Genital warts: causes, symptoms, diagnosis, treatment

More than 20 types of human papillomavirus (HPV) can infect the genital tract. Most HPV infections are asymptomatic, occur in subclinical form, or remain unrecognized. Visible genital warts are usually caused by HPV types 6 or 11. Other types of HPV that can be detected from the anogenital area (for example, types 16, 18, 31, 33 and 35) are strongly associated with cervical dysplasia. The diagnosis of genital warts can be confirmed by biopsy, although biopsy is rarely necessary (for example, with complications of diagnosis, inefficiency of standard therapy, worsening clinical picture during treatment, reduced immunity, pigmented / compacted / ulcerated warts). There is no evidence to support the use of type-specific DNA tests for HPV in routine diagnosis or management of patients with visible genital warts.

HPV types b and 11 can also cause warts in the vagina, the cervix, inside the urethra and inside the anus. Intraanal warts are found predominantly in patients who practice receptive anal intercourse and differ from warts in the perianal area that may occur in men and women who do not practice anal sex. In addition to lesions of the genital area, these types of HPV can cause warts conjunctiva, nasopharynx and oral cavity. HPV types 6 and 11 are rarely associated with invasive squamous cell carcinoma of the vulva. Depending on the size and anatomical location, genital warts can be painful, easily traumatized and / or itchy.

HPV types 16,18, 31, 33, 35 are rarely found in visible genital warts and are associated with squamous intraepithelial neoplasia (squamous cell carcinoma in-situ, papular bovenoid, erythroplasia Keira, Bowie's disease). These types of HPV are associated with vaginal anal and cervical intraepithelial dysplasia and squamous cell carcinoma. Patients with visible genital warts can be simultaneously infected with a variety of types of HPV.

Treatment of genital warts

The primary goal of treating visible genital warts is to remove the warts that cause symptoms. As a result of treatment, a "non-population" period may occur. Genital warts often do not cause symptoms. None of the currently available treatments have an effect on the natural course of HPV infection and does not destroy this infection. Removal of warts can and reduce, and not reduce their infectiousness. If left untreated, visually-determined genital warts can resolve themselves, remain unchanged or increase in size. There is no reason to believe that the treatment of visually-defined warts can affect the development of cervical cancer.

Schemes of treatment of genital warts

When choosing a method for the treatment of genital warts, one should proceed from the patient's preferences, available means and the experience of the health worker. None of the currently available drugs has a higher efficacy than the others, or is the ideal drug for all patients.

The treatment methods currently available for visually detectable genital warts are local treatment agents that are used by the patient: podophylox and imiquadam, and therapist-mediated therapy: cryotherapy, podophyllinic resin, trichloroacetic acid, bichloroacetic acid, interferon and surgical method. Most patients have from one to ten genital warts, a total area of 0.5 to 1.0 cm2, which are amenable to most methods of exposure. Factors that may influence the choice of treatment include the size of the warts, their number, location, morphology, patient preference, cost, ease of use, side effects and experience of the health care provider. It is important to have a treatment plan or protocol, because Many patients require a course of therapy, rather than a single treatment. In general, warts located on wet surfaces and / or skin folds respond better to local treatments with drugs such as trichloroacetoacetic acid (TCA), podophyllin, podophylox, and imiquamod than warts on dry skin surfaces.

If, when using the methods of treatment conducted by a doctor, there is no significant improvement after three courses of treatment, or full resolution of warts after six courses of treatment, then the therapeutic mode of treatment should be changed. The risk / benefit ratio of the course of treatment should be comprehensively assessed in order to avoid excessive healing of the patient. The doctor should always weigh and, if necessary, change the methods of local treatment used by the patient and the methods performed by the doctor.

With proper treatment, complications are rare. Patients should be warned that after applying the excising methods of removing warts, hypo- and hyperpigmented scars are often formed. Sown or hypertrophic scars are rare, but can occur if the patient does not have a sufficient time between treatment courses. Treatment in rare cases leads to disruptive ability of the patient to chronic pain syndromes, such as vulvodynia or hypersthesia at the site of treatment.

