Genital wart

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Genital warts
Other namesCondylomata acuminata, venereal warts, anal warts, anogenital warts
SOA-Condylomata-acuminata-around-anus.jpg
Severe case of genital warts around the anus of a female
Specialty Infectious disease [1]
Symptoms Small bumps in skin of genital area, varying sizes and shapes but typically protrude out, burning, itch [2] [3]
Usual onset1-8 months following exposure [4]
CausesHPV types 6 and 11 [5]
Diagnostic method Based on symptoms, can be confirmed by biopsy [5]
Differential diagnosis Molluscum contagiosum, skin tags, condyloma latum, squamous cell carcinoma [3]
Prevention HPV vaccine, condoms [4] [6]
TreatmentMedications, cryotherapy, surgery [5]
Medication Podophyllin, imiquimod, trichloroacetic acid [5]
Frequency~1% (US) [4]

Genital warts are a sexually transmitted infection caused by certain types of human papillomavirus (HPV). [1] They may be flat or project out from the surface of the skin, and their color may vary; brownish, white, pale yellow, pinkish-red, or gray. [1] [2] [3] There may be a few individual warts or several, either in a cluster or merged together to look cauliflower-shaped. [2] [7] They can be itchy and feel burning. [2] Usually they cause few symptoms, but can occasionally be painful. [5] Typically they appear one to eight months following exposure. [4] Warts are the most easily recognized symptom of genital HPV infection. [4]

Contents

HPV types 6 and 11 are responsible for causing majority of genital warts whereas HPV types 16, 18, 31, 33, and 35 are also occasionally found. [5] It is spread through direct skin-to-skin contact, usually during oral, manual, vaginal, or anal sex with an infected partner. [4] [8] Diagnosis is generally based on symptoms and can be confirmed by biopsy. [5] The types of HPV that cause cancer are not the same as those that cause warts. [9]

Some HPV vaccines can prevent genital warts as may condoms. [4] [6] Treatment options include creams such as podophyllin, imiquimod, and trichloroacetic acid. [5] Cryotherapy or surgery may also be an option. [5] After treatment warts often resolve within six months. [4] Without treatment, in up to a third of cases they resolve on their own. [4]

About 1% of people in the United States have genital warts. [4] Many people, however, are infected and do not have symptoms. [4] Without vaccination nearly all sexually active people will get some type of HPV at one point in their lives. [9] [10] The disease has been known at least since the time of Hippocrates in 300 BC. [11]

Signs and symptoms

Severe case of genital warts on a vulva SOA-Condylomata-acuminata-female.jpg
Severe case of genital warts on a vulva
Severe case of genital warts on a penis SOA-Condylomata-acuminata-man.jpg
Severe case of genital warts on a penis
Small condylomata on a scrotum Small condylomata on testicles.jpg
Small condylomata on a scrotum

They may be found anywhere in the anal or genital area, and are frequently found on external surfaces of the body, including the penile shaft, scrotum, or labia majora. They can also occur on internal surfaces like the opening to the urethra, inside the vagina, on the cervix, or in the anus. [12]

They can be as small as 1–5 mm in diameter, but can also grow or spread into large masses in the genital or anal area. In some cases they look like small stalks. They may be hard ("keratinized") or soft. Their color can be variable, and sometimes they may bleed. [13]

In most cases, there are no symptoms of HPV infection other than the warts themselves. Sometimes warts may cause itching, redness, or discomfort, especially when they occur around the anus. Although they are usually without other physical symptoms, an outbreak of genital warts may cause psychological distress, such as anxiety, in some people. [14]

Causes

Transmission

HPV is most commonly transmitted through penetrative sex. While HPV can also be transmitted via non-penetrative sexual activity, it is less transmissible than via penetrative sex. There is conflicting evidence about the effect of condoms on transmission of low-risk HPV. Some studies have suggested that they are effective at reducing transmission. [15] Other studies suggest that condoms are not effective at preventing transmission of the low-risk HPV variants that cause genital warts. The effect of condoms on HPV transmission may also be sex-dependent; there is some evidence that condoms are more effective at preventing infection of males than of females. [16]

