Genital warts are one of the most common sexually transmitted infections in Australia. They are caused by the human papilloma virus (HPV, "wart virus"). There are about 100 strains of HPV, but most do not affect the genitals.
Infection by the wart virus may result in:
These are growths that appear around the genitals or anus, and sometimes in the vagina, rectum or urethra.
They may be raised or flat, single or multiple, small or large, and may cluster together with a cauliflower-like appearance. They are painless and rarely cause discomfort.
No warts are visible but microscopic changes in cells show evidence of the virus.
HPV is spread by direct skin contact with a partner during vaginal or anal intercourse. Infection may occur by contact with a visible wart, and possibly also from an area of skin with no visible wart (subclinical infection).
After sex with an infected person, warts may take a few weeks to many months (or even years) to appear.
Genital warts are diagnosed by looking for them.
Subclinical HPV infection is difficult to diagnose. However, if present on the cervix, it may show up on a Pap smear.
There are no blood tests or swab tests to diagnose genital warts.
Treatment removes visible warts, but does not eradicate the wart virus. There are several types of treatment. Each may cause mild irritation, but if you experience significant discomfort or inflammation you should tell your doctor. An alternative treatment may be required.
Warts are frozen by applying liquid nitrogen or dry ice once a week. It usually takes several applications before the warts disappear. You may not be able to see the warts yourself, so it is important to continue the treatment until the doctor says the warts have gone.
Podophyllotoxin paint (Condylline) is a plant extract that is easily absorbed through the skin. It should be carefully applied to the warts twice daily for 3 days, followed by a break of 4 days. This treatment may be repeated for several cycles. Podophyllotoxin does not need to be washed off after application, but it should not be applied inside the vagina, urethra or anus.
Podophyllotoxin should not be used by pregnant women.
Imiquimod 5% cream (Aldara) helps stimulate the immune system to destroy cells infected with HPV. Studies suggest it works better in women than men.
Rub a small amount of cream on to the warts, avoiding the surrounding skin. Wash the cream off with soap and water after 6 to 10 hours. Apply the treatment 3 times a week (on alternate nights) for up to 3 months. Imiquimod must be prescribed by a doctor. It is expensive, but private health insurance may reimburse you for some of the cost.
Imiquimod should not be used by pregnant women.
Laser treatment is used when warts are in places that are difficult to reach, very extensive or resistant to other treatments.
If a Pap smear reveals evidence of HPV on the cervix, laser treatment may be used to remove the affected cells.
Laser treatment is administered in hospital under a general anaesthetic.
Most of the treatments destroy cells that are infected by the wart virus, but do not remove the virus from the body.
Because the virus may persist in the skin, it is possible for warts to return after treatment. If warts reappear, it does not necessarily mean that you have caught the infection again.
In most people, warts go away eventually and do not reappear. This is thought to be due to the body¡¯s natural defences.
When some strains of HPV infect the cervix, they cause changes to its cells. These changes can be detected on a Pap smear, and they may be present in women who have never had visible genital warts.
Often these cells return to normal without any treatment, but sometimes the abnormalities persist and there may be an increased risk of developing cancer of the cervix in future. The risk is further increased in women who smoke.
Fortunately, cancer can be prevented by treating the abnormal cells.
Women with a history of genital warts or HPV need regular Pap smears. Your doctor can advise how often smears are needed.
HPV is easiest to pass on when there are visible warts present, but there is an infectious period before they appear and after they resolve. The length of this period is unknown. People with visible warts can reduce the risk of spreading HPV infection by having warts treated as soon as they appear. Those with subclinical HPV infection may pass it on without realising they have the infection.
Condoms will help to prevent spreading warts, but they will only protect the area they cover. As HPV may be present anywhere in the anal and genital area, they may not provide full protection. For people in steady sexual relationships, the benefit of condoms is less clear, especially if both partners have warts. Discuss this with your doctor.
It is common for people with warts or HPV infection to feel upset, ashamed or concerned about the risk of cancer. This is normal, and it may help to remember the following points:
Genital warts can be managed. With patience and persistence, the warts will go away.
Cervical cancer, the most serious problem associated with HPV, is easily prevented by regular Pap smears and treatment of abnormal cells.
Genital warts are caused by the human papilloma virus (HPV), and resemble warts found on other parts of the body. Human papilloma virus (HPV) types 6,11,16,18 commonly cause anogenital infection, whereas types 1,2,3,4 and 10 cause skin warts. Warts usually appear 2 to 8 months after the infection has been acquired, but may take longer, even years, to appear. Asymptomatic infection is also common.
It is important to realise that many people can be infected with the genital wart virus but show no obvious lumpy warts. Individuals infected with the virus, even without the lesions, can infect sexual partners. Some women have no evidence of genital wart virus, except on their Pap smear. Unfortunately, there is no comparable test available for men to ascertain the presence of wart virus infection when there are no lesions.
