genital warts

22 Jul

Genital warts are caused by the Human Papillomavirus (HPV). The types HPV 6 and 11 cause genital warts. HPV is the most common sexually transmitted infection and mostly affect the person for 1-2 years however it can reside for longer. This sexually transmitted disease, can be passed through sexual intercourse, sharing sex toys and in people with reduced immune strength eg. HIV patients and pregnant people. HPV vaccines are currently available and the CDC (Centre for Disease Control) have suggested vaccination for those in age groups 27-45 years.

Epidemiology

The estimated lifetime risk of genital warts in sexually active people is 10% [1]
Globally, 80% of sexually active unvaccinated people get the virus at some point in their lives
Annually, the US experiences 14 million people with new infection of HPV [2]
About 30% of genital warts will disappear within 4 months of their appearance
Peak ages affected were 20—24 year olds [3]
According to a study found in the BMJ, the diagnosis for HPV was more frequent in men who have sex with men (MSM) and in women reporting sex with women [4]

Genital warts

Can appear in a cauliflower pattern anywhere on the groin and can vary in size

Pathophysiology [2]
- Medical students
  - There are over 100 known types of HPV, some of which infect cutaneous epithelium and cause skin warts, while others primarily infect the mucosa of the anogenital, oropharyngeal, and laryngeal areas.
  - Important manifestations of anogenital HPV include genital warts, intraepithelial neoplasia, and carcinoma in various areas like the cervix, vulva, vagina, anus, or penis, as well as laryngeal and oropharyngeal cancers
  - Genital, laryngeal, and oropharyngeal warts are usually caused by HPV types 6 and 11
  - Virtually all cases of cervical cancer are caused by HPV, with types 16 and 18 responsible for about 70% of cases
  - HPV types that affect the anogenital area can be transmitted to the oropharynx through oral contact.
  - Types 16 and 18 can also cause cancer in other areas like the vulva, vagina, anus, and penis.
  - Genital warts are more common among immunocompromised patients, and their growth rates can vary, but pregnancy, immunosuppression, or skin maceration (moisture exposure) may accelerate their growth and spread.
- Patients

There are over 100 known types of HPV, some of which infect the skin lining and cause skin warts, while others primarily infect the mucous membranes (lining of the mucuses such as the nose, mouth) of the anogenital (affects the anus and genitalia), oropharyngeal and laryngeal areas (parts of the membrane-lined cavity behind the nose and mouth, known as an pharynx)
Important symptoms of anogenital HPV include genital warts, uncontrollable cell growth within the layers of cells (intra-epithelium), and cancer in various areas like the cervix, vulva, vagina, anus, or penis, as well as laryngeal and oropharyngeal cancers
Genital, laryngeal, and oropharyngeal warts are usually caused by HPV types 6 and 11
Virtually all cases of cervical cancer are caused by HPV, with types 16 and 18 responsible for about 70% of cases
HPV types that affect the anogenital area can be transmitted to the oropharynx through oral contact.
Types 16 and 18 can also cause cancer in other areas like the vulva, vagina, anus, and penis.
Genital warts are more common among patients with weakened immune systems. Growth rates of HPV can vary, but pregnancy, weakened immune systems, or excessive skin moisture may accelerate their growth and spread.

Source: DermNetNZ.org

Genital warts
Anal warts seen with brown discolouration

Causes
- Human Papilloma Virus 6 and 11
- Contact with genitals of an HPV carrier
- Unprotected sex (specifically vaginal and anal sex)
- Childbirth from infected mother to baby [5,6]

Risk factors
- Younger age of onset of sexual activity
- Increased number of sexual partners
- Weakened immune responses in people
- Failure to use condoms
- Smoking
- History of Chalmydia and herpes [7,8]

Presentations [2]
- In men; found in the foreskin (movable skin at the end of the penis), penile shaft (from the top of the penis to the connection to the lower stomach) and urethral meatus (opening of the penis where urine leaves)
- In women; found at the vulva (external female genitalia), vaginal wall, cervix (lower, narrower end of the uterus that connects uterus and vagina) and perineum (skin between anus and genitals)
- Soft, moist, small pink or grey raised spots
- Rough surfaces
- Some warts are do not present with symptoms
- Itching
- Burning
- Pain/discomfort
- Purple or pink discolouration on the penis

Investigations

Clinical examination of appearance
History of symptoms and sexual partners [6,9]

Differential diagnosis [10]
- Pearly papules (raised spots around the head/tip of the penis)
- Sebaceous glands on the labia (folds found on either side of the vagina- part of the external female genitalia)
- Vestibular papillae- leaf shape protrusions in the opening to the vagina
- Seborrheic keratosis- harmless wart found in older adults
- Carcinoma of the anal/genital area