The types of HPV that cause warts are highly transmissible. Roughly three out of four unaffected partners of patients with warts develop them within eight months. [16] Other studies of partner concordance suggest that the presence of visible warts may be an indicator of increased infectivity; HPV concordance rates are higher in couples where one partner has visible warts. [15]

Latency and recurrence

Although 90% of HPV infections are cleared by the body within two years of infection, it is possible for infected cells to undergo a latency (quiet) period, with the first occurrence or a recurrence of symptoms happening months or years later. [4] Latent HPV, even with no outward symptoms, is still transmissible to a sexual partner. If an individual has unprotected sex with an infected partner, there is a 70% chance that he or she will also become infected.[ citation needed ]

In individuals with a history of previous HPV infection, the appearance of new warts may be either from a new exposure to HPV, or from a recurrence of the previous infection. As many as one-third of people with warts will experience a recurrence. [17]

Children

Anal or genital warts may be transmitted during birth. The presence of wart-like lesions on the genitals of young children has been suggested as an indicator of sexual abuse. However, genital warts can sometimes result from autoinoculation by warts elsewhere on the body, such as from the hands. [18] It has also been reported from sharing of swimsuits, underwear, or bath towels, and from non-sexual touching during routine care such as diapering. Genital warts in children are less likely to be caused by HPV subtypes 6 and 11 than adults, and more likely to be caused by HPV types that cause warts elsewhere on the body ("cutaneous types"). Surveys of pediatricians who are child abuse specialists suggest that in children younger than 4 years old, there is no consensus on whether the appearance of new anal or genital warts, by itself, can be considered an indicator of sexual abuse. [19]

Diagnosis

Micrograph of a genital wart with the characteristic changes (parakeratosis, koilocytes, papillomatosis). H&E stain. Anal condyloma (3).jpg
Micrograph of a genital wart with the characteristic changes (parakeratosis, koilocytes, papillomatosis). H&E stain.

The diagnosis of genital warts is most often made visually, but may require confirmation by biopsy in some cases. [20] Smaller warts may occasionally be confused with molluscum contagiosum. [19] Genital warts, histopathologically, characteristically rise above the skin surface due to enlargement of the dermal papillae, have parakeratosis and the characteristic nuclear changes typical of HPV infections (nuclear enlargement with perinuclear clearing). DNA tests are available for diagnosis of high-risk HPV infections. Because genital warts are caused by low-risk HPV types, DNA tests cannot be used for diagnosis of genital warts or other low-risk HPV infections. [4]

Some practitioners use an acetic acid solution to identify smaller warts ("subclinical lesions"), but this practice is controversial. [14] Because a diagnosis made with acetic acid will not meaningfully affect the course of the disease, and cannot be verified by a more specific test, a 2007 UK guideline advises against its use. [18]

Prevention

Gardasil (sold by Merck & Co.) is a vaccine that protects against human papillomavirus types 6, 11, 16 and 18. Types 6 and 11 cause genital warts, while 16 and 18 cause cervical cancer. The vaccine is preventive, not therapeutic, and must be given before exposure to the virus type to be effective, ideally before the beginning of sexual activity. The vaccine is approved by the US Food and Drug Administration for use in both males and females as early as 9 years of age. [21]

In the UK, Gardasil replaced Cervarix in September 2012 [22] for reasons unrelated to safety. [23] Cervarix had been used routinely in young females from its introduction in 2008, but was only effective against the high-risk HPV types 16 and 18, neither of which typically causes warts.[ citation needed ]

Management

There is no cure for HPV. Existing treatments are directed towards the removal of visible warts, but these may also regress on their own without any therapy. [14] There is no evidence to suggest that removing visible warts reduces transmission of the underlying HPV infection. As many as 80% of people with HPV will clear the infection within 18 months. [16]

