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Chicago College of Osteopathic Medicine Downers Grove, Illinois Rainbow Clinic Aurora, Illinois

Marilyn Scott, MS, APN, Volunteer Director

Rainbow Clinic Aurora, Illinois

To the Editor:

In March 2004, a 40-year-old homeless male reported to our clinic complaining of a large, painful mass growing posterior to his scrotum. The patient rated the severity of the pain as an 8 on an ascending scale with 10 as the most severe. He noted that the pain was worse when he sat on cold concrete, and that walking provoked additional pain. His pain while sitting was so unbearable that it interfered with his ability to operate a forklift, resulting in the subsequent loss of his job.

Upon physical examination, a fungating mass measuring 4 cm by 7 cm, consistent with condyloma acuminatum, was noted posterior and to the left of the scrotum (Figure). The mass was ulcerated and bleeding. The patient stated that the bleeding occurred daily and required that he dispose of his undergarments every 1 to 2 days.

View larger version (112K): [in this window] [in a new window]   Figure. Condyloma acuminatum lesion posterior and to the left of patient's scrotum.

Approximately five weeks before the patient arrived at our clinic, the condyloma acuminatum began to ulcerate and tear, leading to a rapid growth of the lesion. According to the patient, the lesion grew by some 50% during that period.

The patient's past medical history was significant for alcoholism, but the physical examination at the clinic was otherwise within normal limits. The patient was referred to a local hospital for treatment. However, as is the case with many of the homeless patients who are treated at our clinic, follow-up care was not performed because the patient moved and could not be located again.

Condyloma acuminata are usually cauliflowerlike masses found on the urethra, penis, female genitalia, perianal area, or rectum.¹ The lesions are typically limited to a few centimeters in diameter at the time of presentation to physicians. Human papillomavirus type 6 and type 11 are responsible for most cases of condyloma acuminatum,¹ which affects slightly more than 1% of the adult population.² The peak incidence occurs in individuals who are between 20 and 24 years old, with a peak prevalence in individuals 17 to 33 years old.³ The differential diagnoses for such large, bleeding masses include bowenoid papulosis, Buschke-Löwenstein tumor, condyloma latum, and squamous cell carcinoma.¹

Surgical treatment options include cauterization, laser ablation, and surgical excision.⁴ However, only 36% of patients remain free of condyloma acuminatum three months after surgery.⁴ Pharmacologic treatment usually involves topical therapy with imiquimod or podophyllin.^4,5 Although pharmacologic treatment is effective for 70% of patients, the rate of long-term cure with this treatment modality is only 60%, at best.⁵

Patients need to be educated about the risk of relapse. The patient in this case was not informed of the low rate of remaining asymptomatic after surgery. When the condyloma acuminatum returned, the patient developed a distrust of physicians—a distrust that contributed to his refusal to seek treatment until the lesion grew quite large. Proper education from his physician might have encouraged the patient to seek treatment sooner, making it unlikely that he would have lost his job.

Footnotes
As the premier scholarly publication of the osteopathic medical profession, JAOA—The Journal of the American Osteopathic Association encourages osteopathic physicians, faculty members and students at osteopathic medical colleges, and others within the healthcare professions to submit comments related to articles published in JAOA and the mission of the osteopathic medical profession. The JAOA's editors are particularly interested in letters that discuss recently published original research.

Letters to the editor are considered for publication in JAOA with the understanding that they have not been published elsewhere and that they are not simultaneously under consideration by any other publication.

All accepted letters to the editor are subject to copyediting. Letter writers may be asked to provide JAOA staff with photocopies of referenced material so that the references themselves and statements cited may be verified.

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References
1. Ghadishah D. Condyloma acuminata [eMedicine.com Web site]. April 29, 2005. Available at: http://www.emedicine.com/EMERG/topic107.htm. Accessed September 23, 2005.

2. Takahashi S, Shimizu T, Takeyama K, Kunishima Y, Hotta H, Koroku M, et al. Detection of human papillomavirus DNA on the external genitalia of healthy men and male patients with urethritis. Sex Transm Dis. 2003;30:629 -633.[Medline]

3. Fazel N, Wilczynski S, Lowe L, Su LD. Clinical, histopathologic, and molecular aspects of cutaneous human papillomavirus infections [review]. Dermatol Clin.1999; 17:521 -536.[Medline]

4. Maw RD. Treatment of anogenital warts [review]. Dermatol Clin. 1998;16:829 -834.[Medline]

5. Von Krogh G, Longstaff E. Podophyllin office therapy against condyloma should be abandoned [review]. Sex Transm Infect. 2001;77:409 -412. Available at: http://sti.bmjjournals.com/cgi/content/full/77/6/409. Accessed September 23, 2005.[Abstract/Free Full Text]

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