Anogenital Warts

Anogenital warts, for the most part, are sexually transmitted viral warts caused by infection with specific types of HPV. Despite the generally benign nature of the proliferations, certain types of HPV can place patients at a high risk for anogenital cancers.
Transmission of HPV is by sexual contact, oral sex, and by vertical infection (mother to baby by passing through an infected birth canal).
In infants and small children, genital warts raise the possibility of sexual abuse, but in many cases it is due to vertical transmission or by incidental spread caused by nongenital HPV infections.
The incubation period is variable, ranging from 3 weeks to 8 months, with a reported average, in one study, of 2.8 months.
HPV has been identified in the skin of infected persons at a distance of up to 1 cm from the actual lesion; this feature may explain the high recurrence rate.
HPV types 16, 18, 31 to 35, 39, 42, 48, and 51 to 54 have been identified in cervical and anogenital cancers.
Lesions tend to be more extensive and recalcitrant to treatment in immunocompromised persons; they also tend to grow larger and more numerous during pregnancy.
Women with HPV infection who are pregnant or who are considering pregnancy pose specific challenges. In addition to the potential for rapid proliferation, the presence of HPV infection raises concerns regarding the risk of laryngeal papillomatosis or genital HPV infections in the newborn. A cesarean section does not eliminate the risk of transmission.

There are various morphologic types of anogenital warts. The appearance of warts depends on its location; for example, the condyloma acuminatum type tends to occur on moist surfaces.
Condyloma acuminatum may resemble small cauliflowers (Fig. 28.1).
Warts may appear as smooth, dome-shaped, papular lesions (Fig. 28.2).
They can appear as typical lobulated verrucous papules or plaques that resemble common warts (Fig. 28.3).
Usually asymptomatic; however, they may become pruritic, particularly the perianal and inguinal lesions. Pain and bleeding may occur if lesions are traumatized.
They may resolve spontaneously or, rarely, progress to invasive squamous cell carcinoma.

The diagnosis of anogenital warts is generally straightforward when the patient presents with the typical cauliflower-like lesions of condyloma acuminatum or with characteristic verrucous or filiform lesions.
However, when lesions are papular (flat-topped), pigmented, moist, or erosive, the diagnosis may not be as clinically obvious.
Normal anatomical structures may easily be confused with AGA.

Acetowhite Test on Mucous Membranes

In women, colposcopy is performed using 35% acetic acid, which produces an acetowhitening of subclinical lesions on the vaginal and cervical mucosa (Fig. 28.6).
Atypia or koilocytosis found on PAP smears represents early changes resulting from HPV infection.

Biopsy

A biopsy may be needed to identify confusing anogenital lesions.
After local anesthesia with lidocaine, a curved iris scissors may be used to obtain a small specimen (snip biopsy) from the labia minora, or perianal area. A punch biopsy or a shave biopsy may be obtained from nonmucous membrane skin (see Chapter 35: Diagnostic and Therapeutic Techniques). If an ulcer or an indurated nodule is present—particularly if carcinoma or bowenoid papulosis is suspected—a punch or excisional biopsy should be performed.

Differential Diagnosis

Normal Anatomic Structures

In women, vestibular papillae are normal anatomic structures. Unlike warts, vestibular papillae (vulvar papillomatosis) occur near the vaginal vestibule in symmetric clusters or in a linear pattern. They often appear as monotonous, small, smooth projections that resemble cobblestones (Fig. 28.7).
In men, pearly penile papules are frequently mistaken for warts. They are small, skin-colored to shiny, pearly papules that are located around the rim of the corona of the glans penis (Figs. 28.8 and 28.9).

Benign Lesions

Common benign skin lesions, such as skin tags, seborrheic keratoses, and melanocytic nevi, may also be easily mistaken for warts.
Fordyce spotsare angiokeratomas. They occur on the medial labia minora in women and on the scrotum in men (seeFigs. 30.44and30.45).
Skin tags are smooth and may be pigmented or skin-colored. Seborrheic keratoses and melanocytic nevi often have a verrucous (keratotic) appearance and may be pigmented.

Other Conditions

Hemorrhoids

Not infrequently, anal hemorrhoids are mistaken for warts. Hemorrhoids are smooth and compressible.

Molluscum Contagiosum

This pox virus infection can easily be confused with, and may coexist with, genital warts. Seen most often in young children and in patients with HIV infection and in sexually active young adults (seeChapters 17and33).
The lesions are dome-shaped, waxy or pearly white papules with a central white core, which is often revealed by inspection with a handheld magnifier.

Condyloma Latum of Secondary Syphilis

Lesions are “moist,” smooth-surfaced, and, usually, whitish and flat-topped. Serologic tests for syphilis are positive (see Fig. 28.20).

Malignant Neoplasms

When any of the following conditions are suspected, a biopsy should be performed:

Bowenoid Papulosis

These lesions are clinically similar to, and often indistinguishable from, flat or dome-shaped genital warts. They are associated with HPV type 16 or 18. Histologically, bowenoid papulosis demonstrates squamous cell carcinoma in situ; however, it follows a largely benign clinical course.

Giant Condyloma Acuminatum

Also known as the Buschke-Löwenstein tumor, this lesion is a low-grade, locally invasive squamous cell carcinoma that can arise from and appear as a fungating condyloma (Fig. 28.10). It is associated with HPV types 6 and 11 and should be considered in the differential of lesions measuring greater than 1 cm in diameter. Radical surgical extirpation is considered appropriate treatment.

Squamous Cell Carcinoma

These lesions are rapidly growing nodules or tumors, and they may be erosive or ulcerative.