A healthcare practitioner may offer one of several ways to treat warts, depending on their number, sizes, locations, or other factors. All treatments can cause depigmentation, itching, pain, or scarring. [14] [24]

Treatments can be classified as either physically ablative, or topical agents. Physically ablative therapies are considered more effective at initial wart removal, but like all therapies have significant recurrence rates. [14] [18]

Many therapies, including folk remedies, have been suggested for treating genital warts, some of which have little evidence to suggest they are effective or safe. [25] Those listed here are ones mentioned in national or international practice guidelines as having some basis in evidence for their use.[ citation needed ]

Physical ablation

Physically ablative methods are more likely to be effective on keratinized warts. They are also most appropriate for patients with fewer numbers of relatively smaller warts. [18]

Topical agents

Discontinued

  • A 5% 5-fluorouracil (5-FU) cream was used, but it is no longer considered an acceptable treatment due to the side-effects. [26]

Podophyllin, podofilox and isotretinoin should not be used during pregnancy, as they could cause birth defects in the fetus.

Oral agents

Isotretinoin taken orally has been shown to treat recalcitrant condylomata acuminata (RCA) of the cervix.

Epidemiology

Genital HPV infections have an estimated prevalence in the US of 10–20% and clinical manifestations in 1% of the sexually active adult population. [27] US incidence of HPV infection has increased between 1975 and 2006. [27] About 80% of those infected are between the ages of 17–33. [27] Although treatments can remove warts, they do not remove the HPV, so warts can recur after treatment (about 50–73% of the time [31] ). Warts can also spontaneously regress (with or without treatment). [27]

Traditional theories postulated that the virus remained in the body for a lifetime. However, studies using sensitive DNA techniques have shown that through immunological response, the virus can either be cleared or suppressed to levels below what polymerase chain reaction (PCR) tests can measure. One study testing genital skin for subclinical HPV using PCR found a prevalence of 10%. [27]

Etymology

A condyloma acuminatum is a single genital wart, and condylomata acuminata are multiple genital warts. The word roots mean 'pointed wart' (from Greek κόνδυλος 'knuckle', Greek -ωμα -oma 'disease', and Latin acuminatum 'pointed'). Although similarly named, it is not the same as condyloma latum, which is a complication of secondary syphilis.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Wart</span> Small, rough growth resembling a cauliflower or a solid blister

Warts are non-cancerous viral growths usually occurring on the hands and feet but can also affect other locations, such as the genitals or face. One or many warts may appear. They are distinguished from cancerous tumors as they are caused by a viral infection, such as a human papillomavirus, rather than a cancerous growth.

<span class="mw-page-title-main">Cervical cancer</span> Cancer arising from the cervix

Cervical cancer is a cancer arising from the cervix or in the any layer of the wall of the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer.

<span class="mw-page-title-main">Human papillomavirus infection</span> Human disease

Human papillomavirus infection is caused by a DNA virus from the Papillomaviridae family. Many HPV infections cause no symptoms and 90% resolve spontaneously within two years. In some cases, an HPV infection persists and results in either warts or precancerous lesions. These lesions, depending on the site affected, increase the risk of cancer of the cervix, vulva, vagina, penis, anus, mouth, tonsils, or throat. Nearly all cervical cancer is due to HPV, and two strains – HPV16 and HPV18 – account for 70% of all cases. HPV16 is responsible for almost 90% of HPV-positive oropharyngeal cancers. Between 60% and 90% of the other cancers listed above are also linked to HPV. HPV6 and HPV11 are common causes of genital warts and laryngeal papillomatosis.

<span class="mw-page-title-main">Plantar wart</span> Medical condition

A plantar wart, or verruca vulgaris, is a wart occurring on the bottom of the foot or toes. Its color is typically similar to that of the skin. Small black dots often occur on the surface. One or more may occur in an area. They may result in pain with pressure such that walking is difficult.

Vaginitis, also known as vulvovaginitis, is inflammation of the vagina and vulva. Symptoms may include itching, burning, pain, discharge, and a bad smell. Certain types of vaginitis may result in complications during pregnancy.

