesion
- Cauterization: Application of an electrical heat current to destroy the lesion
- Laser Ablation: Use of specific types of laser to destroy the lesion
- Excisional Biopsy: Surgically removing a specimen (done for large lesions or for those where we are not completely certain that the lesion represents condyloma)
The remainder of this section will focus on the procedures (cryotherapy, cauterization, and laser therapy). The proper use of and side-effects of the topically applied medicines would be discussed with you much like any other medicine that you receive from a physician.
Any of the three treatments can be performed in an office setting. Cryotherapy, small fulgurations, excisional biopsy of small lesions, and even cystoscopy (putting a scope in the urethra) with fulguration of small intraurethral lesions can be done in the office. For office-based treatments there is no particular preparation. *If your surgery is being done in the office, however, we suggest that you eat lightly no closer than one hour prior to your procedure.
If you are scheduled for a laser procedure in the hospital, a large volume fulguration, or a large excisional biopsy in the hospital using some form of anesthesia, you will be asked not to eat or drink anything after midnight on the evening prior to your procedure. You may brush your teeth in the morning but not swallow the water.
If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
To review the basics of what we discussed in the office: The procedure time varies considerably based on the location, size, and extent of the lesions. The type of anesthesia used will again depend on these same factors. Not all procedures require anesthesia. Local anesthesia, sedation, and rarely general anesthesia (complete sleep) may be used according to the suggestion of your surgeon as well as on your preference. We typically reserve general anesthesia for cases of high volume perianal (around the anus) condyloma or significant intraurethral (in the tube through which you urinate) condyloma. When there are just a few lesions, they may be individually numbered with a tiny injection of local anesthetic. This is true for fulguration, laser ablation, or excision.
In most instances, we are confident that a specific appearing lesion represents condyloma by looking at it. If the lesion appears atypical, we may perform an excisional biopsy of the lesion. In these cases, the area is cut away with a surrounding margin of what appears to be normal tissue. If the lesion is large, it may require a few sutures to close it. With small excisions, we may treat the base with laser or fulguration to kill possible virus left behind. An antibiotic ointment may then be applied to the area. A dressing is rarely, if ever, required. This sample will be sent to the pathologists (doctors who examine tissue specimens) who examine it under the microscope to confirm the tissue type.
When performing fulguration, an electric current (termed an electrocautery) is used to burn the lesion itself while making every effort to leave surrounding tissue untreated. The same is true for laser treatment. Again, antibiotic ointment may be applied to the areas.
For intraurethral lesions, the cystoscope is placed in the urethra and the lesion is biopsied or simply laser ablated. In very rare instances of high volume intraurethral condyloma, we may elect to leave a catheter in your bladder for one or two nights. This is to ensure that you do not go into urinary retention (inability to urinate) from the inflammation in the urethra.
After fulguration or laser ablation, you may feel some minor discomfort over the treated areas. It is described as a stinging feeling much like a minor burn. Many patients have no pain whatsoever.
If your procedure was performed in the hospital, you will be in the recovery room for a short time before being sent home. If the procedure was performed in the office with mild sedation, we will observe you for a while. In either of these instances, you must have someone to take you home. If only local anesthetic was used, we may let you drive after a period of observation.
Areas that were treated will appear red and occasionally black. Over the next day or so, small scabs will form. Do not attempt to remove these scabs.
We may provide you with a prescription for pain medication but you certainly may take an over-the-counter medication to which you are not allergic. We may also ask you to apply antibiotic ointment to the treated areas a few times per day for just a few days. If a deep excision was performed, we may place you on a course of oral antibiotics. You may shower whenever you desire. If sutures were placed, you may shower, but please avoid bathing or swimming for a couple of days unless otherwise instructed to take warm baths. The sutures we use are usually self-dissolving, and therefore just fall out on their own within 1-2 weeks after surgery.
Expectations of Outcome
As mentioned previously, the available therapies are intended to destroy the existing lesions and should not be considered a "cure" of HPV. It is possible to develop new lesions during treatment or at any time in the future.
Until completion of your treatment, you should abstain from sexual contact to reduce the risk of HPV transmission to other non-infected individuals. You and your partners must realize, however, that HPV transmission is still possible even if no lesions are present. In other words, the virus may still be present.
Following treatment with the topical therapies, it
may take weeks to months for lesions to completely disappear.
For any of the treatments, but particularly with cauterization, cryotherapy, or laser ablation, it is quite possible that you will have small permanent scar where the lesion was treated. These scars are rarely skin deformities (like a wound scar), but rather are a white spot representing a loss of pigmentation where the treatment occurred. These areas are typically very small and barely noticeable. Every patient has a different tendency to form scars, and it is not possible to predict in whom a slightly more noticeable scar may form.
Women treated for condyloma, or even exposed to a partner who was treated for condyloma, must be extra diligent about having their regularly scheduled Pap smears. As mentioned, there is an increased incidence of cervical cancer with certain types of HPV.
Possible Complications of the Procedure ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may generate questions if you are still concerned.
Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Recurrence: Condyloma does have a propensity to return. This is not a complication, but more of an expectation.
- Infection: Infection is possible in any procedure. Usually, local wound care and antibiotics are sufficient. Occasionally, an infection following excision biopsy would require partially opening the wound to allow proper drainage.
- Scarring: All surgeries leave some degree of a scar. As mentioned, fulguration, cryotherapy, or laser ablation often leave a white scar.
- Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery.
Although very rare following such procedures, it is still possible. In almost all instances, the pain disappears over time. If persistent, further evaluation would be necessary.
- Hematoma: This complication will very rarely occur if an excisional biopsy was performed. Even when all noticeable bleeding is stopped, it is possible for a small vessel to have a delayed bleed under the sutures. The collection of this blood under the skin is termed a hematoma. Intervention is very rarely necessary and it almost always resolves over time...much like any bad bruising or swelling. If the hematoma is unusually large (cumbersome or painful) or does not show resolution in a reasonable amount of time, a procedure to evacuate the clots may be required.
- Urethral Stricture: This complication may be seen following procedures treating intraurethral condyloma. Following any intraurethral procedure (from the cystoscopyalone or more commonly from the laser fulguration), it is possible to develop a stricture (occlusive scar tissue) anywhere in the urethra. If it is significant and interferes with normal urination, a repeat scope procedure may be necessary to open the scar.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.