PATIENT INFORMATION LEAFLET Genital warts (condylomata acuminata)

This leaflet has been written to help you understand more about genital warts. It will tell you what it is, what causes it, what can be done about it, and where you can find out more information about it.

What are genital warts?
Genital or more accurately anogenital warts are benign skin tumours of the genital, perineal and anal areas; the medical term is condylomata acuminata.

What causes genital warts?
Genital warts are an infectious disease caused by sexually transmitted viruses, the Human Papilloma Virus (HPV), types 6 and 11.

The incubation period (time between infectious contact and showing clinical signs) can be as long as eight months.

Most contaminations by HPV are asymptomatic and the virus will clear itself within 2 years. This means, that you might not realize that you carry the virus (there is therefore a small chance that you transmit the virus to another person without knowing it).
The virus can persist for months or years in the skin, with or without clinical symptoms. If the warts reappear after resolution of clinical disease (the warts) it is a recurrence usually due to the original contamination and not a new infection. Infection can occur in up to 30% of women between 20 and 30 years of age; elderly women are less frequently affected.

Are genital warts hereditary?
No.

What are the signs and symptoms of genital warts?
The presence of external genital warts (at the outside of the ano-genital skin) is nearly always detected by the patient herself. You do not usually feel them but there may be some degree of itching.
Early diagnosis is increasing, due to greater patient awareness.

Internal warts/condylomata (inside the genitals for example the cervix or the anus) you are not usually aware of. However, they may cause vaginal discharge, anal or voiding discomfort and very rarely bleeding.

What do genital warts look like?
The warts are small warty papules resembling cock’s combs, some have a smooth surface. They may be more pigmented (brown coloured) than the surrounding skin.

How is the diagnosis made?
The diagnosis is usually easily made on clinical grounds.

A biopsy is especially warranted if the diagnosis is uncertain, if standard treatments are not successful or if the warts are heavily pigmented, ulcerated or feel very hard.

Vaginal examination may show vaginal or cervical warts and rarely endoscopic (internal anal and/or urethral) examinations may be necessary if internal lesions are suspected.

Natural course of genital warts
The natural clinical course is variable; it depends on the individual’s immune status. They may resolve spontaneously; however, they may also re-appear after clearing.

Can genital warts be cured?
Yes, but it is very difficult to know if the virus has been eradicated. Persistent or recurrent lesions often require repetitive treatments; recurrences may occur even months or years after clinical resolution.

Warts/Condylomata are very contagious. The use of condoms is the only way to prevent sexual transmission, but this does not offer complete protection. The risk of transmission is increased by a high number of sexual partners.

Complications
Large condylomatous tumours are rare in healthy individuals; however, they can be seen in pregnant women and in immunocompromised patients. They can cause pain, secondary bacterial infections, bleeding and functional impairment affecting the urethra, vagina and anus may occur.

Cervical screening for dysplasia should be encouraged because of a possible additional co-infection of the cervix with carcinogenic HPV (mainly types 16 and 18). However, women with genital warts are not normally at higher risk of developing pre-malignant cervical lesions or invasive cervical cancer just because they have acquired warts/condylomata (it is a benign infection).

How can genital warts be treated?
The choice of the therapy is dependent on the type, the extent and the location of the warts. Destructive treatment options are cryotherapy, laser vaporisation, electro surgery / cauterization, trichloroacetic acid or podophyllotoxin application. Another option is increasing the local immune defence against the virus with imiquimod cream.
Recently vaccines against carcinogenic and non-carcinogenic HPV viruses (types 16, 18 and 11, 6) have been developed. They will probably reduce the risk of infection in the future.

Specific management during pregnancy
Treatment should be started as soon as possible. However, in the last eight weeks of pregnancy extensive destructive methods should be avoided in order to facilitate skin repair before delivery.

Localized lesions can be treated with cryotherapy or with TCA (Trichloroacetic acid, 33% to 50%) which is a liquid that “burns” or “peels” the warts away. Those products can be applied to the lesions with a cotton tip by a physician once every 2 to 3 weeks or once a week respectively.

Podophylotoxin is potentially harmful for the foetus and strictly prohibited during pregnancy.
Imiquimod has been used in pregnancy without observed adverse effects but is not licensed for use in pregnancy.

After delivery, the immune status of a woman improves and condylomata often regress spontaneously, totally or partially.

What can I do?
Condylomata acuminate are highly contagious and spontaneous resolution is uncertain.
Disease progression can lead to extensive lesions, therefore, treatment is mandatory!

How will condylomata acuminata affect the baby? 
The unborn is not affected by the condylomata.
Maternal antibodies against the HPV are transmitted to the unborn and may contribute to its protection, which will reduce the risk of viral transmission from mother to baby during delivery. Therefore, the chance for the baby to acquire HPV from the mother during delivery is very low. The only serious complication is “juvenile laryngeal papillomatosis” (numerous warty papules on the vocal cords; they need to be removed surgically but may recur). However, a caesarean section is not justified because it does not prevent the risk of viral transmission completely. Instead, the period of delivery should be as short as possible with the use of vaginal antiseptics.

Investigation of the male partner and his treatment
Similar diagnostic and treatment options are available for men and women. Male partners with genital warts are referred to a dermatologist, an urologist or a GU physician.

Where can I find more information about genital condylomata?

Books:

1. Human Papilloma Virus Infection. A clinical atlas. Gross GE and Barrasso R eds. Berlin. Ullstein Mosby. 1997.

2. The Sanford Guide to Antimicrobial Therapy, 20th edition of the Belgian / Luxembourg version, 2006-2007.

3. Sexually transmitted diseases treatment guidelines, 2006. Centers for diseases treatment guidelines, 2006. Worwoski KA, Berman SM.

 

Note: While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Your own doctor will be able to advice in greater detail.

This leaflet has been prepared by the EADV task force “skin disease in pregnancy”, it does not necessarily reflect the official opinion of the EADV – August 2010 submitted to EADV.