Genital lumps

Question 1

Which types of HPV are giant condylomata of bushke and lowenstein associated with?

Answer 1

types 6 and 11

Question 2

What % of giant condylomata of bushke and lowenstein are associated with malignant transformation?

Answer 2

50% (verrucous carcinoma)

Question 3

When is change of wart treatment indicated?

Answer 3

If <50% response at 6 weeks (8-12 weeks for imiquimod)

Question 4

Can wart treatment be used in pregnancy?

Answer 4

Podophyllotoxin (warticon) is CI

Imiquimod is not approved

Question 5

Which other strains of HPV do gardasil/cervarix cross cover against?

Answer 5

31,33,45,58

Question 6

when was cervarix introduced in UK in school girls?

Answer 6

2008

12-13 yo

Question 7

when was gardasil introduced in schools for boys?

Answer 7

september 2019- 12-13 year old boys and girls offered gardasil
6, 11,16, 18

Question 8

Which HPV types are associated with neoplasia?

Answer 8

16, 18, 31 and 33

Question 9

Most common HPV type in squamous intraepithelial lesions ( CIN, VIN, VAIN, PIN, AIN)?

Answer 9

6, 11, 16, 18, 31, 52

Question 10

Most common HPV type in skin warts?

Answer 10

1, 2, 3, 7, 10

Question 11

Most common HPV type in anogenital SCC?

Answer 11

16, 18, 31, 33, 45, 52, 58

Question 12

Most common HPV type in head and neck cancer?

Answer 12

16

Question 13

What is the incubation of HPV?

Answer 13

Variable.

Generally 3 weeks to 8 months

Question 14

What immune response causes persistence of HPV?

Answer 14

Response to E6 antigen in host immune response leads to clearance
E7 results in relapsing or persistent infection

Question 15

How is HV transmitted?

Answer 15

Direct contact with clinical/subclinical lesions
Or Genital fluids
Microabrasion causes viral inoculation into basal layers

Question 16

What is the risk of MTCT during delivery of HPV?

Answer 16

Not common (reported as 10-70%)

Question 17

Can prepubertal children get genital warts?

Answer 17

Yes- always consider safeguarding issues

But digital warts can be transmitted to genital region- up to 20% off which are skin types

Question 18

Which warts are usually found of moist mucosal/warm/non hairy skin?

Answer 18

Condymolata acuminata (cauliflower like)

Question 19

Aetiology of molluscs contagiosum?

Answer 19

Pox virus
Large DNA virus
Replicates in cytoplasm of epithelial cells
Humans are only natural host

Question 20

What to consider if patient presents with molluscum on the face or more than 12-20 lesions?

Answer 20

HIV

Question 21

What is the incubation of molluscum contagiosum?

Answer 21

2-12 weeks

Up to 6 months

Question 22

How long does it usually take for MC to clear?

Answer 22

Spontaneous clearance can occur within 2-3 months

But recurrence common in 15-35% over 18-24 months

Question 23

Treatment of MC?

Answer 23

pectant management (no treatment) is recommended for immunocompetent patients

Curretage
Cryotherapy
Electrocautery
Puncture with sharpened orange stick dipped in 80% phenol

Imiquimod/podophylotoxin- unlicensed but can use

No shaving/waxing
No sharing towels etc
Cover lesions prior to swimming

Question 24

Common side effects of cyotherapy?

Answer 24

Pain, inflammation and oedema at treated areas.

Pigment change, hair loss and superficial scarring are rare.

Question 25

What is a lymphocoele?

Answer 25

``` Non tender cord like seeing Usually in coronal sulcus Probably related to sexual trauma Self limiting Reassure ```

Question 26

When did Gardasil become available on NHS for MSM?

Answer 26

From April 2018, MSM <=45 became eligible for free HPV vaccination on the NHS

Question 27

Are transgender eligible for HPV vaccine?

Answer 27

Trans women are eligible in the same way as MSM | Trans men are eligible if they have sex with other men and are aged 45 or under.

Question 28

What is the vaccine schedule for HPV in UK in schools?

Answer 28

The first injection is given in year 8 _12-13 yo) | 2nd- 6 to 12 months later.

Question 29

If not yet had HPV vaccine and >15 yo what is the vaccine schedule?

Answer 29

3 doses -response to two doses in older girls and boys is not as good. 0, 1m, 6m

Question 30

What if missed a school HPV vaccine?

Answer 30

Can have until 25th birthday

Question 31

Aetiology of molluscum

Answer 31

``` Benign skin eruption Caused by replication of Molluscs contagious virus in epithelial cells Family poxviridiae Genus Molluscipox More common in warm climates 4 subtypes MCV 1-4 ```

Question 32

How many subtypes are there of molluscs?

Answer 32

4 subtypes MCV 1-4

Question 33

Incubation of molluscum?

Answer 33

2-12 weeks

Question 34

Varicocoeles: which side is it more common on and why?

