Genital warts

Question 1

what causes genital warts

Answer 1

HPV (human papilloma virus) low grade strains mainly HPV 6 and 11

Question 2

How do people ‘catch’ genital warts

Answer 2

HPV is a sexually transmitted virus by close skin to skin contact, there is some evidence that it can be transmitted from genital warts on the hand to the genitals in children, or perinatally

Question 3

What are genital warts?

Answer 3

Genital warts are benign epithelial skin tumours they can be single or multiple

Question 4

what strains of HPV does the bivalent vaccine provide protection against?

Answer 4

HPV 16 and 18

Question 5

what strains of HPV does the quadrivalent vaccine provide protection against?

Answer 5

HPV 6, 11, 16 and 18 therefore hopefully we will start to see a reduction in GW since it’s introduction in the vaccine programme in 2012.

Question 6

On average how many cases of GWs are treated in GUM clinics in the UK per year

Answer 6

> 130,000 cases per year are treated in UK GUM clinics

Question 7

What are the symptoms patients may present with in association with GWs?

Answer 7

New lumps - these can be single or multiple - soft or keratinised (usually soft on non-hair bearing areas and hard/keratinsed on hair bearing dry skin)
can be asymptomatic just incidentally found
lumps can be associated with itching, discomfort, bleeding

Question 8

A patient has peri-anal genital warts, this means she must have had anal sex
True or false

Answer 8

false - patients can have peri-anal GWs despite never having penetrative anal sex
however warts inside the anal canal are usually associated with penetrative sex

Question 9

a female patient presents with symptoms of genital warts, as part of the examination what procedures and investigations should you perform?

Answer 9

examine the external genitalia including peri-anal region
if GW are present then perform a speculum to ensure there are no internal warts/ warts on the cervix - if none present then this examination does not need to be repeated at follow up appointments
offer STI screen - CT/GC/HIV and STS

Question 10

An MSM presents with symptoms of peri-anal warts, when would you consider performing a protoscope?

Answer 10

Proctoscope should be performed if the bases/margins of the warts are not visible at the anal margin or if the patient has rectal symptoms (change in bowel habit, rectal discharge or bleeding)

Question 11

List extra-genital sites that can genital HPV infection may be seen

Answer 11

oral cavity,
larynx
nasal cavity
conjunctiva

Question 12

what is the incubation period for genital warts

Answer 12

3 weeks - 8 months but can extend to up to 18 months

N.B some ‘new’ presentations will actually represent recurrences

Question 13

Rarely warts may grow rapidly and cause local tissue infiltration or erosion. What is the name of the lesion that can occur as a result of this process

Answer 13

Buschke-Lowenstein lesion

Question 14

how are genital warts diagnosed? when might you consider a biopsy for histological confirmation of the diagnosis?

Answer 14

Genital warts are a clinical diagnosis. Rarely if genital warts are failing to respond to treatment, or there are associated symptoms such as pigmentation or bleeding, or the lesions appear atypical/ concerning features of intra-epithelial neoplasia then biopsy may be considered

Question 15

for intra-mental warts where the base can not be visualised what investigation needs to be performed?

Answer 15

Meatoscopy or occasionally urethroscopy for more proximal lesions –> this may require referral to urology

Question 16

what general advice should you give patients with genital warts

Answer 16

correct condom use can prevent the spread of genital warts
stop smoking - as smokers may respond less well to treatment
latex condoms may be weakened if in contact with imiquimod (aldara)

Question 17

All treatments have significant failure rates and relapse rates
True or false?

Answer 17

True

Question 18

What treatments options do soft non-keratinised warts respond to?

Answer 18

soft non keratinised warts can respond better to podophyllotoxin or TCA

Question 19

what treatment options do keratinised warts respond best?

Answer 19

respond better to ‘physical ablative’ therapy e.g. cryotherapy, surgical excision, TCA or electrocautery

Question 20

What type of warts is Imiquimod a good treatment option for

Answer 20

Imiquimod can be used for both keratinised and non-keratinised warts
typically used earlier for keratinised warts and then treatment progresses to imiqimod in non-keratinised warts after no response to podophyllotoxin.

