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6 Apr 2009 Sexually transmitted diseases ( STDs ) and infections (STIs): types, symptoms, transmission, and treatment. HPV types 6 or 11 are commonly found before, or at the time of, detection of genital warts (406).
Physician-developed info for Sexually transmitted diseases ( STDs ) are caused by infections that are passed from one person to another during sexual contact. HPV types 16, 18, 31, 33, and 35 are found occasionally in visible genital warts (usually as coinfections with HPV 6 or 11) and can be associated with foci of high-grade intraepithelial neoplasia, particularly in persons who are infected with HIV infection. In addition to warts on genital areas, HPV types 6 and 11 have been associated with conjunctival, nasal, oral, and laryngeal warts.Genital warts are usually asymptomatic, but depending on the size and anatomic location, they can be painful or pruritic.
Genital warts occur commonly at certain anatomic sites, including around the introitus in women, under the foreskin of the uncircumcised penis, and on the shaft of the circumcised penis. Intra-anal warts are observed predominantly in persons who have had receptive anal intercourse, but they can also occur in men and women who do not have a history of anal sexual contact.Diagnosis of genital warts is usually clinical, made by visual inspection. Genital warts are usually asymptomatic, but depending on the size and anatomic location, they might be painful or pruritic. Therefore, the routine use of this procedure for screening to detect mucosal changes attributed to HPV infection is not recommended.TreatmentThe primary reason for treating genital warts is the amelioration of symptoms (including relieving cosmetic concerns) and ultimately, removal of the warts.
If left untreated, visible genital warts can resolve on their own, remain unchanged, or increase in size or number.
Available therapies for genital warts likely reduce, but probably do not eradicate, HPV infectivity.
Whether the reduction in HPV viral DNA resulting from treatment reduces future transmission remains unclear. No evidence indicates that the presence of genital warts or their treatment is associated with the development of cervical cancer.RegimensTreatment of genital warts should be guided by the preference of the patient, available resources, and the experience of the health-care provider.
No definitive evidence suggests that any of the available treatments are superior to any other, and no single treatment is ideal for all patients or all warts. The use of locally developed and monitored treatment algorithms has been associated with improved clinical outcomes and should be encouraged. Because of uncertainty regarding the effect of treatment on future transmission of HPV and the possibility of spontaneous resolution, an acceptable alternative for some persons is to forego treatment and wait for spontaneous resolution.Factors that influence selection of treatment include wart size, wart number, anatomic site of the wart, wart morphology, patient preference, cost of treatment, convenience, adverse effects, and provider experience. Factors that might affect response to therapy include the presence of immunosuppression and compliance with therapy, which can consist of either a single treatment or complete course of treatment. In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment. The treatment modality should be changed if a patient has not improved substantially after a complete course of treatment or if side effects are severe. Patients should be warned that persistent hypopigmentation or hyperpigmentation occurs commonly with ablative modalities and has also been described with immune modulating therapies (imiquimod). Depressed or hypertrophic scars are uncommon but can occur, especially if the patient has had insufficient time to heal between treatments. A limited number of case reports of severe systemic effects resulting from treatment with podophyllin resin and interferon have been documented.Treatment regimens are classified into patient-applied and provider-applied modalities. Patient-applied modalities are preferred by some patients because they can be administered in the privacy of the patient’s home.