Because genital warts is not a notifiable disease, no direct statistics are available on its prevalence in Australia. However, in the United Kingdom and many parts of the world, the incidence of genital warts has doubled over the last 10 years.
Genital warts are the most common STD in South Australia. They were present in 13-18% of clients with STDs diagnosed at Clinic 275 between 1988 and 1995.
The warts have a variable morphology, being flat, small and resembling skin warts on cold, dry areas whilst often large and filiform in warm moist areas. Sub-clinical wart virus infection can only be detected on colposcopy.
Males: Condylomata accuminata are typically located around the coronal sulcus, on the glans and the frenulum, at the meatus and sometimes on the shaft and surrounding skin. The rectum, anal canal and perianal areas can also be involved, particularly in homosexual men (but heterosexual men can also be affected).
Warts are rarely found on the scrotum and urethra. Occasionally rectal and genital warts can undergo malignant changes.
Females: The vulva is the commonest site for genital warts in females, especially at the introitus and on the labia. The perineum, perianal region, vagina and cervix can also be involved.
Infants: The virus can be vertically transmitted (from mother to child) during parturition, producing laryngeal papillomata in the newborn.
In women, genital warts have been linked to abnormal changes in cervical cells that can lead to cancer, and are thought to be a co-factor in the development of cervical cancer. This link is not conclusive and has been the subject of much debate. Women who have the wart virus and who smoke are known to have a much higher risk of developing cervical cancer.
Genital warts often spread and enlarge in pregnancy, and may complicate labour by blocking the birth canal or by bleeding.
In men there is a slight risk that untreated warts could develop into cancer of the penis.
It is important that individuals have a check-up if they suspect that they may have genital warts. A doctor will examine the genitals and in some cases my use a diluted acetic acid that turns the warty areas white.
Diagnosis is based on the appearance of the warts which should be differentiated from:
It is important that women have a Pap smear to check if there is evidence of cervical infection or atypical cells.
Treatment may be prolonged and involves the following important general principles:
Cryotherapy (preferably with liquid nitrogen) is the preferred treatment. Response to therapy, followed by further treatment if necessary, is assessed once or twice weekly.
When cryotherapy is not available podophyllin in concentrations of 10-50 percent dissolved in spirit or other solvents can be used. The podophyllin should be carefully washed away by the patient after 2-4 hours. If the response is unsatisfactory, the concentration and duration of application would be increased. Podophyllin should NOT be given to patients for self application and should NOT be used in pregnancy, on urethral or cervical warts.
If repeated applications of podophyllin do not clear the condition, trichloroacetic acid or electrocautery (under general anaesthesia if there is an extensive crop of warts), or laser therapy should be tried. In a few patients treatment is ineffective, but the warts eventually disappear.
Genital warts are sexually transmitted and spread most readily in moist areas such as beneath the foreskin of the penis of an uncircumcised man, around the vulva, or around the anus. Warts are spread by genital-to-genital contact, and not by other practices such as oral sex or mutual masturbation.
The genital wart virus continues to live in the body even when no warts are visible, and transmission may occur from "viral shedding" when no obvious warts are present. When warts occur, they may take months to develop after the infection has been acquired
Transmission to infants at birth can occur, and may be reduced by effective treatment of warts in pregnancy - preferably using cryotherapy.
Diagnosis is made on clinical grounds. Biopsy is rarely required for unusual presentations.
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| Penile warts. | Warts scattered over the vestibule and perineum. |
The aim of treatment is to remove clinically evident warts. No treatment has been demonstrated to eradicate HPV. All treatment modalities are associated with high recurrence rates.
In some cases, genital warts may regress spontaneously.
Liquid nitrogen is applied to visible warts at weekly intervals until resolution.
Podophyllotoxin 0.5% solution may be applied and provided for self-treatment. It is associated with a far lower rate of adverse reactions than treatment with podophyllin. The patient applies podophyllotoxin with a special applicator (included in packaging) twice daily for 3 days followed by 4 days of no therapy. This cycle may be repeated as necessary for a total of 4 cycles.
The doctor should demonstrate the proper application technique and identify which warts should be treated.
Podophyllotoxin should never be used in pregnancy.
Notes on Podophyllotoxin Therapy:
Imiquimod 5% cream (Aldara) may be prescribed for self-application. It is more effective for women than men.
Surgical removal, electrosurgery or laser therapy are used for warts resistant to the foregoing methods, for extensive warts or warts in certain locations, eg rectal warts.
Women with genital warts should have a Pap smear taken at the initial consultation. Patients with cervical or extensive intravaginal warts should be referred for colposcopy.
Urethroscopy is indicated before treating recurrent meatal warts, and proctoscopy before treatment of perianal warts.
Clinical assessment at one week, to assess response to therapy, and re-treatment as required.
Women with genital warts, or female partners of patients with genital warts should be encouraged to have regular Pap smears
Genital Warts(Chinese Version)