External genital warts, recommended treatment

Treatment conducted by the patient independently

Podofilox, 0.5% solution or gel. Patients can apply the Podophilox solution with a cotton swab, or podophylox gel with a finger, 2 times a day for 3 days; then follows a break for 4 days. This cycle can be repeated, if necessary; up to 4 cycles. The total area of the treated warts should not exceed 10 cm ², and the total volume of Podophilus should not exceed 0.5 ml per day. If possible, the health worker should himself conduct the first treatment to show how to apply the medication correctly and what warts to process. The safety of the use of podophyllose during pregnancy is not proven.

Or Imiquamod 5% cream. Patients should apply imiquamod-cream with a finger, at night, three times a week, up to 16 weeks. It is recommended that after 6-10 hours after application, rinse the area of the cream with mild soap and water. With this method of treatment, many patients warts disappear after 8-10 weeks or earlier. The safety of the use of podophylox during pregnancy is not established.

Treatment by a doctor

Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1-2 weeks.

Podofillinovaya resin, 10-25% in the tincture of benzoin. A small amount should be applied to each wart and wait until it dries under the influence of air. In order to avoid problems associated with systemic absorption and toxicity, some experts recommend limiting the amount of the drug (<0.5 ml of pofillin) or the area of the wart (10 cm ² ) per application. Some experts suggest that it is necessary to wash the drug 1-4 hours after the application to avoid tissue irritation. If necessary, repeat the procedure weekly. The safety of the use of podophylox during pregnancy is not established.

Or Trichloroacetic acid (TCAA), or dichloroacetic acid (DHAQ) of 80-90%. It is applied in small amounts only to warts and aged until dry, until a white "hoarfrost" appears. Powder with talc or sodium bicarbonate (baking soda) is used to remove unreacted acid. If necessary, repeat the procedure weekly.

Or Surgical removal - tangential excision with scissors, tangential razor excision, curettage or electrosurgery.

External genital warts, alternative treatment regimens

Interferon administration inside lesions

Or Laser Surgery

The patient can carry out treatment independently, if the location of the warts allows for their treatment. Podophylox in the form of a 0.5% solution or gel is relatively inexpensive, easy to use, safe and can be used alone by patients at home. Podofilox is an antimitotic drug that causes destruction of warts. Most patients reported mild to moderate pain or local irritation after treatment. Imiquimod is a locally acting immunostimulant that promotes the production of interferon and other cytokines. Before the disappearance of the wart, there are usually local inflammatory reactions, most often mild or moderate.

Cryotherapy destroys warts due to cytolysis occurring under the influence of temperature and requires the use of special equipment. Its main disadvantage is that proper use requires considerable preparation, without which warts often fail to completely cure, and as a result, the effectiveness of the method may be low, or the chance of complications increases. Soreness in the application of liquid nitrogen occurs due to necrosis, and, quite often, bubbles are formed at the site of exposure. Although local anesthesia (when using local drugs or injections) is not routinely used, its use facilitates treatment with a large number of warts or with a large area of freezing.

The podophyllene resin contains many components, including ligand-podophyllin, which is an antimitotic agent. The resin is most often prepared in 10-25% tincture of benzoin. However, this drug varies widely in concentration and in the content of active and inactive components. The time interval at which podofillin preparations retain their active properties is unknown. It is important to apply a thin layer of podophylline resin on the warts and let it dry in the air until the place of contact with the clothing comes into contact. Abundant applications or insufficient air drying can lead to local irritation, due to the spread of the drug to the unaffected skin.

TCAH and BHUK are caustic substances that destroy warts, thanks to the chemical coagulation of proteins. They are widely used, but not enough studied. Solutions TCAK have a very low viscosity (in comparison with water) and with too much applique can quickly spread, damaging a significant area of normal adjacent tissues. Applying drugs TCAH and BHUK should be very careful and you need to let them dry before the patient sits down or stands up. In the event of intense painful sensations, the acid can be neutralized with soap or soda.

