Genital warts

human papillomavirus | warts | HPV |

Overview

  • Human papillomavirus (HPV) transmission is from direct skin to skin contact with apparent or sub-clinical lesions and/or contact with genital secretions. Micro-abrasions in the recipients skin allow viral access to the basal cells of the epithelium.
  • Most ano-genital warts are caused by HPV types 6 and 11 and infection results in type-specific protection (but whether there is cross protective immunity is uncertain).
  • The long latent period, just as with herpes, means that the presence of warts in only 1 partner, does not necessarily imply recent infidelity.

Cause

Human papillomavirus (HPV).

Clinical presentation

Male Female
Symptoms
Warty growths in and around genital skin. Little discomfort (sometimes itchy) but often psychological distress is significant. Warty growths in and around genital skin. Little discomfort. Sometimes itchy. Often psychological distress is significant.
Distorted urinary stream or bleeding with urethral lesions Cervical lesions noted on vaginal examination should be assessed by cervical cytology and if abnormal by colposcopy
Perianal itch Perianal itch
PR bleeding after passage of stools with anal lesions PR bleeding after passage of stools with anal lesions
Complications
Rarely malignancy (penile, anal, oropharynx) unless associated with oncogenic genotypes

Rarely malignancy (vulvar, vaginal, cervical, anal, oropharynx) however generally associated with oncogenic genotypes

  Often detected on cervical cytology producing LSIL
LSIL – Low grade squamous intraepithelial neoplasia

See STI Atlas for images.

Special considerations

  • Consider referral and/or biopsy of atypical lesions or new lesions in the elderly (to test for malignancy).
  • Atypical lesions, lesions with variable pigmentation or raised plaque-like lesions should be biopsied to exclude pre-cancerous change especially in patients who are immunosuppressed or have HIV infection.
  • Warts can grow rapidly in pregnancy and can only safely be treated with cryotherapy or diathermy during pregnancy.

Diagnosis

Diagnosis is usually based on visual appearance. If there are atypical lesions (e.g. variable pigmentation, raised plaque-like lesions or cervical warts), consider histology biopsy to exclude cancer.

Investigations

  • Comprehensive STI testing may be appropriate depending on the individual patient’s sexual history.
  • No specific diagnostic test for HPV is available.

Management

Principal Treatment Options
SituationRecommendedAlternative
Treatment for genital warts Patient applied podophyllotoxin 0.15% cream or 0.5% paint topically applied, BD for 3 days, then 4 days off, repeated weekly for 4-6 cycles until resolution. Paint is more suited for use on external keratinised skin. Cream is best used in perianal area, introital area and under the foreskin.
OR
Patient applied imiquimod 5% cream topically, 3 times per week at bedtime (wash after 6-10 hours) until resolution (up to 16 weeks).
Clinician initiated Cryotherapy weekly.

Excision under local anaesthetic e.g. localised pedunculated warts.
Ablative therapy under general anaesthetic.

Treatment advice

  • Treatment is cosmetic rather than curative.
  • HIV infection: genital warts can have a poor response to treatment and may require longer cycles of treatment and are more likely to recur.

Other immediate management

  • If warts are in the pubic region avoid shaving or waxing as  this may facilitate local spread by autoinoculation of HPV into areas of microtrauma
  • Provide patients with factsheet
  • Genital warts is not a notifiable infection.

Special treatment situations

Special considerations

  • Consider seeking specialist advice before treating any complicated presentation.
SituationRecommended
Complicated or disseminated infection

Consider referral for laser or diathermy. Persistent intra-anal lesions in HIV positive patients should be considered for surgical excision and HPV DNA typing to inform follow-up
Pregnant women 
pregnancy
Cryotherapy can have a poor response. Lesions often resolve spontaneously postnatally when immune function returns to normal following delivery
Allergy to principal treatment choice Cryotherapy or imiquimod. Use imiquimod with care in patients with history of significant eczema or dermatitis
Regional/Remote Podophyllotoxin or imiquimod

Special considerations

  • Meatal warts: treat with cryotherapy
  • Intra-anal warts: treat with cryotherapy or refer for surgical management
  • Cervical warts: initial cervical cytology and refer to gynaecologist for consideration of colposcopy, biopsy and treatment as indicated.

Contact tracing

Not recommended. The majority of partners are probably infected subclinically.

Follow up

Not required if symptoms resolve. Review if patient anxious or warts are difficult for patient to visualise.

Test of Cure (TOC)

Not required.

Retesting

Not required. Consider testing for other STIs, if not undertaken at first presentation, or retesting post the window period.

Auditable outcomes

100% of patients diagnosed are offered treatment.

Last Updated: Monday, 27 June 2016