Anogenital Dysplasia

Anogenital dysplasia is a condition where cells in the genital or anal areas become abnormal. While these changed cells are not cancer, they could develop into cancer over time, making monitoring and treatment important.

Table of contents

• What Is Anogenital Dysplasia?
• Types of Anogenital Dysplasia
• Symptoms
• Causes and Risk Factors
• Screening and Diagnosis
• Understanding the Grades
• Treatment Options
• Prevention

What Is Anogenital Dysplasia?

Dysplasia means abnormal growth or development of cells. Anogenital dysplasia is a condition in which some cells of the anus or genitals change and become abnormal^[1]. These cells are not cancerous but could be precancerous, with the potential to develop into cancer over time^[1].

Most anogenital dysplasia goes away on its own^[1]. However, sometimes dysplasia can turn into cancer, so it’s important to monitor this condition^[1]. The condition is often found during routine screening tests before any symptoms appear.

Many cases of anogenital dysplasia and some other genital diseases are linked to human papillomavirus (HPV) infection^[1]. Most adults get HPV at some point in their lives. People with HPV often don’t know they have the virus unless they have a wart or an abnormal Pap smear with an HPV test^[1].

Types of Anogenital Dysplasia

Anogenital dysplasia can affect different areas of the body^[1]:

• Anal dysplasia affects the anus, the opening at the end of the digestive tract^[1]
• Cervical dysplasia impacts the cervix, which is the lower neck of the uterus^[1]
• Vaginal dysplasia occurs in the vagina, also called the birth canal, the channel between the vulva and cervix^[1]
• Vulvar dysplasia affects the vulva, the outer part of the female genitals^[1]
• Penile dysplasia occurs in the penis, the organ that transfers sperm and urine^[1]
• Scrotal dysplasia affects the scrotum, the skin pouch containing the testicles^[1]

• Anus
• Cervix
• Vagina
• Vulva
• Penis
• Scrotum

Symptoms

Most people with anogenital dysplasia have no symptoms^[1]. The condition is often discovered during routine screening before any problems develop.

When symptoms affecting the anus or genitals do occur, they can include^[1]:

• Abnormal discharge
• Bleeding
• Itching
• A lump or small growth
• Persistent pain that lasts longer than three to four weeks

For anal dysplasia specifically, symptoms may include anal pain, anal bleeding, anal itching, or a feeling like there is a bump in the anus^[7]. Some people with anal dysplasia notice warts in their anus. These warts aren’t cancer but are a symptom of HPV^[3].

Causes and Risk Factors

Medical researchers believe variants of the human papillomavirus (HPV) cause nearly all cases of anogenital dysplasia^[3]. HPV is a common viral infection that can be transmitted through sexual contact or skin-to-skin contact^[5]. The virus can infect the anus, genital area, mouth, and even the skin^[10].

You may have an elevated risk of anogenital dysplasia if you have^[1]:

• HPV that you contracted in your genital or anal area
• A pap smear that reveals abnormal results
• A weak immune system, as a result of having the human immunodeficiency virus (HIV) or other autoimmune conditions. Certain medications that weaken the immune system can also increase your risk
• Personal history of anogenital warts
• Personal history of anal cancer, cervical cancer, vaginal cancer, or vulvar cancer

Other risk factors for anogenital dysplasia include^[1]:

• Having sex without a barrier method, such as a condom
• Having multiple sexual partners
• Smoking
• Being a man who has sex with men
• Being a transgender woman

People with weakened immune systems, including those receiving immune-suppressing medications for conditions like organ transplant or rheumatoid arthritis, and those with HIV infection, are more likely to acquire HPV infection and to develop disease related to HPV infection^[5].

Screening and Diagnosis

Screening for anogenital dysplasia often begins with a Pap test (also called Pap smear or cytology). During this test, your doctor will put a small swab in the affected area to collect cells. These cells are sent to a lab, where they are viewed under a microscope to check for abnormal cells and human papillomavirus^[8].

If your Pap test finds abnormal cells, you will be referred for a more detailed examination. For anal dysplasia, this is called high-resolution anoscopy (HRA)^[8]. This procedure allows a doctor to look directly into the anal canal for areas that appear to be abnormal.

During HRA, a thin, hollow tube called an anoscope is coated with numbing gel and inserted about 3 inches into the anal canal^[7]. A microscope called a colposcope (which does not go inside the anal canal) is used by the provider to magnify and examine the tissue for any abnormal cells. Liquid stains are also used to help identify any abnormal cells^[7].

If needed, a tiny sample of tissue (about 2mm) is taken during the exam of any abnormal cells that may have been found. This biopsy sample is sent to a lab to be evaluated^[7]. After the biopsy, there may be some occasional bleeding or discomfort for 1-2 days, usually with bowel movements^[7].

For other types of anogenital dysplasia, similar procedures may be used. A pelvic exam with speculum and colposcopy can diagnose cervical, vaginal, or vulvar dysplasia^[18].

