The Ins and Outs of Gay Sex (16 page)

Some of the following treatments may not sound like surgery, but they all require some form of anesthesia.
If your warts are small and isolated, local anesthesia may be enough, but if extensive or inside your anorectal canal, more complete relaxation is needed.
Some doctors can remove even the most extensive anal warts safely in their offices, but most often you’ll need a trip to an operating room at a hospital or ambulatory surgery center.
(An overnight stay is rarely required.
)

Surgeons use scalpels and scissors to cut out warts and send them to a pathologist, who checks for cancer.
After removing some warts for biopsy, most surgeons then switch to destroying the bulk of the warts with high heat from electric current (cautery) or freezing them away with liquid nitrogen.
Extreme temperatures have the advantage of killing warts with very little bleeding, but to prevent recurrence, the entire wart must be destroyed.

Some surgeons also use lasers to eradicate warts.
The frequently used carbon dioxide laser beam hits a wart with energy from its invisible light and instantly heats it to the boiling point.
The wart goes up in a cloud of smoke with very little injury to surrounding healthy tissue.
Physicians who advocate this technique of laser vaporization report faster healing with a lower incidence of wart recurrence over other standard surgical methods.

No matter what treatment method your doctor employs, be sure he or she uses acetic acid to bring out the tiniest warts that might otherwise be missed.
A missed wart guarantees you’ll be back for more treatment, and neither you nor your doctor wants that.
If you have external anal warts, your surgeon must carefully dilate your sphincter to check inside for hidden warts.

Whether your warts are burned, frozen, or cut away,
don’t be surprised when your surgeon doesn’t sew up the hole left behind.
To prevent infection, the skin is left open so healing occurs from the inside out.
While tiny warts heal quickly, large open areas from bulky warts often take weeks to fill in.
Taking frequent baths to keep your wounds clean prevents infection and speeds healing.

Unfortunately, most gay men know someone who has been surgically treated for anal warts—someone who all too willingly recounts the horrors of his postoperative period.
Sadly, these men are not exaggerating when they describe hours soaking in the tub (sitz bath) moaning with pain.
Gay men often put off treatment until they are walking around with an asshole that looks like it’s been hung with Christmas tree ornaments.
They have so many warts that any surgical procedure becomes extensive.
And afterward, their open wounds discharge a bloody fluid that stains their underwear.

If you need surgery, be sure your physician gives you adequate pain medication.
(A narcotic is often required.
) While you won’t be pain free (for that you’d have to be in a coma), you should be fairly comfortable.
In short, expect a week of hell.
The only way to avoid it is to see your doctor at the first sign of condyloma.
The quicker you’re treated, the less chance there is for spread.

Some surgeons advise a series of surgeries for advanced cases, removing a little each time.
I am opposed to this practice, because mini-treatments are no less painful and the process is spread out over many weeks.
Also, while one area is treated, it can become reinfected from another.
Bite the bullet, bend over, and get it done all at once.

Wart recurrence is a major problem, no matter what the treatment.
Even after radical surgery aimed at total elimination of anorectal condyloma, expect a recurrence rate of up to 50 percent, with 20 to 30 percent being average.
Fortunately, subsequent treatments don’t have to be as bad
as your first.
Most recurrences, if caught early, are handled with a simple “touch-up” in the doctor’s office with topical agents.
Don’t keep putting it off until your warts have multiplied and you’re right back where you started.

Patients with HIV are more prone to extensive warts that recur more often.
Unfortunately, HIV treatment alone will not make warts disappear.
If you have HIV and suspect venereal warts (most patients with HIV also harbor the human papillomavirus), seek treatment immediately.
This is not something that will go away, and, in all likelihood, it will get worse very quickly.
And don’t assume that just because you see doctors for HIV, they also check you for warts (or any other STD) regularly.
If you feel something, tell your doctor about it and be sure it’s looked at.

ANAL CANCER
   It may seem absurd to include anal cancer under the global heading of STDs, but more and more scientific data support just this conclusion.
Anal cancer is neither the typical colon cancer nor the Kaposi’s sarcoma common in AIDS.
Anal cancer is a squamous cell tumor that closely resembles cervical cancer in women.
Squamous cells, as you may recall from
Chapter 2
, line your anus and are similar to skin cells found elsewhere on your body.
Your anal lining ends with a series of glands at the dentate line.
(See
Figure 2.
1
.
) These glands are analogous to those found in a woman’s cervix, and doctors have long known that cervical cancer is directly related to infection with certain types of human papillomavirus.
The many varieties of HPV are numbered; types 16 and 18 predispose you to cancer, whereas types 6 and 11 cause warts.
The same virus can infect a woman’s cervix and your anus.
Unfortunately, most HPV infections contain multiple types, so you end up with warts as well as dangerous areas progressing toward cancer.

Before the HIV epidemic, the incidence of anal cancer
in gay men who had anoreceptive intercourse was equal to the rates of cervical cancer in women before the advent of Pap smears.
In the AIDS era we have seen a dramatic increase in anal cancer in men who have sex with men.
It is now the fourth most common malignancy associated with HIV.
Frightening?
You bet, but it doesn’t have to be.

From the comprehensive study of cervical cancer, doctors know that squamous cell cancer progresses through various stages whereby normal cells infected with HPV gradually change into cancerous cells.
The various stages in this transformation can be seen with a microscope.
For years women have routinely gone for a Pap smear, in which a swab is used to pick up samples of their cervical cells for microscopic examination.
Mildly abnormal cells are called low grade dysplasia; severely abnormal cells (potentially malignant) are high grade dysplasia.

