Speaker: Stephen E. Goldstone, M.D., Board Certified General Surgeon
Dr. Goldstone is a surgeon who specializes in anal and rectal disorders. December's Community Forum was an informal, well-attended discussion on rectal health. Rectal health is a topic often considered taboo by conservative medical society, particularly amongst surgeons. The field is expanding quickly. Because it is known that human papilloma virus (HPV) is one of the most prevalent sexually transmitted infections, Dr. Goldstone focused much of his discussion on HPV, and the practical screening methods used to prevent the disease from becoming cancerous.
The truth is that you cannot really discuss the topic of rectal health without discussing a common sexually transmitted infection called HPV.
HPV is a common viral infection, caused by a number of strains of human papillomavirus. HPV can lead to warts on the skin and mucous membranes (particularly in the genitals), and is often associated with cervical or anal dysplasia, and in some cases, cervical and anal cancer.
To date, there are over sixty types of HPV that have been identified, some more common than others. Certain strains of HPV are associated with warts on the skin, particularly on or around the anus, inside the rectum, penis, labia, or vagina. Warts appear when a person's immune system responds to the virus in the skin cells and causes inflammation in that area. Though HPV is probably best know for its association with genital warts, it is possible to carry HPV and never have genital warts. Some strains of papillomavirus, which can reside in the area between the vagina and cervix, or the anus and rectum, can cause inflammation and changes in the cervical or anal tissue to varying degrees. This is called dysplasia. High-grade dysplasia is strongly associated with an increased risk of cervical and anal cancer, especially for men and women living with HIV/AIDS.
Close to 50% of sexually active men and women have HPV. The number is higher among men who have sex with men, and for both women and men living with HIV. In women, HPV infection is more common for those who become sexually active at an early age, and for those with multiple sexual partners. It is estimated that 85% of women living with HIV and close to 100% of gay and bisexual men with HIV have HPV, though many don't know it. HPV infection is one of the most common reasons for abnormal results on Pap smears.
This viral infection is, unfortunately, fairly easy to pass through lots of common sex acts. Many sexually active adults have it because it is so easy to transmit, even with condom use. Men with HPV can have virus present on the anus, on or around the penis, thighs, or butt cheeks, and may not necessarily know it. Condoms, when used, don't cover all of these areas. Women can have virus in the thighs and butt cheeks, but also in their cervix, in the skin cells around and inside the vagina, labia, and in the rectum. For people with compromised immune systems, HPV is sometimes found in the mouth in the form of small bumps.
You don't have to have semen present to catch the virus. Skin to skin contact can be more than enough. HPV can be present in the cells lining the rectum even for people who haven't had lots of anal sex. Dr. Goldstone explained that through sexual activity, with fingers, penises, or sex toys, and possibly through other ways, HPV can migrate from a place like the vagina to the rectum, or from the thighs to the rectum. Simply rubbing yourself against an area where virus is present, like the shaft of someone's penis, or the outer labia, can sometimes be enough.
The short answer is, not much. Having HPV doesn't mean you can't have sex. Dr. Goldstone advised people to worry less about getting HPV and focus more on getting regular Pap smears to screen for HPV-associated dysplasia. This is good advice for both sexually active women, and for all men who have sex with men.
Because it is possible to have HPV, warts, or anal dysplasia without realizing it, Dr. Goldstone strongly urged all men who have had sex with men, women who have had anal sex, and people who already know they have HPV, to see their doctor regularly. He recommends that people request both a rectal exam and an anal Pap smear once a year as part of routine preventive care. This is the best method currently available to screen for possible inflammation and precancerous changes in the cells of the rectum that may happen as a result of HPV infection.
A Rectal Exam is when a doctor inserts one finger inside the anus, into the rectum, and feels around for abnormal growths. Warts, and other obvious problems, can sometimes be detected this way, but the rectal exam is unable to detect subtle changes that can be precursors to bigger problems. Because rectal exams only spot fairly obvious or advanced problems, it's important to ask for a Pap smear, which is more sensitive, and a better predictor of whether you may need further observation or treatment.
A Pap smear is a simple procedure, most commonly used by gynecologists to screen for cervical cancer. Dr. Goldstone explained that the Pap smear can also be used anally in men and women to screen for changes and abnormal cells in the rectum, associated with HPV infection. Pap smears usually involve thin dacron swabs or a nylon brush inserted through the vagina to collect cervical cells. The cells are then sent to a lab, where a pathologist analyzes it for any changes, or abnormal activity.
To perform an anal Pap smear, any trained physician can insert a dacron swab inside the anus to collect a sample of the cells. Because anal paps must be done without the use of any lubricant, they can be uncomfortable. Once cells are collected, they are sent to a cytologist, who will determine whether or not those cells are abnormal. If there is a finding of abnormal, further tests can be done to determine whether the cells are reactive, and to what degree.
