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Genital Lumps Flashcards

1
Q

What virus causes genital warts

which types are most common

A

HPV

types 6 or 11 = 90% of warts

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2
Q

Are warts transmitted by formites?

A

No good evidence of transmission from fomites

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3
Q

Treatment of genital warts

A

Podophyllin - BD application 3 days, followed by 4 days rest, for 4-5 cycles
Imiquimod (Aldara) - apply 3x per week, wash off 6-10 hours later
Cryotherapy - liquid nitrogen
Hyfrecation / excision
(Catephen)
(TCA- specialist clinic only)
(5-Fluorouracil 5% cream - not routinely advised)
(Interferons- expert advice)

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4
Q

Mode of transmission of genital warts

A

Most often - sexual contact

Also - perinatally and auto-inoculation from hands

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5
Q

Can oncocenic types of HPV cause genital warts?

A

Yes

but oncogenic HPV types most commonly cause anogenital dysplastic lesions and cancers

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6
Q

which HPV types are covered for by the quadrivalent vaccine

A

quadrivalent vaccine = HPV 6 / 11 / 16 / 18

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7
Q

incubation period for genital warts?

A

Variable
Generally 3 weeks to 8 months
Can be as long as 18 months

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8
Q

What is a Buschke- Lowenstein lesion?

A

A rapidly growing, locally infiltrating and locally eroding wart lesion

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9
Q

Diagnosis of genital warts

A

Clinical diagnosis
May require examination under magnification (e.g. with a colposcope)
Rarely - biopsy to confirm atypical lesions.
Advisable to biopsy cases not responding to treatment

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10
Q

When does BASHH guidance recommend examination of the anal canal for warts

A

Patients who have peri-anal warts and anal symptoms such as irritation or discharge

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11
Q

In patients with genital warts when should there be suspicion of co-exisiting anogenital neoplasia

A 
Presence of: 
Pigmentation
Depigmentation
Pruritus
Underlying immune-deficiency
Prior history of intraepithelial neoplasia
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12
Q

general advice for patients with genital warts

A

Consistent condom use has been shown to reduce the risk of acquisition of HPV infection and genital warts (30- 60% reduction)
Latex condoms weakened by Imiquimod.
Smokers may respond less well to treatment

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13
Q

Which treatment option do soft non-keratinised warts respond well to?

A 
podophyllotoxin,
trichloroacetic acid (TCA)
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14
Q

Which treatment option do keratinised warts respond well to?

A 
may be better treated with ablative methods:
cryotherapy  (LN)
excision
electrocautery (hyfrecation) 
TCA
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15
Q

Management of large genital warts

including Buschke-Lowenstein tumours

A

consider surgical treatment

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16
Q

what is the rate of spontaneous clearance of genital warts

A

spontaneous clearance of warts
30% by 6 months
65 - 78% at 2 years

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17
Q

What is Podophyllotoxin

A

Podophyllotoxin = Warticon and Condyline
A purified extract of podophyllin
0.5% solution or 0.15% cream

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18
Q

recommended treatment regimen for using warticon or condyline (Podophyllotoxin)

A

Warticon and Condyline are licensed for use up to 4 and 5 weeks respectively
Home treatment
Supervision by medical staff recommended when lesion area > 4 cm2.
Licensed for warts affecting the penis and female external genitalia - commonly used for all anogenital lesions
BD application for 3 days, 4 days’ rest, repeat 4 – 5 cycles.

Repeat cycles, not licensed, may be considered if warts are responding

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19
Q

What is the difference in efficacy between Podophyllotoxin cream or solution (warticon or condyline)

A

Cream and solution have similar efficacy

Cream may be easier for patients to apply

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20
Q

SE of Podophyllotoxin

A

skin irritation, soreness, ulceration

Discontinue treatment if significant side effects

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21
Q

What is Podophyllin

A 
non-standardised preparation for treating warts
Not suitable for self-application 
Worse efficacy 
Higher incidence of local reactions 
Not recommended
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22
Q

What is Imiquimod?

A

immune response modifier.

Acts as a toll-like receptor-7 (TLR7) agonist
Results in stimulation of local tissue macrophages to release interferon-alpha and other cytokines
Local cell-mediated response

Available as a 5% cream = Aldara

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23
Q

Treatment regimen for imiquimod (aldara)