Penile cancer, or penile carcinoma, is a cancer that develops in the skin or tissues of the penis. Symptoms may include abnormal growth, an ulcer or sore on the skin of the penis, and bleeding or foul smelling discharge.

<span class="mw-page-title-main">Molluscum contagiosum</span> Viral infection of the skin

Molluscum contagiosum (MC), sometimes called water warts, is a viral infection of the skin that results in small raised pink lesions with a dimple in the center. They may become itchy or sore, and occur singularly or in groups. Any area of the skin may be affected, with abdomen, legs, arms, neck, genital area, and face being the most common. Onset of the lesions is around seven weeks after infection. They usually go away within a year without scarring.

<span class="mw-page-title-main">Anal cancer</span> Medical condition

Anal cancer is a cancer which arises from the anus, the distal opening of the gastrointestinal tract. Symptoms may include bleeding from the anus or a lump near the anus. Other symptoms may include pain, itchiness, or discharge from the anus. A change in bowel movements may also occur.

<span class="mw-page-title-main">Cervical intraepithelial neoplasia</span> Medical condition

Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer. More specifically, CIN refers to the potentially precancerous transformation of cells of the cervix.

<span class="mw-page-title-main">Genital herpes</span> Infection by herpes simplex viruses of the genitals

Genital herpes is a herpes infection of the genitals caused by the herpes simplex virus (HSV). Most people either have no or mild symptoms and thus do not know they are infected. When symptoms do occur, they typically include small blisters that break open to form painful ulcers. Flu-like symptoms, such as fever, aching, or swollen lymph nodes, may also occur. Onset is typically around 4 days after exposure with symptoms lasting up to 4 weeks. Once infected further outbreaks may occur but are generally milder.

<span class="mw-page-title-main">Gardasil</span> Human papillomavirus vaccine

Gardasil is an HPV vaccine for use in the prevention of certain strains of human papillomavirus (HPV). It was developed by Merck & Co. High-risk human papilloma virus (hr-HPV) genital infection is the most common sexually transmitted infection among women. The HPV strains that Gardasil protects against are sexually transmitted, specifically HPV types 6, 11, 16 and 18. HPV types 16 and 18 cause an estimated 70% of cervical cancers, and are responsible for most HPV-induced anal, vulvar, vaginal, and penile cancer cases. HPV types 6 and 11 cause an estimated 90% of genital warts cases. HPV type 16 is responsible for almost 90% of HPV-positive oropharyngeal cancers, and the prevalence is higher in males than females. Though Gardasil does not treat existing infection, vaccination is still recommended for HPV-positive individuals, as it may protect against one or more different strains of the disease.

<span class="mw-page-title-main">Bovine papillomavirus</span> Group of viruses

Bovine papillomaviruses (BPV) are a paraphyletic group of DNA viruses of the subfamily Firstpapillomavirinae of Papillomaviridae that are common in cattle. All BPVs have a circular double-stranded DNA genome. Infection causes warts of the skin and alimentary tract, and more rarely cancers of the alimentary tract and urinary bladder. They are also thought to cause the skin tumour equine sarcoid in horses and donkeys.

Margaret Anne Stanley, OBE FMedSc, is a British virologist and epithelial biologist. She attended the Universities of London, Bristol, and Adelaide. As of 2018, she is an Emeritus Professor of Epithelial Biology in the Department of Pathology at the University of Cambridge and a Fellow of the Academy of Medical Sciences. She is also an Honorary Fellow of the UK Royal College of Obstetricians and Gynaecologists and an honorary fellow of Christ's College, Cambridge. Stanley is a research scientist in virology focusing on the human papillomavirus (HPV). Her research work has led to new scientific findings on HPV. Additionally, she uses her expertise on HPV to serve on multiple advisory committees and journal editorial boards.

