Genital warts are among the most common STIs and are caused by HPV infection. The incidence of HPV infection has risen dramatically in the last 20 years and it is now thought to occur in over 50 per cent of the adult population, with 1-2 per cent of these developing warts.
Painless, pearly, filiform or smooth eruptions may be seen on the shaft of the penis. Lesions may also be found at the urethral meatus or hidden under the foreskin. From the time of contact with the wart virus infection, it may be months or even years before genital warts develop.
Vulval warts are also common. Lesions similar in appearance to penile warts may be seen on the vulva. As in this case, the warts can sometimes be large, with a cauliflower-like appearance.
Infection with the virus leading to genital warts is usually acquired through sexual contact. When genital warts are diagnosed, infection with other STIs should always be considered. Smoking, oral contraceptive use and multiple sexual partners increase the risk of genital warts.
Perianal warts are seen more frequently in those who practise anal intercourse and in immunosuppressed patients.
Some warts will resolve spontaneously. Patients with a small number of warts can be managed with cryotherapy or topical application of podophyllotoxin, which may be applied at home.
Other treatment options include electrocautery, trichloracetic acid or 5-fluorouracil. For more extensive or persistent genital warts surgical excision or imiquimod may be suggested by a specialist.
Identification of genital warts in a female patient should always lead to further examination to exclude other suspicious lesions in the vagina or on the cervix or urethra. A cervical smear should be taken, although half of women with external lesions will have a negative smear result.
In this patient the lesions were biopsied and showed dyskaryosis, nuclear atypia and loss of polarity with warty atypia indicating the presence of vaginal intraepithelial neoplasia grade 1-2. She underwent laser treatment and continued with regular follow up to watch for recurrence.
Genital warts in a baby
The presence of genital warts in a child should raise concerns about possible sexual abuse. However, it is important to remember that transmission may also occur through manual contact.
In this case, the child had been delivered vaginally and the mother herself had genital warts at the time. Occasionally laryngeal warts may develop after a vaginal delivery to an infected mother. These may sometimes compromise breathing.
Warts outside the genital area
HPV lesions can also occur outside the genital area. The hands, fingers, mouth, larynx or trachea may be affected. There are 60 different types of wart virus, but 90 per cent of genital warts are related to HPV 6 and 11. These types have less risk of neoplastic change. Those with the highest risk of malignancy are HPV 16 and 18.
The introduction of a vaccine effective against HPV 6, 11, 16 and 18 means that genital warts and cervical cancer could be eradicated. Guidelines recommend routine vaccination for girls at the age of 11-12, and a catch-up programme for those aged up to 26.
Carcinoma of the cervix
This 29-year-old mother was on the Pill but had been complaining of intermenstrual and post-coital bleeding for about three months. On examination, a suspicious lesion was found on the cervix and she was referred to the gynaecologist.
A cervical biopsy was taken that confirmed the presence of a moderately differentiated large cell non-keratinising squamous cell carcinoma. A Wertheim's hysterectomy was performed. She made a good recovery but many patients are not so lucky. Each year 2,700 cases of cervical cancer are diagnosed and more than 1,000 women die of the disease.
Bowenoid papulosis is a pre-cancerous condition that is thought to be caused by HPV. Small red or brown, warty lesions develop on the shaft of the penis or on the labia. The lesions are usually symptomless but sometimes become inflamed, painful and itchy.
The diagnosis is confirmed on skin biopsy. In some cases the lesions resolve and disappear spontaneously. Follow up is required so that any changes can be noted early and progression to squamous cell carcinoma can be prevented. Treatment is with cryotherapy, laser therapy, excision or topical applications.