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.

- 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]
- 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]
Medical Students
Human papillomavirus (HPV) includes over 100 types, some targeting cutaneous epithelium (causing skin warts), others infecting mucosal surfaces.
- Mucosal HPV types primarily infect the anogenital tract, oropharynx, and larynx.
- Key anogenital HPV manifestations:
  - Genital warts
  - Intraepithelial neoplasia
  - Cancers (cervix, vulva, vagina, anus, penis, larynx, oropharynx)
- HPV types 6 and 11:
  - Cause most cases of genital, laryngeal, and oropharyngeal warts
- HPV types 16 and 18:
  - Responsible for approximately 70% of cervical cancers
  - Also implicated in cancers of the vulva, vagina, anus, and penis
- Transmission:
  - Anogenital HPV can be transmitted to the oropharynx via oral contact
- Immunocompromised patients are more likely to develop genital warts, which may grow more rapidly with:
  - Pregnancy
  - Immunosuppression
  - Skin maceration (excess moisture)
Patients
Understanding How HPV Affects the Body
- There are over 100 types of HPV. Some affect the skin (causing warts), while others infect moist, soft tissues like those in the genital area, throat, or voice box.
- HPV can cause:
  - Genital warts
  - Abnormal cell growth inside tissues (called intraepithelial changes)
  - Cancer in areas such as the cervix, vulva, vagina, anus, penis, throat, and voice box
- The types of HPV that cause genital, throat, and voice box warts are usually types 6 and 11.
- Nearly all cervical cancers are caused by HPV. Types 16 and 18 cause about 7 in 10 cases.
- HPV can spread to the mouth and throat during oral contact.
- HPV types 16 and 18 can also lead to cancers in other parts of the body like the anus and genitals.
- People with weakened immune systems are more likely to get genital warts.
  - Pregnancy, weakened immunity, or too much moisture on the skin can cause the warts to grow or spread faster. [2]
- 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]
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)
- 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)
- 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 [2]
- Clinical examination of appearance
- History of symptoms and sexual partners [6,9]
- 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 [10]
Medical Students
- Treatment options include:
  - Cytodestructive therapy or excision (e.g. caustics, cryotherapy, electrocauterization, laser, surgical excision)
  - Topical medications
- Key considerations:
  - No single treatment is completely effective; recurrences are common.
  - Genital warts may resolve spontaneously in immunocompetent patients.
  - Immunocompromised patients may be less responsive to treatment.
  - Choose treatment based on:
    Wart size, number, location
    Patient preference
    Cost and convenience
    Side effects
    Practitioner experience
- Specific treatments:
  - Caustics (e.g. trichloroacetic acid)
  - Topical medications
  - Cryotherapy
  - Electrocauterization
  - Laser therapy
  - Surgical excision
  - Local or general anesthesia may be used depending on extent of lesions
- Special cases:
  - Extensive vulvovaginal warts → may require laser ablation
  - Anal warts → may need resectoscope removal under general anesthesia
  - Topical treatments need multiple applications and may be ineffective
  - Interferon alfa (intralesional or IM) has some efficacy for persistent lesions; long-term benefit is unclear
  - Circumcision may help prevent recurrence in uncircumcised men
- Partner management:
  - Current sex partners should be examined and treated if infected
  - Regular screening and counselling recommended for partners
- Other lesions:
  - Intraurethral lesions: Consider thiotepa or 5-fluorouracil, with close monitoring
  - Cervical intraepithelial neoplasia (CIN): Managed with excisional biopsy
  - Vulvar/vaginal intraepithelial neoplasia: Treated with surgical excision
  - Similar management applies to HPV-related rectal lesions
Patients
- Common treatments include:
  - Cell-destroying (cytodestructive) therapy: using chemicals, cold therapy, heat, lasers, or surgery to remove warts
  - Medications applied to the skin (topical treatments)
- What to expect:
  - No treatment works 100%, and warts can come back, needing further treatment.
  - Genital warts may go away on their own in people with a healthy immune system.
  - People with a weakened immune system may need more intensive treatment.
- Treatment decisions are based on:
  - Size, number, and location of the warts
  - Your preferences
  - Costs and side effects
  - Doctor’s experience with the treatment
- Treatment types:
  - Chemicals (caustics) to remove the warts
  - Topical creams
  - Cryotherapy (freezing)
  - Heat treatment (electrocautery)
  - Laser therapy
  - Surgical removal
  - Depending on the number of warts, numbing medicine (anesthetic) may be used
- For more serious cases:
  - Warts in the vulva or vagina may need laser removal
  - Anal warts might be removed with a special surgical tool under general anesthesia
  - Topical creams may take several weeks or months and don’t always work
- Other options and considerations:
  - Circumcision in men who aren’t circumcised may reduce the chance of warts coming back
  - Sexual partners should also be checked and treated if needed
  - For warts inside the urethra, special medications like thiotepa or 5-fluorouracil may be used—these need careful monitoring
- Monitoring for abnormal cell growth:
  - Cervical changes are checked with tissue removal (biopsy)
  - Changes in the vulva or vagina are usually treated with surgery
  - A similar approach is used for HPV in the rectum [2]
- 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 [1]
- 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]
- 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?
- SH:24
- Terrance Higgins Trust
- Jo’s cervical cancer trust
[1] https://cks.nice.org.uk/topics/warts-anogenital/background-information/prevalence/
[2] https://www.msdmanuals.com/en-gb/professional/infectious-diseases/sexually-transmitted-infections-stis/human-papillomavirus-hpv-infection?query=genital
[3] https://www.ncbi.nlm.nih.gov/books/NBK441884/#:~:text=About
[4] https://sti.bmj.com/content/95/5/386
[5] https://www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/genital-warts#:~:text=You
[6] https://www.aad.org/public/diseases/a-z/genital-warts-causes
[7] https://cks.nice.org.uk/topics/warts-anogenital/background-information/prevalence/
[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758246/
[9] https://www.nhs.uk/conditions/genital-warts/
[10] https://dermnetnz.org/topics/anogenital-warts
[11] https://www.ashasexualhealth.org/hpv-myths-facts/#:~:text=Myth%3A
[12] https://www.theindependentpharmacy.co.uk/genital-warts/guides/hpv-myths-debunked