To ensure that patient-applied modalities are effective, patients must comply with the treatment regimen and must be capable of identifying and reaching all genital warts.
Podofilox solution should be applied with a cotton swab, or podofilox gel with a finger, to visible genital warts twice a day for 3 days, followed by 4 days of no therapy.
The total wart area treated should not exceed 10 cm2, and the total volume of podofilox should be limited to 0.5 mL per day.
If possible, the health-care provider should apply the initial treatment to demonstrate the proper application technique and identify which warts should be treated. The safety of podofilox during pregnancy has not been established.Imiquimod is a topically active immune enhancer that stimulates production of interferon and other cytokines. Imiquimod cream should be applied once daily at bedtime, three times a week for up to 16 weeks (407). The treatment area should be washed with soap and water 6–10 hours after the application. No clinical data are available regarding the efficacy or safety of sinecatechins compared with other available anogenital wart treatment modalities.
The medication is not recommended for HIV-infected persons, immunocompromised persons, or persons with clinical genital herpes because the safety and efficacy of therapy in these settings has not been established. The safety of sinecatechins during pregnancy also is unknown.Cryotherapy destroys warts by thermal-induced cytolysis. Health-care providers must be trained on the proper use of this therapy because over- and undertreatment can result in complications or low efficacy. Pain after application of the liquid nitrogen, followed by necrosis and sometimes blistering, is common. The preparation should be thoroughly washed off 1–4 hours after application to reduce local irritation. Podophyllin resin preparations differ in the concentration of active components and contaminants.
The shelf life and stability of podophyllin preparations are unknown.Both TCA and BCA are caustic agents that destroy warts by chemical coagulation of proteins. TCA solutions have a low viscosity comparable with that of water and can spread rapidly if applied excessively; therefore, they can damage adjacent tissues. A small amount should be applied only to the warts and allowed to dry before the patient sits or stands, at which time a white frosting develops. This treatment can be repeated weekly, if necessary.Surgical therapy has the advantage of usually eliminating warts at a single visit.
However, such therapy requires substantial clinical training, additional equipment, and a longer office visit. After local anesthesia is applied, the visible genital warts can be physically destroyed by electrocautery, in which case no additional hemostasis is required.
Alternatively, the warts can be removed either by tangential excision with a pair of fine scissors or a scalpel, by laser, or by curettage. Because most warts are exophytic, this procedure can be accomplished with a resulting wound that only extends into the upper dermis.
Suturing is neither required nor indicated in most cases if surgical removal is performed properly.


Surgical therapy is most beneficial for patients who have a large number or area of genital warts. Both carbon dioxide laser and surgery might be useful in the management of extensive warts or intraurethral warts, particularly for those persons who have not responded to other treatments.Because all available treatments have shortcomings, some clinics employ combination therapy (simultaneous use of two or more modalities on the same wart at the same time). Alternative regimens include intralesional interferon, photodynamic therapy, and topical cidofovir.Recommended Regimen for Cervical WartsFor women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL must be performed before treatment is initiated. Management of exophytic cervical warts should include consultation with a specialist.Recommended Regimens for Vaginal WartsCryotherapy with liquid nitrogen. A small amount should be applied only to warts and allowed to dry, at which time a white frosting develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary.ORSurgical removalIntra-anal warts should be managed in consultation with a specialist. Many types of HPV are passed on through genital contact, most often during vaginal and anal sexual contact. However, HPV is common and often goes unrecognized; persons with only one lifetime sex partner can have the infection.
For this reason, the only definitive method to avoid giving and getting HPV infection and genital warts is to abstain from sexual activity.Tests for HPV are now available to help providers screen for cervical cancer in certain women.
These tests are not useful for screening adolescent females for cervical cancer, nor are they useful for screening for other HPV-related cancers or genital warts in men or women. Either vaccine is recommended for 11- and 12-year-old girls and for females aged 13–26 years who did not receive or complete the vaccine series when they were younger. Although removal of warts during pregnancy can be considered, resolution might be incomplete or poor until pregnancy is complete.
Whether cesarean section prevents respiratory papillomatosis in infants and children also is unclear (412); therefore, cesarean delivery should not be performed solely to prevent transmission of HPV infection to the newborn. Cesarean delivery is indicated for women with genital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding. No data suggest that treatment modalities for external genital warts should be different for HIV-infected persons. However, persons who are immunosuppressed because of HIV or other reasons might have larger or more numerous warts, might not respond as well as immunocompetent persons to therapy for genital warts, and might have more frequent recurrences after treatment (414-416).
Squamous cell carcinomas arising in or resembling genital warts might occur more frequently among immunosuppressed persons, therefore requiring biopsy for confirmation of diagnosis for suspicious cases.
Because of the increased incidence of anal cancer in HIV-infected MSM, screening for anal intraepithelial neoplasia by cytology can be considered (417). However, evidence is limited concerning the natural history of anal intraepithelial neoplasias, the reliability of screening methods, the safety and response to treatments, and the programmatic considerations that would support this screening approach.Squamous Cell Carcinoma in SituPersons in whom squamous cell carcinoma in situ of the genitalia is diagnosed should be referred to a specialist for treatment.



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