Lesions, ulcers, spots and dots

Posted on September 5, 2012 by drtan

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‘This is rather embarrassing’ is probably the most common opening line I hear from patients. This is closely followed by ‘Doc, you must have heard this a thousand times before but…..’

So this brings me to the story of Mr. P. Mr. P was a pale lanky chap fromNew Zealand. He was rather soft spoken and your proverbial Mr. Nice Guy. He came to see me one quiet weekday night and uttered those most familiar words ‘Hey doc, this is rather embarrassing but I have an ulcer.’

Now the problem is the word ‘ulcer’ especially when applied to describe the genital area, conjures up all sorts of nasty possibilities in a doctor’s head namely Syphilis, Chancroid and Herpes. My face fell as I quickly ran through in my head the best way of breaking the news to him.

‘Let’s have a look’ I said as calmly as I could as I motioned him to lie down on the examination couch. When he undressed, what greeted me was a pubic area covered with multiple band-aids. Under each carefully placed band-aid was a skin colored cauliflower like lesion typical of genital warts. ‘You do not have an ulcer’ I confidently proclaimed ‘you have warts.’

For those of you who have read Elisabeth Kubler-Ross’ ‘On Death and Dying’, you would know that she described 5 stages of grieving: Denial, Anger, Bargaining, Depression and Acceptance. I think this model can easily be applied to someone who has just been told he/she has an STD. And Mr. P exhibited every single one of these stages to perfection.

Denial

Mr. P: You are wrong doc. It can’t be warts. I have never visited any sex workers. All my girlfriends never had any symptoms. Anyway I always use protection.

Me: Clinically those lesions look typically like warts. Of course we can take one lesion and send it for histology to be sure but realistically speaking, it’s just gonna tell us what we already know: it’s warts. And another sobering fact: condoms do not protect against HPV which is the virus that causes warts.

Anger

Mr. P: Dam it! Now I remember! It must be Susan. I always knew she was cheating on me. That bitch!

Me: (uncomfortable silence followed by) Uhh… The fact is we cannot tell when you were infected. It could have been recently or maybe years ago.

Bargaining

Mr. P: OK. But I read that HPV most of the time your body just deals with it. So if I keep myself healthy and make sure my immune system is good, the warts will go away right? As long as I keep myself healthy which I can do. Also, I will take lots of Vitamin C and Lysine which I’ve read that helps. And Apple Cider Vinegar. That’s right. If I do all these things, the HPV will definitely disappear. Right doc?

Me: (Sigh) You are right to say that spontaneous clearance can happen but there is no sure thing. Even with all these measures, the warts can remain or even worsen. I am not saying you need treatment right now but I am saying that doing all these things does not guarantee that the warts will disappear. Furthermore, since there is no test for HPV in men, we cannot determine if the HPV has been cleared from your system or not.

Depression

Mr. P: What am I going to do? I cannot have meaningful relationships any more! I cannot get married, I cannot have children. I can’t even live in the same house with my family. What if I pass it to them? I am going to get cancer! Oh my god my future wife is going to get cancer!

Me: The fact is many people in this world suffer from HPV and warts and they lead perfectly normal and happy lives. It really does not help you to be worrying about these things now. Instead of wringing your hands and worrying, you might as well take firm actions to help rid yourself of this infection.

Acceptance

Mr. P: Alright doc. Tell me what I need to do. Whatever it takes, I just need to get rid of this ASAP.

In the months that followed, Mr. P got multiple treatments with Cryotherapy and Laser ablation. He also completed a course of Gardasil vaccines against HPV. He was screened for all other STDs and found to be clear of everything else.

I am happy to say that he has been free of warts ever since but now jumps at every single thing he sees on the skin in his genital area. Fortunately, a quick visit and some reassurance is all he needs these days.

Learning points

1. Do not use terms you do not understand.

Medical terminology is very specific macule, papillae, blister, ulcer etc etc refer to very specific lesions. Using a wrong term can often confuse your doctor. This is especially dangerous if your doctor cannot physically examine you e.g. over the phone. It is always best to let a doctor examine your skin problems.

2. Be vaccinated with Gardasil.

Gardasil is a vaccine that protects against Genital warts, Cervical Cancer, Vaginal Cancer, Vulval Cancer, Anal Cancer and even some protection against Penile Cancer. Getting vaccinated protects not only yourself but also your sexual partner.