In order to obtain a sample of your anal cells for cytologic examination (a Pap smear), the doctor passes a Dacron swab into your anus.
Abnormal cells stick to the swab, and the doctor can transfer them to a microscope slide.
Although lubricant cannot be used because it distorts cells, the Dacron swab is small and causes minimal discomfort.
Unfortunately, a Pap smear is still not a routine part of most medical evaluations.
If your doctor doesn’t do one, ask for it.

Low grade dysplasia carries little risk of underlying malignancy, but high grade dysplasia is a more serious threat.
Although the study of anal dysplasia is just beginning, given the cervical cancer model, many doctors believe that high grade dysplasia has a significant risk of progressing to an invasive cancer.
Men with HIV have a higher risk for developing high grade dysplasia that progresses to invasive cancer than do those who are HIV negative.

HIV-negative men who have anoreceptive intercourse should obtain a Pap smear once a year, and HIV-positive men should have it twice a year.
If normal cells are found,
nothing further needs to be done.
Low grade dysplasia might mean underlying condyloma or cells in the early stages of transformation to cancer.
Low grade dysplasia doesn’t always progress to high grade, and the cells can return to normal.
Obviously a Pap smear with low grade changes needs to be followed with repeat examinations at six- to twelve-month intervals.

When women have abnormal Pap smears, their gynecologist does a colposcopy and checks the cervix with a microscope.
Under magnification, abnormal areas of dysplasia look different from normal counterparts.
The gynecologist can then sample these areas for cancer.
Surgeons are just beginning to apply colposcopy to men with dysplasia.

If your doctor tells you that you have high grade dysplasia, don’t automatically assume that you have a deadly cancer.
For cancer to be lethal, its cells must be more than malignant, they must also have the ability to spread.
This ability to spread is the last step in evolution for any cancer and cannot be determined through a Pap smear.
You need to have a biopsy where a tiny piece of anal lining is snipped out (it doesn’t hurt) and sent to the lab to be studied.
The pathologist looks at an entire cluster of cells and determines if there is any sign of invasion (the ability to spread).
If there is, then you have a true cancer, and chemotherapy and radiation may be required.
When only dysplasia is present without any sign of invasion, simple excision of all abnormal tissue is treatment enough.
Your doctor needs to use a microscope to magnify your anal glands to find these tiny areas that typically don’t look like warts.
If your surgeon just treats your warts, dangerous areas of dysplasia may be left behind.

Hepatitis is a viral infection of the liver caused by several different types of viruses.
The most common are hepatitis
A, B, and C.
Although hepatitis D, E, and G also have been identified, they are rare.
I include hepatitis as an STD because, for many men who have sex with men, the virus passes between partners during sex.
The word “hepatitis” fills most of us with dread, but often the virus, no matter what type, causes an asymptomatic infection (you don’t know you have it) that goes away on its own.
The only indication that you ever had the disease comes when your doctor tells you blood tests showed you’re immune to future infections.

Hepatitis can, on rare occasions, take a much more dangerous course and, instead of a mild infection, progress to liver failure and death.
Other times the infection improves but never quite goes away (chronic hepatitis), and the virus slowly, over many years, destroys your liver.
Fortunately, liver failure occurs in less than 1 percent of infections, but chronic hepatitis can be much more common and depends on the type of infecting virus.
Chronic hepatitis may eventually lead to cirrhosis or liver cancer.

When first infected with hepatitis, you feel fine—but the virus continues to multiply, destroying more and more liver cells.
Your urine darkens to tea color and the whites of your eyes turn yellow as jaundice begins.
Profound weakness and fatigue set in, along with loss of appetite, nausea, and vomiting.
Many men feel like they can’t even get out of bed.
Smokers complain that cigarettes have lost their taste—a strong indication that they may have hepatitis.
Doctors diagnose hepatitis through blood tests, which identify either the virus or the antibodies made to fight the infection.

HEPATITIS A
   Hepatitis A is often called infectious hepatitis, but this is really a misnomer because all forms of hepatitis are infectious.
Hepatitis A is frequently passed via a fecal-oral route.
Sound disgusting?
A common way for many diseases to spread, fecal-oral contamination does not imply
that you’ve eaten an infected person’s shit (although always beware of rimming!
).
People can transmit the virus from their stool to your mouth when they don’t wash their hands before preparing food.
(Now you know why your mother always told you to wash!
) Clams and other shellfish also can ingest hepatitis virus in contaminated water and pass it when you enjoy those raw bar delicacies.

Although you certainly feel sick, hepatitis A is rarely fatal and does not progress to a chronic condition.
You become infectious at the end of an incubation period (approximately two to six weeks)—even before you know you’re sick.
During this dangerous time you can unwittingly pass the virus to other people, even through kissing.
You remain infectious until your antibody levels rise high enough to contain and then kill the virus.
In most cases the disease runs its course within six to eight weeks and your liver recovers completely.

To prevent infecting household members, separate your dishes from theirs, washing everything thoroughly.
Hand washing after a bowel movement is, of course, crucial, but self-isolation is not.
If you lock yourself away, you’ll only feel more depressed, and this will worsen your condition.
You need someone around to cheer you up, push you to eat when food has no taste, and dispense that all-important bit of TLC.
Stories detail ridiculous extremes people go to trying to protect themselves from hepatitis:
One man drained his pool because a friend recovering from hepatitis went for an uninvited swim, and another threw out every dish his lover touched before they switched to paper.