Source: DermNetNZ.org

Genital warts
Grey and white discolouration on the vulva

Management [2]

Medical Students
- Treatment options for anogenital warts include:
  - Cytodestructive therapy or excision (e.g., caustics, cryotherapy, electrocauterization, laser, or surgical excision)
  - Topical medications
- No single treatment is entirely satisfactory, and relapses are common, requiring retreatment.
- Genital warts may resolve without treatment in immunocompetent patients but may be less responsive to treatment in immunocompromised patients.
- Treatment choice should consider factors such as wart size, number, and location; patient preference; cost; convenience; adverse effects; and the practitioner's experience.
- Specific treatments for genital warts include:
  - Caustics
  - Topical medications
  - Cryotherapy
  - Electrocauterization
  - Laser
  - Surgical excision
- Local or general anesthesia may be used depending on the extent of warts to be removed.
- Extensive vulvovaginal warts may require laser ablation, while for anal warts, removal with a resectoscope may be most effective with general anesthesia.
- Topical treatments usually require multiple applications over weeks to months and can be ineffective.
- Interferon alfa, administered intralesionally or IM, has been shows to be effective in clearing stubborn lesions but long-term effects are uncertain.
- Circumcision in uncircumcised men may prevent recurrences of genital warts.
- Current sex partners of individuals with genital warts should be examined and treated if infected.
- For intraurethral lesions, thiotepa or 5-fluorouracil may be used depending on the gender, but they require appropriate management to avoid complications.
- Cervical intraepithelial neoplasia (CIN) is monitored with excisional biopsy.
- Vulvar and vaginal intraepithelial neoplasia are treated with surgical excision.
- Sex partners of patients affected should be counselled and regularly screened for HPV-related lesions. A similar approach can be used for HPV in the rectum.
Patients
- Treatment options for anogenital warts include:
  - Cytodestructive (cell destructive) therapy or removal of the warts with chemicals, lasers, heat to destroy tissue or surgery
  - Topical (placed on the skin) medications
- No single treatment is entirely satisfactory, and relapses are common, requiring retreatment.
- Genital warts may resolve without treatment in patients with weakened immune systems but may be less responsive to treatment
- Treatment choice should consider factors such as wart size, number, and location; patient preference; cost; convenience; adverse effects; and the practitioner's experience.
- Specific treatments for genital warts include:
  - Caustics (chemicals to remove the warts)
  - Topical medications
  - Cryotherapy (cold liquid is used to freeze and destroy tissue)
  - Electrocauterization (heat used to remove warts)
  - Laser
  - Surgical excision
- Anesthesia may be used depending on the extent of warts to be removed.
- Extensive vulvovaginal (affecting the vulva and vagina) warts may require laser ablation, while for anal warts, removal with a resectoscope (a thin, tube-like instrument used to remove tissue from inside the body) may be most effective with general anesthesia.
- Topical treatments usually require multiple applications over weeks to months and can be ineffective.
- Circumcision in uncircumcised men may prevent recurrences of genital warts.
- Current sex partners of individuals with genital warts should be examined and treated if infected.
- For intraurethral (in the urethra) lesions, thiotepa (a chemotherapy drug) or 5-fluorouracil (drug used to treat cancer) may be used depending on the gender, but they require appropriate management to avoid complications.
- Cervical intraepithelial neoplasia (uncontrollable growth of cells in the layers of cell lining) is monitored with excisional (removal of tissue) biopsy.
- Vulvar and vaginal intraepithelial neoplasia are treated with surgical excision.
- Sex partners of patients affected should be counselled and regularly screened for HPV-related lesions. A similar approach can be used for HPV in the rectum.

Complications [1]
- May be co-existing with a more harmful HPV type that is associated with cancer of the anal/genial areas
- Self esteem issues
- Treatment complications such as
- Hyper or hypo pigmentation due to ablation therapy
- Hypertrophic (build up of tissue) scarring
- Bleeding
- Infection
- Scarring due to surgical removal of warts

Source: DermNetNZ.org

Genital warts
Warts found on the shaft of the penis

Myths behind genital warts

Genital warts lead to cervical cancer
You can only get genital warts from unprotected sex
Condoms completely stop you from catching genital warts
No warts means you don’t have an infection
HPV can be cured [11,12]

Questions you may want to ask your doctor
- Are the warts treatable?
- If I decide not to undergo treatment for warts, will to persist or disappear by itself?
- What are the chances of re-occurrance of the warts?
- Can warts also place me at risk of cancer? What can I do to prevent getting cancer?
- What can I do to protect myself from re-occurance of warts?
- What are the signs that my HPV is progressing into cancer?