Surgical removal of warts has advantages over other methods of exposure in that rapid removal of warts occurs, usually in one visit. However, this requires significant clinical practice, some equipment, and a longer processing time. After achieving the effect of local anesthesia, visually detectable genital warts can be physically destroyed by electrosurgery, in which case no additional hemostasis is usually required. Alternatively, warts can be removed by tangential excision with sharp scissors or a scalpel, or removed by curettage. Since most warts are exophytic, the use of this method can be complicated by the formation of a wound within the epidermis. Hemostasis can be achieved by electrocoagulation or chemical hemostatic agents, such as a solution of aluminum chloride. Stitching is not required and is not shown in most cases if surgical removal is performed correctly. Surgical method is most applicable in the treatment of patients with a large number or with a large area of genital warts. CO laser and surgical method can be used in managing patients with multiple or intraurethral warts, especially if other methods of treatment have proved ineffective.

Interferon, either natural or recombinant, has been used to treat genital warts systemically (subcutaneously, to a remote site or intramuscularly) or to the affected area (injections into warts). Systemic use of interferon was not effective. Interferon, introduced into the lesion area, showed comparatively the same efficacy and level of relapses with other methods. It is believed that interferon should be effective because it has an antiviral and / or immunostimulating effect. However, interferon treatment is not recommended for routine use because of the inconvenience of its appointment, the need for frequent visits and its ability to often cause systemic side effects, with relatively equal effectiveness with other methods.

Due to the lack of available effective therapies, some clinics use a combination treatment (two or more simultaneous methods of influencing the same wart). Most experts believe that combined methods do not increase efficacy, but may increase the number of complications.

Cervical warts

In women with exophytic cervical warts, a highly differentiated squamous intraepithelial lesion (PIP) must be excluded before treatment begins. Treatment should be conducted under the expert's supervision.

Vaginal Warts

Cryotherapy with liquid nitrogen. Due to the risk of perforation and fistula formation, the use of a cryoprobe in the vagina is not recommended.

Or TCAK or BHUK, 80-90% are applied only to warts. Apply the drug should be in small quantities and only on warts, to withstand until drying, until a white "hoarfrost" appears. Powder with talc or sodium bicarbonate (baking soda) is used to remove unreacted acid. If necessary, repeat the procedure weekly.

Or Podofillin, 10-25% in benzoyin tincture is applied to the affected area, which must be dry before removing the vaginal mirror. During one procedure, treat <2 cm ². If necessary, the procedure is repeated at intervals of 1 week. In connection with the possibility of systemic absorption, some experts warn against using podophyllin in the vagina. The safety of the use of podophyllin during pregnancy is not proven.

Warts in the opening of the urethra

Cryotherapy with liquid nitrogen.

Or

Podofillin, 10-25% in the tincture of benzoin. The area of application should be dried before contact with normal mucosa. If necessary, the procedure should be carried out weekly. The safety of the use of podophyllin during pregnancy is not proven.

Anal Warts

Cryotherapy with liquid nitrogen.

Or THUK or BHUK, 80-90% is put on warts. The drug is applied in small amounts only to warts and aged until dry, until a white "hoarfrost" appears. Powder with talc or sodium bicarbonate (baking soda) is used to remove unreacted acid. If necessary, repeat the procedure weekly.

Or Surgical removal.

NOTE. Treatment of warts on the rectal mucosa should be conducted under the supervision of an expert.

Warts of the mouth

Cryotherapy with liquid nitrogen

Or Surgical removal.

Follow-up

If visually-determined warts respond well to treatment, follow-up is not required. Patients should be warned about the need to monitor the possible occurrence of relapses, which often occurs within the first three months. Since it is not known how sensitive and specific the self-diagnosis of genital warts is, patients should be offered to follow up for follow-up at three months after treatment in order to control the possible recurrence of the disease. An earlier re-visit will help control the disappearance of warts and the occurrence of possible complications of therapy, as well as provide an opportunity for training and counseling the patient. Women should be advised to undergo regular cytological screening. The presence of genital warts is not an indication for colposcopy.

