Genital warts diagnosis and management

Last updated: August 2013

Diagnosis

Clinical

Typical appearance of papillomatous growths in anogenital area including cervix and rectum

Histopathological

Not routinely indicated.

Indications for biopsy may include

  • atypical appearance
  • in HIV positive persons
  • pigmented warts
  • poor response to treatment
  • unclear diagnosis.

Nucleic Acid Amplification Test for HPV DNA

Most genital warts are caused by type 6 and 11 which are low oncogenic risk.

There is no role for testing for high risk HPV of genital warts.

Treatment

The choice of treatment is guided by practitioner experience and patient choice.

See the Wart Treatment Algorithm (PDF 28KB) for treatment approaches.

In providing treatment note the following:

  • 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 but this can take a few years
  • Intrameatal warts cryotherapy only
  • Cervical warts need referral to colposcopy
  • Urethroscopy is indicated before treating recurrent meatal warts, and proctoscopy before treatment of perianal warts
  • Consider obtaining a specialist review in HIV positive with anal warts
  • Internal rectal & vaginal warts may spontaneously resolve after treatment to external warts
  • After treating external warts, review internal warts for resolution or determination of further treatment

Cryotherapy

Liquid nitrogen is applied to visible warts at weekly intervals until resolution. Warts can usually be treated with two 15 to 30 second freeze thaw cycles

  • The nozzle tip of the spray gun is held about 1cm from the treatment site & liquid nitrogen is sprayed on the lesion until a 2-3 mm ice halo is formed around the wart.
  • Side effects can include a small risk of scaring, hypo or hyperpigmentation and should be discussed prior to treatment
  • Avoid cryotherapy to large areas and in particular cirumferential cryotherapy to the penis
  • Patients may experience pain and or blistering at the site of freezing.
  • A weak salt solution is an effective skin wash after cryotherapy
  • Patients may benefit from simple analgesia
  • Efficacy rates around 70% and recurrence rates around 30%

Podophyllotoxin

  • This is self applied treatment
  • Efficacy rates around 70% and recurrence rates around 30%
  • The doctor should demonstrate the proper application technique and identify which warts should be treated.

Podophyllotoxin 0.5% solution or 0.15% cream topical 12 hourly for 3 days followed by 4 days of no therapy. This cycle may be repeated up to a total of 4 times after which time the patient should return for review. The total wart area being treated should not exceed 10cm2 and the total volume should be limited to 0.5ml per day (D)

Warning

  • Do not use in pregnancy
  • Do not use on cervical, rectal or urethral warts (because of difficulty in preventing damage to adjacent moist tissues and the potential for systemic absorption).
  • Treat warts in the outer vagina or vestibular area with extreme caution. Only treat small isolated warts and allow to dry, to minimise contact with normal mucosa.
  • Never use large volumes by treating extensive or very large warts.

Imiquimod

This is self applied treatment.It is more effective for women than men.

Imiquimod is an immune response modifier and treatment response typically takes 12 to 6 weeks.

Imiquimod 5% cream once a day topically and washed off 6-10 hours three times per week on alternate days for up to 16 weeks (B1)

Note the following:

  • Assess response to treatment after every 4 weeks for up to 16 weeks.
  • Response to treatment may be delayed for some weeks.
  • Local inflammatory reactions are common. Temporary reduction in frequency and amount of imiquimod may facilitate resolution of a local reaction. Severe reactions may necessitate alternative treatments. Local inflammatory reactions include:
    • redness
    • irritation
    • induration
    • ulceration/erosions
    • vesicles
  • Not approved for use in pregnancy or for internal warts.
  • May weaken latex condoms and diaphragms.
  • May cause irritation to sexual partners and sex should be avoided immediately after application.
  • Efficacy rates around 50% and recurrence rates around 10-20 2%

Other treatment modalities

Referral for surgical removal, electrosurgery or laser therapy should be considered for the following:

  • warts resistant to standard treatment
  • extensive warts
  • warts in certain locations for example, rectal warts which haven’t resolved after treatment and resolution of external warts.

Treatment in pregnancy

  • Warts may worsen in pregnancy and resolve after delivery
  • Cryotherapy is the preferred method of treatment
  • Management of vaginal warts at the time of delivery should be discussed with the treating obstetrician

Patient education

The following points should be covered:

  • The nature of the infection
  • HPV is very common.Most people will become infected with genital types during their sexual life
  • Most infected people are asymptomatic with only a very small number developing visible warts
  • The oncogenic types (mostly 16 and 18) of HPV rarely cause visible genital warts
  • HPV infection is often present in the absence of genital warts
  • It is impossible to diagnose subclinical HPV infection clinically.
  • Side effects of treatment and their management.
  • If podophyllotoxin has been used, stress the need to return immediately if a severe reaction results from treatment

Follow up

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 as recommended for women without warts.

Further information

For further information on diagnosis and management of genital warts contact Adelaide Sexual Health Centre.

Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.

They are written primarily for use by Adelaide Sexual Health Centre staff and some flexibility is required in applying them to certain private practice situations.