Treatment of anal HPV-associated disease depends on the diagnosis, location, and size or amount of disease. Most clinicians treat grossly evident genital warts, or those that can be seen with the naked eye. There are no current standards of care for non-warty anal LSIL or the precancerous HSIL. There are arguments both in favor and against treatment of anal warts, LSIL and HSIL disease. Because LSIL (including warts) is benign, and usually regresses on its own, it may be unnecessary to treat. However, many patients and clinicians prefer to remove warts rather than waiting for them to go away on their own. Treatment of HSIL may be unnecessary because most HSIL does not progress to cancer, and much of it also regresses without treatment, nor it been proven to be the definitive cancer precursor lesion. A study underway nationwide is exploring whether or not it is necessary to treat HSIL in order to prevent anal cancer.
It is important to understand that in treatment of any HPV-associated disease, the underlying cause itself is not treated. In other words the HPV virus, which causes the problem, cannot be treated. Only the disease that the HPV causes, i.e., warts or lesions can be treated. Some treatments may affect the amount of HPV that the body sheds but we do not currently have any treatments that can rid the body of the HPV. However, in most cases we can effectively treat anything that the HPV causes.
Treatment of anal warts, LSIL or HSIL can take a long time and may require many visits over several months. It will also require long-term follow up to be certain that the disease has not recurred and to evaluate for any new developments. It is common, especially in people who are immune-compromised, to have ongoing HPV and to develop HSIL within a few years of developing LSIL or warts. It is important for patients to work with their providers in developing both a treatment and follow-up plan.
HPV only affects squamous epithelium, which includes the anus and perianal areas, as well as the cervix, vagina and vulva in women. or penis in men. HPV does not extend beyond the anus into the colon. The colon is a different tissue type, which is not infected by HPV. Therefore it is not necessary to have a colonoscopy in order to determine if warts are further inside the colon. However routine colonoscopies also do not typically find LSIL or HSIL in the anus either.
Treatment of warts, LSIL or HSIL can be a long and frustrating process. This is especially true in the primary outbreak of warts. It takes the immune system time to "figure out" how to cope with this new virus. Once the immune system has learned to control the virus, there are generally few recurrences for most people. This means the HPV will be latent and will not cause any outbreaks unless the immune system stops suppressing it. This can happen if you become immune-compromised (for example, becoming HIV positive, or needing steroid therapy for asthma or auto-immune diseases such as Lupus, or following an organ transplant). There are times when it will not be possible or desirable to treat the lesions. Untreated, these lesions may regress on their own, may persist unchanged, or may increase in size and quantity. This cannot be predicted by any factors.
Not everyone will respond to every type of treatment and it may take several types of treatment before there is finally a response. This can take many months. In some cases, the lesions will never be completely eradicated. However, whatever is treated will be gone and that lesion cannot progress to cancer. So even treatment that is not 100% effective may still help prevent progression to cancer.
Once it is determined whether the patient has LSIL (which includes warts), HSIL, or both, as well as the location and extent of the lesions, a treatment plan will be suggested which may include a single type of treatment or a combination of treatments. The goal of treatment will be to ablate (get rid of) all the lesions that can be seen. Once this is accomplished, the clinician will determine a follow-up plan to look for recurrences or just to be certain that the patient remains healthy and free of any further disease.