Question 21

What percentage of warts will resolve spontaneously without treatment and in what timeframe

Answer 21

30% of patients will experience spontaneous resolution of warts over a period of up to 6 months

Question 22

list the topical treatment options available for warts and how they should be applied

Answer 22

1. podophyllotoxin (warticon) - applied twice a day for 3 consecutive days, then 4 days off, repeat cycles for 4-5 weeks, Rx can be extended longer but this is off licence
2. Imiquimod (Aldara) - apply 3 times a week (on alternate nights) leave on over night and wash off in the morning. Ensure you wash off prior to using condoms as can destroy the latex. Use up to 16 weeks (can be extended longer but off licence)
3. TCA (Trichloroacetic acid) - not suitable for home therapy; applied by a clinician. It is a solution 80-90% strength. ensure you protect surrounding skin with petroleum jelly. An intense burning can be experienced for 5-10 minutes after application
4. Catephen - an extract from green tea leaf plant camellia sinensis, applied TDS for up to 16 weeks
5. 5-FU (5 Fluorouracil) - îs a DNA metabolite available as a 5% cream. It’s use is limited by adverse effects - can cause chronic neovascularisation and vulval burning. It is no longer recommended in routine management of genital warts
6. Interferons - interferon alpha, beta and gamma are not recommended for routine management due to expense and systemic side effects but could be considered based on expert advice

Question 23

List the physical ablative therapies available for treatment of genital warts

Answer 23

1. Surgical excision
2. Crytotherapy with LN2 - repeated at weekly intervals; lack of response at 4 weeks should consider Rx options with other modalities
3. Laser treatment - uses a carbon dioxide laser
4. electrosurgery - electrocautery results burning of the treatment site and surrounding tissue,

Question 24

what strains of HPV does the gardasil vaccine protect against?

Answer 24

Gardasil is a quadrivalent vaccine; it protects against HPV 6,11, 16 and 18

Question 25

what type of vaccine is Cervarix and which strains of HPV does it protect against

Answer 25

Cervarix is a bivalent vaccine and protects against HPV 16 and 18

Question 26

what strains of HPV does Gardasil9 protect against

Answer 26

Gardasil9 was licensed in Europe in 2015 and contains the same 4 antigens (HPV 6, 11, 16 & 18) as Gardasil plus five additional high risk types (31, 33,45,52,58).. hence the ‘9’

Question 27

When is a change in therapy recommended in the treatment pathway of genital warts?

Answer 27

If the patient is not tolerating the treatment or less than a 50% response to the current treatment in 4-5 weeks or (8-12 weeks with Imiquimod)

Question 28

What treatment options are liscenced for intra-vaginal warts

Answer 28

usually we don’t treat intra-vaginal warts or cervical warts and just treat external genital warts and hope this treatment clears them
however TCA, cryotherapy and electrosurgery are considered options

Question 29

How should urethral metal warts be managed

Answer 29

If the base can be seen treatment with cryotherapy, electrosurgery, laser ablation, wart icon, Aldara are appropiate.
Lesions deeper in the urethra should be surgically ablated under direct vision under urology

Question 30

What are the treatment options for intra-anal warts

Answer 30

TCA, Aldara (off licence), cryotherapy, TCA, laser ablation, electrosurgery

Question 31

What are the treatment options for GW during pregnancy and BF?

Answer 31

avoid topical treatments, cryotherapy is suitable as are surgical excision and ablative methods

Question 32

Is c-section recommended to prevent vertical transmission of genital warts from mother to baby at the time of vaginal delivery?

Answer 32

No - c-section is not recommended to prevent vertical transmission of HPV infection.

Question 33

what complication can result if vertical transmission of HPV occurs to the neonate?

Answer 33

Respiratory papillomatosis in the infancy which occurs in about 4/100,000 births

Question 34

write out the treatment pathway of female genital warts as published in the BASHH guidelines

Answer 34

See BASHH guidelines

Question 35

write out the treatment pathway of male genital warts as published in the BASHH guidelines

Answer 35

see BASHH guidelines