Genital Warts Flashcards
Genital warts are caused by ____________
Human papillomavirus (HPV)
90% of genital warts are caused by (HPV subtypes)
HPV 6 or 11
How many types of HPV are there?
> 100
How many types of HPV can infect the anogenital and oropharyngeal mucosa
> 40
HPV can be divided into ______ and ______ types, based on their association with the development of malignancy
Low-risk and high-risk
Are HPV 6 and 11 low risk or high risk
These are low-risk types of HPV, which are generally not associated with malignancy
How common is HPV in sexually active populations
Almost universal
Can be regarded as an inevitable consequence of being a sexually active adult
How is HPV transmitted?
Skin-to-skin contact
What types of sex can transmit HPV?
Can occur through penetrative and non-penetrative sex, as well as sexual activity through fingers or sex toys from genital areas infected with HPV
Are most anogenital HPV infections symptomatic or asymptomatic?
Asymptomatic
Is HPV infection permanent or transient?
Most HPV infection is transient and often becomes undetectable within 12 months
What should you advise patients if genital warts develop during a long term relationship?
HPV infection may become latent, and reactivate after several years –> doesn’t necessarily imply the presence of other sexual contacts
Can immunity develop from natural infection?
Immunity from natural infection is poor. Previous infection does not necessarily create long-term immune memory, so may not prevent future infection with the same HPV type
How effective is vaccination at preventing HPV infection
Vaccination provides effective long-term protection against HPV acquisition
What is the vaccination available for HPV in NZ
Gardasil 9
What age group is Gardasil 9 funded for?
9-26 year olds
What does Gardasil 9 protect against?
Protects against the types of HPV that cause most genital warts, as well as 7 types of oncogenic HPV
Is vaccination recommended if you are already sexually active?
Yes
Clinical presentation anogenital warts
Warty growths in and around anogenital skin. Little discomfort (sometimes itchy)
Clinical presentation for warts on penile urethra
Distorted urinary stream or bleeding with urethral lesions
Clinical presentation for warts on cervix
Cervical lesions noted on vaginal examination
May cause mild transient cervical smear abnormalities
Clinical presentation for anal warts
Rectal bleeding may occur after passage of stools with anal lesions
Diagnosis of genital warts is made by…
Genital warts are clinically diagnosed, based on characteristic appearance. Consider biopsy if lesions are atypical
The goal of treatment of genital warts is to…
Eliminate warts that cause physical or psychological symptoms
Does the elimination of visible external warts decrease infectivity?
May not decrease infectivity since the warts may not represent the entire viral burden. For this reason recurrence is common, esp in first 3 months
Treatment options for genital warts
No treatment
Cryotherapy
Podophyllotoxin 0.5% solution
Imiquimod 5% cream
No treatment as an option
An option for asymptomatic warts. 30% of patients will experience spontaneous clearance of warts over a 6-month period.
What is the only treatment suitable in pregnancy?
Cryotherapy
How often does cryotherapy need to be repeated?
Weekly until clearance
Instructions for treatment with podophyllotoxin 0.5% solution
Apply carefully to warts twice daily for 3 consecutive days, followed by 4 days rest each week, until warts have resolved, or for a maximum of 5 consecutive weeks
Can you use podophyllotoxin 0.5% solution in pregnancy (or if partner is pregnant) or breastfeeding
No
Teratogenic
Why does podophyllotoxin have very limited utility for vulvovaginal warts
Patients must be able to visualise, identify and reach their warts, as the solution must not come in contact with normal skin
Instructions for treatment with Imiquimod 5% cream
Apply to affected area at bedtime 3 times per week (alternate days), wash off in the morning
Duration of treatment with imiquimod
Can be used for up to 16 weeks, although the majority who clear their warts will do so by 8 weeks
How often should you review someone on treatment with imiquimod?
Monthly review recommended
S/E imiquimod
Local skin reactions are common, but rarely result in discontinuation of treatment
What patients should you use imiquimod cautiously in
Patients with autoimmune conditions or those on systemic immunosuppressant drugs (discussion with specialist recommended)
Can you use imiquimod in pregnancy?
No
Do you need to treat genital warts in pregnancy?
Smaller genital warts may not require treatment as spontaneous resolution often occurs after delivery.
Genital warts are not a contraindication to vaginal delivery.
When would c section be indicated due to genital warts
When genital warts are likely to cause obstruction of the pelvic outlet or excessive bleeding
Special management considerations for immunocompromised patients with genital warts
May respond less well to therapy and may have more frequent recurrences after treatment. Manage in consultation with a sexual health specialist
If a patient has urethral warts what should you do?
Refer for specialist management (risk of stenosis with over-zealous treatment)
Management of cervical or vaginal warts
High rate of spontaneous resolution – consider no treatment
Follow up at 6 months, refer if still present
Cryotherapy possible
Do you need to do a cervical smear for cervical or vaginal warts?
Not indicated unless due
What should you for a patient with Intra-anal warts
Refer to specialist for management
If no response to treatment in 4-6 weeks consider…
Change in treatment modality or onward referral
What additional advice should you give to patients undergoing treatment? (Other supportive measures)
Saltwater baths can sooth and heal the genital skin during treatment
Avoid shaving or waxing as this may spread the warts
Advice to a patient with genital warts re sexual activity
No need to alter sexual activity with a regular partner (sharing of HPV would have occurred long before the clinical appearance of the lesions)
Consistent condom use recommended if new sexual contact
Consistent condom use has been shown to reduce the risk of HPV acquisition and genital warts by ____%
30-60%
Is follow up with patients recommended?
Not required if symptoms resolve
Review if patient anxious, warts are difficult to visualise, or poor response to treatment
Indications for specialist referral
Lack of response to therapy
Diagnosis unclear
Immunocompromised patients with genital warts
Urethral warts
Cervical warts which are still present after 6 months
Intra-anal warts