A

cream applied to lesions
3x per week
wash off 6-10 hours later

Use for up to 16 weeks

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24
Q

Advice re use of imiquimod in patients with immune deficiency

A

immune deficiency is not a contraindication

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25
SE of imiquimod
frequently causes local skin / mucous membrane irritation when applied for anogenital warts. Temporary halting of treatment may be required to manage side effects.
26
regimen for Trichloroacetic acid (TCA) treatment of warts
``` Trichloroacetic acid (TCA) 80-90% solution Suitable for weekly application in a specialist clinic setting only. ``` Caustic agent resulting in cellular necrosis extremely corrosive. Careful application is essential. • P
27
SE of Trichloroacetic acid (TCA) treatment of warts
Intense burning sensation experienced for 5-10 minutes after application. Ulceration penetrating into the dermis can occur protect the surrounding skin with petroleum jelly have a topical neutralising agent, e.g. 5% sodium bicarbonate solution, available in case of excess application or spills
28
What is 5-Fluorouracil?
a DNA anti-metabolite available as a 5% cream. Used to treat warts
29
What limits the use of 5-Fluorouracil for warts?
Local adverse effects including chronic neovascularisation Vulval burning. May be teratogenic No longer recommended for routine treatment
30
How are interferons used for the treatment of genital warts?
Various regimens nterferons alfa, beta, and gamma as creams or intra-lesional injection or systemic injections used only on expert advice
31
What limits the use of interferons for treating genital warts?
use limited by: expense systemic side effects variable response rate
32
When is excision of genital warts the recommended treatment option?
pedunculated warts large warts For small numbers of keratinised lesions at anatomically accessible sites. under local anaesthetic injection BASHH states is a treatment option that may be underused
33
Advice for how to use cryotherapy for treating genital warts
Using a liquid nitrogen spray or a cryoprobe Applied until a "halo" of freezing established a few millimetres around the lesion Either a single freeze or a double freeze- thaw technique. Duration of freezing (typically 15-30 seconds) May respond to a single treatment. Usually repeated at weekly intervals Lack of response after 4 weeks should prompt consideration of an alternative treatment
34
Mechanism of action of cryotherapy for treatment of genital warts
causes cytolysis at the | dermal/epidermal junction resulting in necrosis
35
What is hyfrecation?
A type of electrosurgery Causes electrofulguration Resulting in superficial charring and limited dermal damage
36
What evidence exists regarding combination therapy for managing genital warts
Applications of podophyllotoxin and cryotherapy have been used RCT double blind placebo study showed clearance rates were higher in the combination arm (60% vs 45%) at 12 weeks But no difference in clearance rates at 24 weeks f No evidence on combining treatments in other ways
37
What is gardasil?
Gardasil (Sanofi Pasteur MSD) A quadrivalent vaccine Protection against HPV 6, 11, 16 and 18 Used in the UK national HPV vaccine programme since 2012
38
What is Cervarix?
Cervarix® (Glaxo SmithKline) Bivalent vaccine Protection against HPV 16 and 18
39
What is Gardasil9
Gardasil9® (Sanofi Pasteur MSD) Licensed in Europe in 2015 a Protection against HPV 6, 11, 16 and 18 AND five additional high-risk types - 31, 33, 45, 52, 58
40
What evidence exists for Photodynamic therapy for treatment of genital warts?
Preliminary data only Use of photodynamic therapy with topical 5-aminolevulinic acid (ALA) Insufficient evidence to make a recommendation
41
What evidence exists for Tellurium immunomodulator AS101 therapy for treatment of genital warts?
Tellurium immunomodulator AS101 novel agent Assessed for safety and efficacy Insufficient data to make a recommendation
42
What evidence exists for Polyhexamethylene biguanide therapy for treatment of genital warts?
Polyhexamethylene biguanide Single small randomised double-blind trial in 2005 Clearance rate of 52% No further data
43
Recommendation for partner notification for genital warts
Notification of previous sexual partner(s) is not recommended Current sexual partner(s) may benefit from assessment - may have undetected warts + offer STIs screen + offer explanation/ advice about HPV infection
44
Advice for follow up of genital warts
Review is recommended at the end of a treatment course Monitor response and SE Assess the need for further therapy
45
Management of intravaginal warts
Consider: Cryotherapy, electrosurgery and trichloroacetic acid Or consider no treatment - particularly if asymptomatic podophyllotoxin- not licensed for internal use - has been used, applied carefully
46
Management of cervical warts
Consider no treatment - particularly if asymptomatic or cryotherapy, electrosurgery, trichloroacetic acid, laser ablation or excision. NHS Cervical Screening Programme guidelines do NOT recommend routine colposcopy in women with cervical warts Colposcopy is indicated if there is diagnostic uncertainty
47
Management of urethral meatal warts
If the base of the lesions is seen: cryotherapy, electrosurgery, laser ablation, podophyllotoxin or Imiquimod. Lesions deeper in the urethra - surgical ablation under direct vision - may require referral to urologist or use of a meatoscope
48
Management of intra-anal warts
Treatment options include | cryotherapy, topical Imiquimod (unlicensed indication), electrosurgery, laser ablation and trichloroacetic acid.
49
Management of warts in pregnancy