Management of sexual partners

In the management of patients with genital warts, testing of sexual partners is not necessary, since the role of reinfection appears to be minimal, and in the absence of curative therapies, treatment aimed at reducing the risk of transmission of infection does not make sense. However, since the diagnostic value of self-diagnosis and examination by partners of each other is not accurately determined, partners of patients with genital warts can be examined to assess whether they have genital warts and other STDs. Because treatment of genital warts probably does not destroy HPV, patients and their partners should be warned that they can infect uninfected sexual partners. The use of condoms may reduce, but not exclude, the likelihood of transmission of HPV to an uninfected partner. Women who are partners of patients with genital warts should be reminded that cytological screening for cervical cancer is recommended for all sexually active women.

Special Remarks

Pregnancy

Imiquimod, podophyllin and podophylox should not be used during pregnancy. Because during pregnancy genital papillomatous lesions tend to proliferate and become loose, many experts advise them during pregnancy to remove them. HPV Types 6 and 11 can cause laryngeal papillomatosis in newborns and children. The path of transmission of infection (transplacental, with the passage of the birth canal or postnatal) is not entirely clear. The prophylactic value of cesarean delivery is unknown; Thus, cesarean section should not be performed only to prevent the transmission of HPV infection to a newborn. In rare cases, a caesarean section can be shown to women with genital warts if they prevent the passage of the fetus through the birth canal, or if they are localized in the vagina, natural births can lead to massive bleeding.

Patients with reduced immunity

Treatment of genital warts in individuals who are immunocompromised due to HIV infection or other causes may be less effective, as well as in patients with normal immune response. There may be more frequent relapses after treatment. The incidence of squamous cell carcinoma or similar genital warts may be higher in this population, and such patients often require a biopsy to confirm the diagnosis.

Squamous cell carcinoma in situ

In establishing the diagnosis of squamous cell carcinoma in situ, the patient should be referred to a specialist in the field. In general, excising methods of action are effective, but after their use careful monitoring is necessary. The risk that these lesions will lead to the development of squamous cell carcinoma in situ exists, but it is probably not high. Female partners of such patients are at very high risk of developing cervical pathologies.

Subclinical genital HPV infection (without exophytic warts)

Subclinical HPV infection is much more widespread than exophytic warts, both in men and in women. Infection is often found in the cervix when taking Pap smears, colposcopy or biopsy, as well as on the penis, vulva and other areas of the genital skin after the appearance of white spots after applying acetic acid. However, routine use of acetic acid and examination with magnifying lenses under illumination as screening tests for the detection of "subclinical" or "acetic white" genital warts is currently not recommended. The appearance of white spots after treatment with acetic acid is not a specific test for HPV infection. Thus, in populations with low risk, many false positive results can be identified if this test is used as a screening test. The specificity and sensitivity of this procedure remain undefined. In special situations, experienced clinicians consider this test useful for identifying flat genital warts.

The exact diagnosis of HPV infection is based on the definition of viral nucleic acid (DNA) or capsid proteins. The diagnosis of HPV infection using Pap smears does not usually correlate with the definition of HPV DNA in cervical cells. Cell changes in the cervix associated with HPV infection are similar to cellular changes with mild dysplasia and often spontaneously regress. There are tests to determine the DNA of some types of HPV in cervical cells obtained by scraping, but their clinical significance for the management of patients is unknown. The decision to treat patients should not be made on the basis of HPV DNA test tests. Screening of subclinical genital HPV infection using DNA or RNA tests or acetic acid is not recommended.

Treatment

In the absence of concomitant dysplasia, the treatment of subclinical HPV infection diagnosed with Pap smears, colposcopy, biopsy, skin treatment or mucosal acetic acid, and when detecting HPV (DNA or RNA) is not recommended, since the diagnosis is often questionable and treatment does not eliminate the infection. HPV is found in men and women in adjacent tissues after laser therapy for HPV-associated dysplasia and after attempts to eliminate subclinical HPV infection by extensive laser vaporization of the anogenital area. In the presence of concomitant dysplasia, the approach to treatment should be based on the degree of dysplasia.

Management of sexual partners

Examination of sexual partners is optional. Most partners, as a rule, already have subclinical HPV infection. There are no tests for practical screening of subclinical HPV infection. The use of condoms can reduce the likelihood of infection of an uninfected or new partner; however, the period of infectiousness is unknown. Are patients with subclinical HPV infection as contagious as patients with exophytic warts, is unknown.

[1],