Understanding the Grades

Healthcare providers place anogenital dysplasia into categories by examining cells under a microscope. These categories help determine the best course of treatment^[3].

Low-grade dysplasia (also called grade 1 or low-grade squamous intraepithelial lesion): The cells in low-grade dysplasia look like healthy cells. Low-grade dysplasia often goes away without treatment and isn’t likely to become cancer^[3]. Low-grade dysplasia does not need treatment unless it is a benign wart^[7].

High-grade dysplasia (also called grade 2/3 or high-grade squamous intraepithelial lesion): The cells in high-grade dysplasia look abnormal. High-grade dysplasia is less likely to go away without treatment. In time, high-grade dysplasia could become cancer^[3]. High-grade dysplasia is considered precancerous and requires treatment to prevent the abnormal cells from progressing to cancer^[7].

A 2020 study estimated 3% to 14% of people with high-grade dysplasia develop cancer^[3]. The chance that dysplasia will become cancer varies based on people’s situations. For example, one study indicated about half of people with HIV and anal dysplasia developed anal cancer^[3].

Treatment Options

The type and grade of anogenital dysplasia you have and your overall health determine your treatment^[12]. Your medical team assesses your condition, listens to your preferences, and offers personalized treatment plans^[12].

Active Surveillance

With low-grade anogenital dysplasia, your doctor may recommend active surveillance. This means your doctor watches the abnormal cells but does not treat them yet^[12]. Low-grade lesions are low risk and generally do not require treatment. They can be monitored for signs of progression^[5].

Medication

Your doctor may recommend topical medication (applied to your skin) to treat anogenital dysplasia. Topical drugs include^[12]:

• Creams that you apply at home
• Medical-grade acidic treatment

Topical treatments such as 5-fluorouracil or imiquimod have the advantage of being nonsurgical and are well suited for treating widespread multifocal disease^[15]. However, topical treatments have the disadvantage of requiring extended treatment courses and causing a symptomatic inflammatory response. Successful treatment requires adherence to a regime that is uncomfortable at best and at worst painful^[15].

Surgical Treatments

Types of anogenital dysplasia surgery that remove abnormal cells include^[12]:

Ablation: This procedure destroys abnormal cells using extreme heat, freezing temperatures, or a laser. Different ablation methods include:

• Hyfrecation/electrocautery: This uses low-voltage electricity to destroy the abnormal high-grade dysplasia cells. It is a simple procedure that is done in the office. A local anesthetic is used to numb the area before the treatment. No preparation is required, and no sedation is given^[7]
• Infrared coagulation: This uses a high-heat infrared light^[13]
• Radiofrequency ablation: This uses radio waves^[6]
• Cryotherapy: This uses freezing temperatures^[13]

Surgical excision: Your doctor surgically removes the affected area and sends the tissue to a lab for evaluation under a microscope^[12].

These methods for dysplasia ablation can be performed with local anesthesia on outpatients and are relatively well tolerated^[15]. Anesthesia and sedation options help patients be more comfortable during procedures^[12].

Follow-up Care

After treatment, you may need periodic surveillance to monitor for additional areas of dysplasia^[7]. Although anogenital dysplasia can be treated successfully, it can sometimes return in a few months or a few years. It is important to follow up with regular screenings with your dysplasia care team^[7].

After you have had treatment for high-grade dysplasia, you will need regular Pap tests and examinations to monitor for recurrences^[13]. Treatment of dysplasia 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^[13].

Prevention

People can reduce their risk of developing anogenital dysplasia by being vaccinated against HPV and by reducing their risk of HPV infection^[3].

The best way to prevent anogenital dysplasia is not to get high-risk HPV in the first place. The most powerful ally against HPV is Gardasil, a vaccine that’s been available since 2006 and is recommended for everyone before the onset of sexual activity^[10]. If you are age 26 or younger, you can get the series of human papillomavirus (HPV) shots. It protects against the types of HPV that can cause dysplasia. If you are age 27 to 45 and haven’t been vaccinated for HPV, ask your doctor if the vaccine is right for you^[24].

Other prevention measures include^[24]:

• Use latex condoms every time you have anal or genital sex. Use them from the start to the end of sexual contact. This will help prevent HPV infection
• Limit your sex partners. Sex with one partner who has sex only with you can reduce your risk of getting a sexually transmitted infection
• Tell any sex partners if you have HPV. Even if you don’t have symptoms, you can still pass HPV to others

While condoms are the best way to prevent most sexually transmitted diseases, it’s unclear how well they stop the transmission of HPV and the development of dysplasia, because HPV can spread in areas that condoms don’t cover^[10][3].

Remember that people can spread HPV (and other sexually transmitted infections) even if they don’t have symptoms^[24]. You and any sex partners may want to get tested for sexually transmitted infections before having sex.