AVOID - podophyllotoxin - possible teratogen - 5-fluorouracil - possible teratogen Imiquimod is not approved for pregnancy - no data Consider no treatment Aim to minimise the number of lesions present at delivery to reduce the neonatal exposure to virus Caesarean section not indicated to prevent vertical transmission of HPV CS rarely indicated due to - obstruction of the vaginal outlet with warts, or large cervical warts SAFE = Cryotherapy, excision and ablative methods
50
Management of warts whilst breastfeeding
Imiquimod: no quantifiable levels (>5 ng/ml) of Imiquimod are detected in the serum after single and multiple topical doses - no specific advice on the SPC Podophyllotoxin - insufficient information on the excretion of topically applied podophyllotoxin in human milk. A risk cannot be excluded - not recommended Cryotherapy, excision and ablative methods are safer
51
What are the serious complications of vertical transmission of HPV to a neonate
Only serious, rare complication = recurrent respiratory papillomatosis in the infant Occurs in about 4:100,000 births
52
Management of warts in children and adolescents
Follow the same principles as in adults | Same range of treatment options
53
Management of warts in Immunosuppressed patients
People with impaired cell mediated immunity E.g. organ transplant recipients / HIV infection Have a lower response and increased relapse rates following treatment. Longer treatment courses may be required and patients followed-up
54
what is Molluscum contagiosum
benign epidermal eruption of the skin caused by a large DNA Virus = Molluscum contagiosum Belongs to the Poxviridae family
55
How many subtypes of Molluscum contagiosum have been identified
Up to four subtypes of Molluscum contagiosum commonest = (MCV)-1 then MCV-2 subtype
56
What is the clinical difference between the subtypes of Molluscum contagiosum
No clinical difference between subtypes No difference in preferred anatomical sites MCV-2 appears relatively common in immunocompromise and HIV Infection is usually only 1 subtype
57
What are the 3 most common settings for Molluscum infection
1) Infection from routine physical contact ( occasionally fomites) = commonest presentation - children are the majority 2) Molluscum as a STI - often young adults - very small proportion of reported infections 3) Severe molluscum infection can manifest in immunocompromise
58
what is the most commonly affected area for childhood molluscum
face and neck, trunk, or limbs. | >90% of molluscum infections presenting to GPs are children <15 years
59
Clinical features of Molluscum
``` dome-shaped papules smooth-surfaced firm central umbilication colour varies - pearly white / pink / yellow 2–5 mm diameter clusters of 1 - 30 lesions can become koebnerised ```
60
When may giant Mollusca be more likely to occur?
in the setting of immuno- compromise
61
Symptoms of molluscum
frequently asymptomatic | Occasionally itch / discomfort or secondary bacterial infection
62
Natural history of molluscum in immunocompetent patients
usually regress spontaneously within months | leaving no sequelae
63
natural history of molluscum in immunocompromised states
``` more aggressive + widespread Presenting with 100+ lesions may coalesce can be atypical in appearance often significantly larger than average ```
64
General advice regarding management of molluscum
Warn of risk of autoinoculation Advise against shaving / waxing to prevent further spread Advise against squeezing molluscum - risk of super- infection and spread to uninfected skin Avoid sharing towels / bed linen / clothes etc. when active lesions present Condoms may reduce transmission of genital molluscum
65
Recommended management of molluscum
``` Expectant management (no treatment) recommended for immunocompetent patients ```
66
If a patient with molluscum opts for treatment then what should they be informed of
new lesions can appear for a while | may need more than one treatment course
67
If a patient with molluscum opts for treatment then what options are available
Podophyllotoxin 0.5% BD for 3 consecutive days, pause for 4 days then repeat Imiquimod 5% cream, apply 3x per week, wash off after 6-10 hours - some limited efficacy Liquid nitrogen therapy
68
treatment options for molluscum in pregnancy or breastfeeding
Cryotherapy / other destructive methods are safe. | AVOID Podophyllotoxin or imiquimod
69
Follow up recommendation for molluscum
No routine follow up required
70
Contact tracing and treatment recommendation for molluscum
Routine PN is not required
71
how does cryotherapy for treatment of warts work
either by simple necrotic destruction of HPV- infected keratinocytes or possibly by inducing local inflammation conducive to the development of an effective cell-mediated response
72
How does hyfrecation work for treatment of warts
Hyfrecation uses low powered electrical impulses delivered to the wart on the surface of the skin causing electrodessication /electrofulguration which removes the localised wart
73
What preparation is required before hyfrecation
Patients need to apply EMLA cream (lidocaine 2.5%/ prilocaine 2.5%) with an occlusive dressing 15 minutes before treatment for men up to 60 minutes for women
74
what is a hydrocele
``` Abnormal collection of fluid between parietal and visceral layers of tunica vaginalis causes painless scrotal swelling non tender mass - unable to get above it transilluminates ```
75
Most hydroceles are idiopathic | but what pathology may they be secondary to
testicular tumours epididymo-orchitis trauma lymphatic filariasis
76
what are epididymal cysts
= spermatoceles painless, smooth, non-tender mass separate from testis fluid filled
77
what is a varicoele
dilated group of veins of pampiniform plexus surrounds testis extends to spermatic cord palpable in scrotum like a 'bag of worms' more apparent when standing or on valsalva

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