Answer 34

90% are on left Left testicle drains into left renal vein (90 degree angle) Right testicle drains directly into IVC (more oblique angle)

Question 35

Advice for mumps orchitis?

Answer 35

``` symptomatic relief, such as: Bed rest. Scrotal support. Application of warm or cold topical packs. Paracetamol or ibuprofen. ``` symptoms will completely resolve within 2 weeks and there are unlikely to be long-term problems with fertility. If the man is concerned about fertility, offer semen analysis 3 months after the mumps has resolved, particularly if there was severe or bilateral epididymo-orchitis.

Question 36

Features of mumps orchitis

Answer 36

Parotitis is present in 95% of symptomatic cases. Diagnosis is clinical/igM - saliva Non-specific symptoms (which may precede parotitis), such as low-grade fever, headache, earache, malaise, muscle ache, and loss of appetite — typically occur 1 day before overt signs of parotitis and peak around the time the parotid glands are most swollen. Epididymo-orchitis — typically, there is an abrupt painful swelling of the testicle, accompanied with systemic symptoms of high fever (39–40°C), chills, headache, and vomiting.

Question 37

Features examination of mumps orchitis?

Answer 37

Testicle is usually enlarged (up to four times the normal size warm, and tender scrotum may be reddened in appearance. It is usually unilateral, and tends to occur about 1 week after symptoms of parotitis. Bilateral mumps epididymo-orchitis occurs in 15–30% of affected men However, it may occur up to 2 weeks after parotitis, and in a significant minority of men there may be no symptoms of parotitis at all.

Question 38

How effective is quadrivalent gardasil in preventing warts?

Answer 38

99%

Question 39

What is % reduction seen in warts (1st diagnosis) in UK?

Answer 39

39% reduction between 2009 and 2015 in women

Question 40

What does gardasil provide cross protection against?

Answer 40

HPV types 31, 33, 45 and 58

Question 41

HPV immunisation programme in UK- who included?

Answer 41

Boys and girls year 8 12-13 yo MSM up to 45 None licensed for treatment of existing HPV

Question 42

Cervical warts?

Answer 42

Routine colposcopy not recommended Rx- cryo/electrocautery, TCA, alder, excision Or NO TREATMENT Cytology as normal

Question 43

How common is HPV?

Answer 43

HPV DNA in 10-40% of unvaccinated heterosexuals/MSM

Question 44

What is the incubation of warts?

Answer 44

3-8 months

Question 45

How many warts regress without rx?

Answer 45

70% within 1 year 90% within 2 years If immunocompetent

Question 46

Testicular torsion- age presents?

Answer 46

Testicular torsion can occur at any age but its peak incidence is between 13-16 years.

Question 47

Varicocele - how common?

Answer 47

Normal finding in 20% of men!

Question 48

Varicocele features?

Answer 48

Time frame: Gradual onset Presentation: Painless, some patients complain of a dragging sensation of a dull ache Clinical findings: Visible when standing, disappears on lying down, sometimes feels like a ‘bag of worms’ 95% on left

Question 49

What is a hydrocele?

Answer 49

It’s an accumulation of peritoneal fluid between the two layers of the tunica vaginalis (parietal and visceral). It is the equivalent of an effusion in secondary cases Primary (idiopathic) is painless; secondary (varicoele, trauma, infection, tumour) can be associated with pain

Question 50

How does EO present?

Answer 50

Pain and swelling associated with dysuria, fever, redness of the scrotum Clinical finding: Tenderness on palpation of the epididymis and the entire testicle can be associated with a hydrocele Features: This is the most common cause of scrotal pain and treatment is associated with the most likely organism i.e. sexually transmitted infections in sexually active patients or enteric organisms in men over 35. There are also many rarer causes such as medication side-effects, rarer infections and autoimmune conditions

Question 51

What are most common types of testicular cancer?

Answer 51

90% of testicular cancer cases are germ cell tumours which include seminomas and non-seminomas

Question 52

VIN3

Answer 52

HPV 16 association 70% smokers 50-90% HPV association One study - 6% of grade 3 VIN already contained SCC a 3% of cases will progress to SCC. On average it takes well over 10 years for VIN to progress to cancer.

Question 53

Prevalence of genital warts (at set point in time)?

Answer 53

1%

Question 54

How many people have had HPV in lifetime?

Answer 54

75-80%

Question 55

How many HPV get better on own?

Answer 55

1/3

Question 56

% of HPV that will progress?

Answer 56

50%

Question 57

% of HPV that persists or recurs?

Answer 57

20%

Question 58

How does imiquimod work?

Answer 58

On innate immune system stimulates toll like receptors--> produce interferons and IL to fight HPV at basal layer up IL and cytokine response

Question 59

How common is laryngeal papillomatosis in babies?

Answer 59

4 in 100,000

Question 60

Main risks for head and neck cancers?

Answer 60

smoking and alcohol | and less so HPV

Question 61

How does HPV vaccine work?

Answer 61

On L1 gene