Genital Lumps Flashcards
What virus causes genital warts
which types are most common
HPV
types 6 or 11 = 90% of warts
Are warts transmitted by formites?
No good evidence of transmission from fomites
Treatment of genital warts
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)
Mode of transmission of genital warts
Most often - sexual contact
Also - perinatally and auto-inoculation from hands
Can oncocenic types of HPV cause genital warts?
Yes
but oncogenic HPV types most commonly cause anogenital dysplastic lesions and cancers
which HPV types are covered for by the quadrivalent vaccine
quadrivalent vaccine = HPV 6 / 11 / 16 / 18
incubation period for genital warts?
Variable
Generally 3 weeks to 8 months
Can be as long as 18 months
What is a Buschke- Lowenstein lesion?
A rapidly growing, locally infiltrating and locally eroding wart lesion
Diagnosis of genital warts
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
When does BASHH guidance recommend examination of the anal canal for warts
Patients who have peri-anal warts and anal symptoms such as irritation or discharge
In patients with genital warts when should there be suspicion of co-exisiting anogenital neoplasia
Presence of: Pigmentation Depigmentation Pruritus Underlying immune-deficiency Prior history of intraepithelial neoplasia
general advice for patients with genital warts
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
Which treatment option do soft non-keratinised warts respond well to?
podophyllotoxin, trichloroacetic acid (TCA)
Which treatment option do keratinised warts respond well to?
may be better treated with ablative methods: cryotherapy (LN) excision electrocautery (hyfrecation) TCA
Management of large genital warts
including Buschke-Lowenstein tumours
consider surgical treatment
what is the rate of spontaneous clearance of genital warts
spontaneous clearance of warts
30% by 6 months
65 - 78% at 2 years
What is Podophyllotoxin
Podophyllotoxin = Warticon and Condyline
A purified extract of podophyllin
0.5% solution or 0.15% cream
recommended treatment regimen for using warticon or condyline (Podophyllotoxin)
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
What is the difference in efficacy between Podophyllotoxin cream or solution (warticon or condyline)
Cream and solution have similar efficacy
Cream may be easier for patients to apply
SE of Podophyllotoxin
skin irritation, soreness, ulceration
Discontinue treatment if significant side effects
What is Podophyllin
non-standardised preparation for treating warts Not suitable for self-application Worse efficacy Higher incidence of local reactions Not recommended
What is Imiquimod?
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
Treatment regimen for imiquimod (aldara)
cream applied to lesions
3x per week
wash off 6-10 hours later
Use for up to 16 weeks
Advice re use of imiquimod in patients with immune deficiency
immune deficiency is not a contraindication
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.
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
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
What is 5-Fluorouracil?
a DNA anti-metabolite
available as a 5% cream.
Used to treat warts
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
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
What limits the use of interferons for treating genital warts?
use limited by:
expense
systemic side effects
variable response rate
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
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
Mechanism of action of cryotherapy for treatment of genital warts
causes cytolysis at the
dermal/epidermal junction resulting in necrosis
What is hyfrecation?
A type of electrosurgery
Causes electrofulguration
Resulting in superficial charring and limited dermal damage
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
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
What is Cervarix?
Cervarix® (Glaxo SmithKline)
Bivalent vaccine
Protection against HPV 16 and 18
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
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
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
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
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
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
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
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
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
Management of intra-anal warts
Treatment options include
cryotherapy, topical Imiquimod (unlicensed indication), electrosurgery, laser ablation and trichloroacetic acid.
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
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
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
Management of warts in children and adolescents
Follow the same principles as in adults
Same range of treatment options
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
what is Molluscum contagiosum
benign epidermal eruption of the skin
caused by a large DNA Virus = Molluscum contagiosum
Belongs to the Poxviridae family
How many subtypes of Molluscum contagiosum have been identified
Up to four subtypes of Molluscum contagiosum
commonest = (MCV)-1
then MCV-2 subtype
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
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
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
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
When may giant Mollusca be more likely to occur?
in the setting of immuno- compromise
Symptoms of molluscum
frequently asymptomatic
Occasionally itch / discomfort or secondary bacterial infection
Natural history of molluscum in immunocompetent patients
usually regress spontaneously within months
leaving no sequelae
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
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
Recommended management of molluscum
Expectant management (no treatment) recommended for immunocompetent patients
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
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
treatment options for molluscum in pregnancy or breastfeeding
Cryotherapy / other destructive methods are safe.
AVOID Podophyllotoxin or imiquimod
Follow up recommendation for molluscum
No routine follow up required
Contact tracing and treatment recommendation for molluscum
Routine PN is not required
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
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
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
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
Most hydroceles are idiopathic
but what pathology may they be secondary to
testicular tumours
epididymo-orchitis
trauma
lymphatic filariasis
what are epididymal cysts
= spermatoceles
painless, smooth, non-tender mass
separate from testis
fluid filled
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