Results are reported according to the same system (Bethesda) used to analyze most cervical Pap smears. According to this system, the possibilities include:
Atypical squamous cells of undetermined significance (ASCUS), referring to cells that can't be categorized as normal or dysplastic, sometimes due to bad specimen.
Low-grade squamous intraepithelial lesions (LSIL). This includes warts (anal/cervical/genital) and mild dysplasia (sample shows evidence of cervical or anal intraepithelial neoplasia grade 1, referred to as CIN I and AIN I). In the Bethesda system, CIN I and AIN I are both reported as LSIL, or low-grade squamous intraepithelial lesions.
High-grade squamous intraepithelial lesions (HSIL). This category is often simply referred to as high-grade dysplasia. It includes samples showing evidence of CIN/AIN grade 2 or 3 (sometimes referred to as moderate and severe dysplasia), or carcinoma in situ.
Regular screening through Pap smears and rectal exams are our best bet for preventing problems, but what if problems are detected?
Dr. Goldstone stressed that treatments for people with abnormal anal paps vary according to the source and the severity of the cellular changes. He suggested that anyone who gets an abnormal Pap smear should have a more sensitive procedure called high resolution anoscopy (HRA). To perform HRA, your doctor inserts a small scope with a light at the end inside your anus to actually look at the cells and see whether there are any warts, precanceorus lesions, or other abnormalities in the tissue. HRA shows a doctor exactly where there may be abnormal tissue and whether surgery, or other methods, are required to effectively treat the lesion. Your doctor may biopsy any lesions (a small pinch) to see if the tissue is high grade or not.
According to Dr. Goldstone, HRA results that indicate a high-grade dysplasia require treatment because, if left untreated, high-grade lesions can progress to anal cancer. In women, some cases of high grade cervical dysplasia are treated by a method known as a cone biopsy, where the surgeon removes the precancerous portion of cervical tissue. In anal dysplasia, physicians can't remove the anus, so they have to directly remove the abnormal tissue through a variety of different methods. Rarely is aggressive surgical removal required to treat these lesions, and Dr. Goldstone emphasized that people should beware of doctors who tell them they require an extensive operation.
When growths or warts are detected, the next step is to treat the spot with an acid, or freeze it, or perform a laser procedure to burn it off. These are common procedures and, if caught early, the precancerous area can be removed before causing further damage. Dr. Goldstone asserts that precancerous areas look different than common warts. If you do have warts, your doctor should be suspicious that you may also have a precancerous area. You should see a doctor and get a HRA to better understand the scope of the problem.
Q: Are topical creams, like gancyclovir, effective at treating the lesions?
A: Not yet. In fact, a number of topical ointments have been tried, like retinoids, all with no results. Dr. Goldstone is currently sponsoring a clinical trial with indole-3-carbonyl, a component found in cabbage. The chemical comes in pill form, and has been effective against other types of HPV lesions. Dr. Goldstone is also testing a vaccine that might stimulate your body's own immunity to kill the high grade lesion.
Q: What is cancer in situ?
A: A lesion looks very similar to a cancer, but has not yet progressed to an advanced stage where it can spread.
Q: What is a fissure?
A: A fissure is a tear in your anus. Generally, fissures will heal if you keep your stool soft and use creams your doctor can prescribe. If it doesn't heal, surgery might be required. While a fissure is most often caused by a large, hard stool tearing the delicate lining of your anus, anal fissures can also be caused by inserting objects into the anus. Some physicians feel the only way to repair this injury is to cut the sphincter, however, this is not necessary for most people who have had anal sex.
Q: Can douching help prevent HPV?
A: Douching doesn't really have a positive effect on the HPV and in fact may only worsen the problem.
Q: Why are anal screens not the normal standard of care?
A: There are many reasons why surgeons and other physicians are sometimes reluctant to do anal screenings. Currently, the Centers for Disease Control (CDC) doesn't recommend the screening. As a result, many physicians are uninformed about the risk of anal cancer and the importance of screenings. Many don't typically perform rectal examinations; some are unfamiliar with how to do an anal Pap smear. This subject not only requires physicians to talk with patients about their butts, but it forces doctors to acknowledge and discuss anal sex and other common sex acts that are still highly stigmatized and, in many states, criminalized. Dr. Goldstone stressed that these limitations make it even more important for informed patients to advocate for themselves and get this screening done once a year.
He concluded with the take-home message of the evening that we all have a tremendous amount of control in our medical care. Getting regular check-ups is a must, as is getting Pap smears. If your doctor doesn't already do this with you, insist on getting it done annually. It is the first and most effective line of defense against anal cancer.