A 33-year-old male with no known comorbidities nor previous surgery presented with a 2-year history of a gradually enlarging anal mass with associated pruritus, foul-smelling discharge, and occasional bleeding. He initially self-medicated with warm sitz bath prior to consult. He was positive for HIV and was on antiretroviral therapy for 2 years before his lesions occur. He admitted to practice heterosexual and homosexual intercourse with multiple partners. He was also involved in both receptive and insertive anal intercourse. On physical examination, there was note of an almost circumferential, fungating anal mass with minimal discharge, enlarged left inguinal lymph node, and multiple small pigmented condylomatous lesions on the base and shaft of the penis and around the scrotum. He underwent left inguinal lymph node biopsy and excision of genital and perianal warts. He stayed for 11 days postoperatively. At 2 months postoperatively, the wound was noted to be completely epithelialized; however, there was also note of recurrence and stricture. The recurrence was addressed by cauterization and the stricture by anal dilatation. However, at 11 months postoperatively, there was further progression of the stricture warranting a proximal bowel diversion. Anoplasty was not done on this patient as he has been lost to follow up.

Another 33-year-old male diagnosed with idiopathic thrombocytic purpura, a 5-pack year smoker, and with no previous surgery presented with a 1-year history of gradually enlarging anal mass. It is associated with foul-smelling discharge, pain, and occasional bleeding. He self-medicated with an unrecalled topical agent prior to consultation. He admitted to engage on homosexual, receptive and insertive anal intercourse with 6 partners. He was tested for HIV, which turned out positive. On physical examination, there was note of a large, circumferential perianal wart, and multiple subcentimeter scrotal and penile shaft warts. He underwent excision of the mass and stayed for 2 days postoperatively (Fig. 1). Complete epithelialization was noted at 4 weeks. However, at 3 months postoperatively, there was note of anal stricture, which was addressed by serial anal dilatation. No other recurrence and complications were noted up to 2 years of follow-up.

A 29-year-old male, positive for HIV and on antiretroviral therapy, presented with an 8-month history of multiple fungating anal lesions. This was associated with foul-smelling discharge, occasional pain, and occasional bleeding. He engaged in homosexual, receptive and insertive anal intercourse with multiple partners. On physical examination, there were several cauliflower-like lesions at the anal verge. He underwent excision of the lesions and was discharged immediately. Complete epithelialization was noted at 4 weeks postoperatively, with no note of recurrence or stricture on follow-up.

A 23-year-old male, positive for HIV and on antiretroviral therapy since 2 years prior to consult, came in for an 8-month history of an enlarging anal mass. It is associated with pruritus, pain, and foul-smelling discharge. He self-medicated by applying apple cider vinegar, with no note of resolution nor improvement. He practiced homosexual, receptive and insertive anal intercourse with 10 partners. On physical examination, there was a circumferential, fungating mass at the anal verge. He underwent excision of the mass and was discharged immediately after. At 2 weeks postoperatively, during the course of the epithelialization process, there was note of a stricture. This was managed with anal dilatation. Complete epithelialization was noted at 4 weeks, but there was note of subcentimeter recurrence at 8 months postoperatively. This was then addressed with cauterization. No recurrence or other complications were noted up to 15 months postoperatively.

A 21-year-old male with no comorbidities nor previous surgery consulted for a 5-month history of an anal mass with occasional bleeding, pain, and foul-smelling discharge. HIV testing was done which turned out positive. He was immediately started on antiretroviral therapy. On physical examination, there was a 15 × 10-cm fungating mass extending up to the dentate line. He underwent flexible sigmoidoscopy, endoanal ultrasonography, and excision of the mass. He was discharged after 2 days. Epithelialization was reported at 2 weeks postoperatively. No complications were noted up to 8 months postoperatively.

A 29-year-old male, on antiretroviral therapy for HIV since 2 years prior to consult, presented with an 8-month history of perianal mass, with associated pain, bleeding, and foul-smelling discharge. He admitted to practice homosexual practice with more than 10 partners. On physical examination, there was a large circumferential perianal mass with multiple lesions at the genital area. He underwent excision of the perianal mass and cauterization of the smaller lesions. He was discharged after 2 days. There was note of stricture formation at 2 months postoperatively managed by anal dilatation. Epithelialization was noted 16 weeks postoperatively. No other complications were noted (Fig. 2).

A 41-year-old male, HIV-positive for 4 years, presented with a 3-year history of slow-growing perianal mass with foul-smelling discharge and pruritus. He self-medicated with an unrecalled cream with no note of improvement. He practiced both heterosexual and homosexual intercourse with multiple partners. On physical examination, there was note of a circumferential, confluent fleshy outgrowth at perianal area with intraanal component and smaller lesions at the gluteal areas. He underwent excision of the lesions and was sent home after 2 days. Complete epithelialization was noted at 8 weeks. No complications were noted up to 5 months postoperatively (Fig. 3).

A total of 7 patients underwent surgery for BLT. All were male with ages ranging from 21 to 41 years (median, 29 years). All presented for consult with the chief complaint of an anal mass (i.e., cauliflower-like lesion). Other reported signs and symptoms were foul-smelling discharge (100%, 7 of 7), pain (71.4%, 5 of 7), bleeding (71.4%, 5 of 7), and pruritus (28.6%, 2 of 7). Duration from the initial discovery of an anal lesion to time of consult ranged from 5 months to 4 years (median, 8 months). Seventy-one percent of the respondents self-medicated with various topical agents and home remedies (i.e., apple cider vinegar) prior to consult with a physician. These were on the recommendation of persons with no medical background.

All the patients were HIV-positive and were already receiving antiretroviral therapy at the time of initial consult. All were involved in MSM, with multiple partners. Two also engaged in heterosexual practice. All patients admitted to having engaged in both insertive and receptive anal intercourse. All disclosed to engage in insertive more frequently than receptive anal intercourse.

All underwent excision in prone jackknife position and allowed to heal by secondary intention. Total operative time has a median of 60 minutes (range, 45–90 minutes). None of these patients required blood transfusion during or after the operation. These patients’ median postoperative length of stay was 2 days (range, 1–11 days).

The median time to complete epithelialization was 4 weeks (range, 2–16 weeks). Two had recurrence of perianal warts between 2 and 3 months from time of surgery. These were addressed with repeat cauterization. No further recurrences have since been observed.

Four had an anal stricture. Of these, 3 underwent anal dilatation alone. No functional impairment was reported in these 3 patients. The 4th patient had to undergo a proximal bowel diversion. The definitive plan to perform an anoplasty has yet to be done, as the patient has been lost to follow up.

On histopathologic analysis, 1 patient was found to have intraepithelial carcinoma without dermal invasion within the BLT (Fig. 4). No adjuvant treatment was recommended after discussion in a multidisciplinary conference. Median follow-up of the patients were reported up to 8 months postoperatively (range, 1–24 months).