<span class="mw-page-title-main">Condom effectiveness</span>

Condom effectiveness is how effective condoms are at preventing STDs and pregnancy. Correctly using male condoms and other barriers like female condoms and dental dams, every time, can reduce the risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) and viral hepatitis. They can also provide protection against other diseases that may be transmitted through sex like Zika and Ebola. Using male or female condoms correctly, every time, can also help prevent pregnancy.

HspE7 is an investigational therapeutic vaccine candidate being developed by Nventa Biopharmaceuticals for the treatment of precancerous and cancerous lesions caused by the human papillomavirus (HPV). HspE7 uses recombinant DNA technology to covalently fuse a heat shock protein (Hsp) to a target antigen, thereby stimulating cellular immune system responses to specific diseases. HspE7 is a patented construct consisting of the HPV Type 16 E7 protein and heat shock protein 65 (Hsp65) and is currently the only candidate using Hsp technology to target the over 20 million Americans already infected with HPV.

<span class="mw-page-title-main">Sexually transmitted infection</span> Infection transmitted through human sexual behavior

A sexually transmitted infection (STI), also referred to as a sexually transmitted disease (STD) and the older term venereal disease (VD), is an infection that is spread by sexual activity, especially vaginal intercourse, anal sex, oral sex, or sometimes manual sex. STIs often do not initially cause symptoms, which results in a risk of passing the infection on to others. Symptoms and signs of STIs may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. Some STIs can cause infertility.

An anal Pap smear is the anal counterpart of the cervical Pap smear. It is used for the early detection of anal cancer. Some types of human papillomavirus (HPV) can cause anal cancer. Other HPV types cause anogenital warts. Cigarette smokers, men who have sex with men, individuals with a history of immunosuppression and women with a history of cervical, vaginal and vulval cancer are at increased risk of getting anal cancer. Vaccination against HPV before initial sexual exposure can reduce the risk of anal cancer.

<span class="mw-page-title-main">Herpes</span> Viral disease caused by herpes simplex viruses

Herpes simplex, often known simply as herpes, is a viral infection caused by the herpes simplex virus. Herpes infections are categorized by the area of the body that is infected. The two major types of herpes are oral herpes and genital herpes, though other forms also exist.

Anal dysplasia is a pre-cancerous condition which occurs when the lining of the anal canal undergoes abnormal changes. It can be classified as low grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL). Most cases are not associated with symptoms, but people may notice lumps in and around the anus.

Human papillomavirus (HPV)-associated oropharyngeal cancer awareness and prevention is a vital concept from a public and community health perspective.

