Types
Most anogenital warts are caused by HPV types 6 and 11.
Causes
Low risk HPV types
- 90% of anogenital warts are caused by HPV 6 and 11, usually asymptomatic
- About 80% of HPV infections resolve within 12 - 24 months via immune clearance
- The quadrivalent and nonavalent vaccines (Gardasil® and Gardasil® 9) provide excellent protection against HPV 6 and 11, but need to be given prior to commencement of sexual activity to be most effective
High risk HPV types
- HPV 16 is the most common high-risk type of HPV. Usually asymptomatic, even though it can bring about cervical changes
- HPV 18 is another high-risk type of HPV. Like HPV 16, its usually asymptomatic, but it can lead to cervical cancer
- HPV 16 and HPV 18 are together responsible for approximately 70% of all cervical cancers worldwide
- The HPV vaccine can protect against HPV 16 and HPV 18
All HPV types
- Most HPV infection is asymptomatic
- Condoms offer some protection against HPV infection, but this is limited as infection is usually multi-focal and often involves surfaces not covered by condoms
- The rate of transmission from mother to baby is estimated to be between 1:80 to 1:1500 affected women, and is thought to occur through direct contact in the birth canal
Clinical presentation
- Warty growths with little discomfort (can be sometimes itchy)
- Psychological distress can be significant
- PR bleeding after passage of stools with anal lesions
- HPV infections in young children can include conjunctival, oral and pharyngeal disease, the most severe of which is juvenile-onset respiratory papillomatosis (JRP)
- JRP is rare, with an estimated incidence of around 4 per 100,000 children, and mostly occurs in children born to mothers with anogenital warts during pregnancy
- Malignancy is associated with persistent oncogenic genotypes (cervical, vulval, vaginal, penile, anal, oropharynx)
Diagnosis
Diagnosis of warts is by visual inspection.
Biopsy should be considered for:
- atypical looking warts
- warts not responding to standard treatment
- cervical warts
Management
Choice of treatment depends on the number, size, degree of keratinisation, distribution, area affected, patient preference and pregnancy status.
Treatment of warts ameliorates symptoms but is not curative.
Asymptomatic infection cannot be treated.
| Condition | Recommended | Comments |
|---|---|---|
| Warts which are soft, vulvar or perianal, on mucosal surfaces, on or under the prepuce or on the perianal area |
Imiquimod 5% cream in sachets or pump, 1/3 to 1 sachet 3 times a week for 4–16 weeks OR Podophyllotoxin 0.5% solution (Condyline Paint™) or 0.15% cream (Wartec® cream) twice daily for 3 consecutive days then none for 4 days. Use for 4 weeks, then review. |
Imiquimod: Always give patients an instruction sheet and warn regarding potential local irritation. Review every 4 weeks. Do not use imiquimod:
Podophyllotoxin: Warn patients regarding potential local irritation:
|
| Keratinised warts, or those which are of long standing | Cryotherapy applied by liquid nitrogen cryospray or by cryoprobe |
Is well tolerated and very unlikely to result in scarring. The only contraindication is cryoglobulinaemia. The application of 5% lignocaine ointment or EMLA cream before treatment may help diminish discomfort. Combined therapies may be used such as imiquimod to debulk a large area of warts prior to cryotherapy, or vice versa |
| Large warts where other treatments have failed or are not tolerated. | Surgical ablation – by laser, diathermy or excision under general anaesthesia |
Surgery will not remove HPV which can result in recurrent warts after surgery. Long term complications are very rare and include hypo or hyper pigmentation and vulvodynia after surgery for extensive warts. |
| Warts in pregnancy |
Expectant management OR Cryotherapy OR Trichloroacetic acid OR Surgical ablation |
Expectant management is reasonable as the warts will usually improve spontaneously following pregnancy, and treatment does not alter risk of neonatal transmission. It is common for genital warts to recur or increase in size or number during pregnancy, and to resolve post-delivery. Podophyllin, podophyllotoxin, interferon and 5 FU are contraindicated in pregnancy. Imiquimod is not recommended due to limited safety information. Surgical ablation is reserved for large obstructive lesions and should be deferred until the third trimester to minimise recurrence. There is a risk of preterm labour. There is no strong evidence that caesarean section reduces the incidence of transmission, therefore this is only recommended if lesions are obstructive or causing extensive cervical disease. Treatment of the warts does not alter viral shedding or potential vertical transmission |
Follow up
Follow up is not required if symptoms resolve.
Review if warts require more than one treatment.
Contact tracing & partner management
Not recommended. The majority of partners are likely to be infected subclinically.
Disclaimer
We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines.
The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.