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Dip GUM > Genital Lumps > Flashcards

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
Q

SE of imiquimod

A

frequently causes local skin / mucous membrane
irritation when applied for anogenital warts.

Temporary halting of treatment may be required to manage side effects.

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26
Q

regimen for Trichloroacetic acid (TCA) treatment of warts

A 
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

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27
Q

SE of Trichloroacetic acid (TCA) treatment of warts

A

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

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28
Q

What is 5-Fluorouracil?

A

a DNA anti-metabolite
available as a 5% cream.
Used to treat warts

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29
Q

What limits the use of 5-Fluorouracil for warts?

A

Local adverse effects
including chronic neovascularisation
Vulval burning.

May be teratogenic
No longer recommended for routine treatment

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30
Q

How are interferons used for the treatment of genital warts?

A

Various regimens
nterferons alfa, beta, and gamma
as creams or intra-lesional injection or systemic injections

used only on expert advice

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31
Q

What limits the use of interferons for treating genital warts?

A

use limited by:
expense
systemic side effects
variable response rate

32
Q

When is excision of genital warts the recommended treatment option?

A

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
Q

Advice for how to use cryotherapy for treating genital warts

A

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
Q

Mechanism of action of cryotherapy for treatment of genital warts

A

causes cytolysis at the

dermal/epidermal junction resulting in necrosis

35
Q

What is hyfrecation?

A

A type of electrosurgery

Causes electrofulguration
Resulting in superficial charring and limited dermal damage

36
Q

What evidence exists regarding combination therapy for managing genital warts

A

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
Q

What is gardasil?

A

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
Q

What is Cervarix?

A

Cervarix® (Glaxo SmithKline)
Bivalent vaccine
Protection against HPV 16 and 18

39
Q

What is Gardasil9

A

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
Q

What evidence exists for Photodynamic therapy for treatment of genital warts?

A

Preliminary data only
Use of photodynamic therapy with topical 5-aminolevulinic acid (ALA)
Insufficient evidence to make a recommendation

41
Q

What evidence exists for Tellurium immunomodulator AS101 therapy for treatment of genital warts?

A

Tellurium immunomodulator AS101
novel agent
Assessed for safety and efficacy
Insufficient data to make a recommendation

42
Q

What evidence exists for Polyhexamethylene biguanide therapy for treatment of genital warts?

A

Polyhexamethylene biguanide
Single small randomised double-blind trial in 2005 Clearance rate of 52%
No further data

43
Q

Recommendation for partner notification for genital warts

A

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
Q

Advice for follow up of genital warts

A

Review is recommended at the end of a treatment course
Monitor response and SE
Assess the need for further therapy

45
Q

Management of intravaginal warts

A

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
Q

Management of cervical warts

A

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
Q

Management of urethral meatal warts

A

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
Q

Management of intra-anal warts

A

Treatment options include

cryotherapy, topical Imiquimod (unlicensed indication), electrosurgery, laser ablation and trichloroacetic acid.

49
Q

Management of warts in pregnancy

A

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
Q

Management of warts whilst breastfeeding

A

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
Q

What are the serious complications of vertical transmission of HPV to a neonate

A

Only serious, rare complication
= recurrent respiratory papillomatosis in the infant
Occurs in about 4:100,000 births

52
Q

Management of warts in children and adolescents

A

Follow the same principles as in adults

Same range of treatment options

53
Q

Management of warts in Immunosuppressed patients

A

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
Q

what is Molluscum contagiosum

A

benign epidermal eruption of the skin
caused by a large DNA Virus = Molluscum contagiosum
Belongs to the Poxviridae family

55
Q

How many subtypes of Molluscum contagiosum have been identified

A

Up to four subtypes of Molluscum contagiosum
commonest = (MCV)-1
then MCV-2 subtype

56
Q

What is the clinical difference between the subtypes of Molluscum contagiosum

A

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
Q

What are the 3 most common settings for Molluscum infection

A

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
Q

what is the most commonly affected area for childhood molluscum

A

face and neck, trunk, or limbs.

>90% of molluscum infections presenting to GPs are children <15 years

59
Q

Clinical features of Molluscum

A 
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
Q

When may giant Mollusca be more likely to occur?

A

in the setting of immuno- compromise

61
Q

Symptoms of molluscum

A

frequently asymptomatic

Occasionally itch / discomfort or secondary bacterial infection

62
Q

Natural history of molluscum in immunocompetent patients

A

usually regress spontaneously within months

leaving no sequelae

63
Q

natural history of molluscum in immunocompromised states

A 
more aggressive + widespread
Presenting with 100+ lesions
may coalesce
can be atypical in appearance 
often significantly larger than average
64
Q

General advice regarding management of molluscum

A

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
Q

Recommended management of molluscum

A 
Expectant management (no treatment) 
recommended for immunocompetent patients
66
Q

If a patient with molluscum opts for treatment then what should they be informed of

A

new lesions can appear for a while

may need more than one treatment course

67
Q

If a patient with molluscum opts for treatment then what options are available

A

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
Q

treatment options for molluscum in pregnancy or breastfeeding

A

Cryotherapy / other destructive methods are safe.

AVOID Podophyllotoxin or imiquimod

69
Q

Follow up recommendation for molluscum

A

No routine follow up required

70
Q

Contact tracing and treatment recommendation for molluscum

A

Routine PN is not required

71
Q

how does cryotherapy for treatment of warts work

A

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
Q

How does hyfrecation work for treatment of warts

A

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
Q

What preparation is required before hyfrecation

A

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
Q

what is a hydrocele

A 
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
Q

Most hydroceles are idiopathic

but what pathology may they be secondary to

A

testicular tumours
epididymo-orchitis
trauma
lymphatic filariasis

76
Q

what are epididymal cysts

A

= spermatoceles
painless, smooth, non-tender mass
separate from testis
fluid filled

77
Q

what is a varicoele

A

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

Dip GUM (27 decks)

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