References

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  2. 1 2 3 4 Tripathi, Anuj; Sahu, Utkarsha (2022). "1. An overview of HPV: causes, symptoms, and clinical manifestations". In Khare, Prashant; Jain, Ashish (eds.). Immunopathology, Diagnosis and Treatment of HPV induced Malignancies. London: Elsevier. pp. 1–13. ISBN   978-0-323-98644-1.
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  5. 1 2 3 4 5 6 7 8 9 "CDC - Genital Warts - 2010 STD Treatment Guidelines". www.cdc.gov. 28 January 2011. Archived from the original on 8 July 2018. Retrieved 2 January 2018.
  6. 1 2 "Genital warts". NHS. 21 August 2017. Retrieved 2 January 2018.
  7. ↑ Madoff, Robert D.; Melton-Meax, Genevieve B. (2020). "136. Diseases of the rectum and anus: anal warts". In Goldman, Lee; Schafer, Andrew I. (eds.). Goldman-Cecil Medicine. Vol. 1 (26th ed.). Philadelphia: Elsevier. p. 938. ISBN   978-0-323-55087-1.
  8. ↑ Hoyle, Alice; McGeeney, Ester (2019). Great Relationships and Sex Education. Taylor and Francis. ISBN   978-1-35118-825-8 . Retrieved July 11, 2023.
  9. 1 2 US National Cancer Institute. "HPV and Cancer" . Retrieved 2 January 2018.
  10. ↑ US Centers for Disease Control. "Genital HPV Infection - Fact Sheet" . Retrieved 16 November 2017.
  11. ↑ Syrjänen, Kari J.; Syrjänen, Stina M. (2000). Papillomavirus infections in human pathology. Chichester [u.a.]: Wiley. p. 1. ISBN   9780471971689.
  12. ↑ Scheinfeld, Noah (2017-01-04). "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis" . UpToDate. Retrieved 2018-01-01.
  13. ↑ "Condylomata Acuminata (Genital Warts)". The Lecturio Medical Concept Library. Retrieved 10 July 2021.
  14. 1 2 3 4 5 6 7 8 9 Lacey, CJ; Woodhall, SC; Wikstrom, A; Ross, J (Mar 12, 2012). "2012 European guideline for the management of anogenital warts". Journal of the European Academy of Dermatology and Venereology. 27 (3): e263-70. doi: 10.1111/j.1468-3083.2012.04493.x . PMID   22409368.
  15. 1 2 Veldhuijzen, NJ; Snijders, PJ; Reiss, P; Meijer, CJ; van de Wijgert, JH (December 2010). "Factors affecting transmission of mucosal human papillomavirus". The Lancet Infectious Diseases. 10 (12): 862–74. doi:10.1016/s1473-3099(10)70190-0. PMID   21075056.
  16. 1 2 3 Gormley, RH; Kovarik, CL (June 2012). "Human papillomavirus-related genital disease in the immunocompromised host: Part I.". Journal of the American Academy of Dermatology. 66 (6): 867.e1–14, quiz 881–2. doi:10.1016/j.jaad.2010.12.050. PMID   22583720.
  17. ↑ Cardoso, JC; Calonje, E (September 2011). "Cutaneous manifestations of human papillomaviruses: a review". Acta Dermatovenerologica Alpina, Pannonica et Adriatica. 20 (3): 145–54. PMID   22131115.
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  22. ↑ UK Department of Health. "Your guide to the HPV vaccination from September 2012" . Retrieved 1 January 2013.
  23. ↑ UK Medicines and Healthcare products Regulatory Agency. "Human papillomavirus vaccine Cervarix: safety review shows balance of risks and benefits remains clearly positive". Archived from the original on 3 April 2013. Retrieved 1 January 2013.
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  25. ↑ Lipke, MM (December 2006). "An armamentarium of wart treatments". Clinical Medicine & Research. 4 (4): 273–93. doi:10.3121/cmr.4.4.273. PMC   1764803 . PMID   17210977.
  26. 1 2 3 4 Mayeaux EJ, Dunton C (July 2008). "Modern management of external genital warts". J Low Genit Tract Dis. 12 (3): 185–192. doi:10.1097/LGT.0b013e31815dd4b4. PMID   18596459. S2CID   33302840.
  27. 1 2 3 4 5 6 7 8 9 Scheinfeld N, Lehman DS (2006). "An evidence-based review of medical and surgical treatments of genital warts". Dermatol. Online J. 12 (3): 5. PMID   16638419.
  28. 1 2 3 Meltzer SM, Monk BJ, Tewari KS (March 2009). "Green tea catechins for treatment of external genital warts". Am. J. Obstet. Gynecol. 200 (3): 233.e1–7. doi:10.1016/j.ajog.2008.07.064. PMID   19019336. S2CID   31437162.
  29. ↑ Grillo-Ardila, Carlos F; Angel-Müller, Edith; Salazar-Díaz, Luis C; Gaitán, Hernando G; Ruiz-Parra, Ariel I; Lethaby, Anne (2014-11-01). "Imiquimod for anogenital warts in non-immunocompromised adults". Cochrane Database of Systematic Reviews (11): CD010389. doi:10.1002/14651858.cd010389.pub2. ISSN   1465-1858. PMC   10777270 . PMID   25362229.
  30. ↑ "Veregen label information" (PDF). Retrieved 2013-01-01.
  31. ↑ CDC. (2004). REPORT TO CONGRESS: Prevention of Genital Human Papillomavirus Infection.
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