Management

Counseling

Treatment of genital warts can be difficult and lengthy and patients should be so advised.
Patients should also be counseled about their risk of infectivity to others, as well as their increased risk of having other STDs.
They should also be informed about the long latency period of HPV; thus, a patient may not have contracted condyloma from his or her current partner.
Male patients should use condoms at least 1 year after clinical infection is treated; however, condoms are not perfect protection because warts can occur on genital areas other than the penis or vagina.
In affected women, there is a risk of malignant degeneration (cervical intraepithelial neoplasia or squamous cell carcinoma). If cervical warts are found during examination or if vulvar neoplasia is confirmed by biopsy, referral for colposcopic evaluation is indicated.
It is recommended that anogenital warts be treated in pregnant women during the second and third trimesters and that vaginal delivery be performed if possible.
In affected men with perianal warts, there is a risk of malignant degeneration to anal intraepithelial neoplasia or anal carcinoma.
The U.S. Centers for Disease Control and Prevention (CDC) recommends cesarean section only when the vaginal outlet is obstructed by extensive condylomata or if vaginal delivery would cause excessive bleeding.
Patients who have internal anal or rectal warts tend to have continual recurrences of external warts and should be referred to a rectal surgeon.
Diagnosis of genital warts in a child requires that the clinician report suspected sexual abuse to begin an evaluation process that may or may not confirm abuse (Fig. 28.11).

Surgical Therapy

Cryosurgery with liquid nitrogen (LN2). Cryosurgery is very effective for treating multiple, small warts (e.g., lesions on the shaft of the penis, vulva, and perianal area). LN2 is also safe for the mother and fetus when used during the second and third trimesters of pregnancy.
Electrodesiccation and curettage. This is quite effective for a limited number of lesions on the shaft of the penis or vulvae.
Surgical excision is useful for debulking large “cauliflower” lesions. Large, unresponsive lesions around the rectum or vulva can be treated with scissor excision of the bulk of the mass followed by electrocautery of the remaining tissue down to the skin surface.

Topical Therapy

Patient-applied Therapy

Imiquimod 5% (Aldara) or 3.75% (Zyclara) cream enhances the body's immune response to the infection by increasing local interferon. Aldara is applied three times weekly at bedtime for up to 16 weeks; and Zyclara should be applied daily for 8 weeks.
Warts seem less likely to recur compared to other treatments. It is not currently recommended during pregnancy.
Podofilox (Condylox) 0.5% solution or gel is used twice daily (morning and evening) for 3 days, then followed by 4 days without therapy. This 1-week cycle of treatment may be repeated up to four times until no wart remains. Safety for use in pregnancy is not known.
Sinecatechins ointment (Veregen) is an extract obtained from green tea leaves. It is applied three times daily for up to 16 weeks. It has antiviral and immune-stimulating properties.

Provider-applied Therapies

Podophyllin resin 10% to 25% in tincture of benzoin is an antimitotic agent that causes local tissue. It is carefully applied to the wart surface. The patient is instructed to wash the area in 4 to 6 hours and the interval is increased for subsequent treatments, as tolerated. It is most effective on warts on moist surfaces (perianal, labial, and under the prepuce). It should not be used in pregnant women or on extensive mucosal surfaces.
Trichloroacetic or bichloracetic acid 80% to 90% are applied after normal epithelium is coated with a protective substance such as 2% lidocaine or Vaseline petroleum jelly. These agents can cause intense burning of mucosal surfaces. They are most effective on small warts and on nonmucosal surfaces.

HPV Vaccination

Gardasil vaccine is recommended for preteen boys and girls at age 11 or 12 so they are protected before ever being exposed to the virus. HPV vaccine also produces a higher immune response in preteens than in older adolescents. Healthcare providers may give it to girls as young as 9 years. The vaccine can prevent almost 100% of disease caused by the four types of HPV (6, 11, 16, and 18) targeted by the vaccine. It may also be given to boys aged 9 to 26.
Cervarix is a bivalent vaccine that helps protect females from 9 to 25 years of age against HPV 16 and 18, the subtypes that cause about 70% of cervical cancer cases. It does not treat these conditions and does not protect against all HPV types.
Only Gardasil has been tested and licensed for use in males. Both Gardasil and Cervarix are given in a series of three shots over a 6-month period.

Helpful Hint

Cesarean delivery should not be performed solely to prevent transmission of HPV infection to the newborn; however, it is advisable to remove visible lesions during pregnancy.

Points to Remember

As with all HPV infections, the underlying viral infection may or may not persist even if the visible warts clear. Although skin warts are common in the general pediatric population, genital warts are uncommon in children. Consequently, the diagnosis of genital warts in children should alert the healthcare provider to the possibility of sexual abuse.
Confusing condyloma lata for genital warts misses the diagnosis of highly infectious secondary syphilis and leads to inappropriate therapy and potentially disastrous sequelae for the patient.
Confusing pearly penile papules, vestibular papillae, or Fordyce spots with genital warts result in unnecessary treatment and unwarranted psychosocial stress.
Pearly penile papules, vestibular papillae, and other normal anatomic structures are often mistaken for condyloma acuminatum.
Developing genital warts during a long-term relationship does not necessarily imply infidelity.

SEE PATIENT HANDOUT “Genital Warts” IN THE COMPANION eBOOK EDITION.

Outline
Acetowhite Test on Mucous Membranes
Biopsy

section name header

Basics ⬇

Clinical Manifestations ⬆ ⬇

Diagnosis ⬆ ⬇

Other Information ⬆