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Genital Warts

The incidence of genital warts is increasing rapidly and exceeds the incidence of genital herpes. The evidence supporting the relationship between genital warts and genital cancer is overwhelming. Genital warts (condyloma acuminata or venereal warts) are pale pink with numerous, discrete, narrow-to-wide projections on a broad base. The surface is smooth or velvety, moist, and lacks the hyperkeratosis of warts found elsewhere. The warts may coalesce in the rectal or perineal area to form a large, cauliflower-like mass.

Another type is seen most often in young, sexually active patients. Multifocal, often bilateral, red- or brown-pigmented, slightly raised, smooth papules have the same virus types seen in exophytic condyloma, but in some instances these papules have histologic features of Bowen's disease.

Warts spread rapidly over moist areas and may therefore be symmetric on opposing surfaces of the labia or rectum. Common warts can possibly be the source of genital warts, although they are usually caused by different antigenic types of virus. Warts may extend into the vaginal tract, urethra.

Oral condyloma in patients with genital human papilloma virus infection.

One study showed that 50% of patients with multiple and widespread genital human papilloma virus (HPV) infection who practiced orogenital sex have oral condylomas.

Pearly penile papules.

Dome-shaped or hairlike projections, called pearly penile papules, appear on the corona of the penis and sometimes on the shaft just proximal to the corona in up to 10% of male patients.

Genital warts in children.

It has been estimated that at least 50% of the cases of condyloma acuminata in children are the result of sexual abuse. In all states there are laws that in effect declare, "If child abuse is recognized or suspected,  

Genital warts and cancer.

There is strong evidence that several HPV types are associated with genital cancers. Genitoanal warts are predominantly induced.

Seventy-three percent of the nonmalignant, clinically and histologically normal tissue 2 to 5 cm from the tumors contained HPV-16. This implies that HPV can persist latently in tissue.

Diagnosis (acetic acid test).

Screening men for papilloma virus infection is important in the prevention of cervical neoplasia and in reinfection of female partners. Application of 3% to 5% acetic acid (vinegar is 5% acetic acid) on the penis, cervix, labia, or perianal area makes visible the inconspicuous, flat genital lesions that would otherwise go unnoticed. Dysplastic and neoplastic tissues with large nuclei and scant cytoplasm.

Treatment

Management of sexual partners.

Examination of sexual partners is not necessary for the management of genital warts because the role of reinfection is probably minimal. Many sexual partners have obvious warts and may desire treatment. The majority of partners are probably already subclinically infected with HPV.

Pregnancy.

The use of podophyllin and podofilox is contraindicated during pregnancy. Genital papillary lesions have a tendency to proliferate and to become friable during pregnancy. Many experts advocate the removal.

Podophyllum resin.

Moist genital warts are most efficiently treated with 20% podophyllin resin in compound tincture of benzoin applied with a cotton-tipped applicator. The entire surface of the wart is covered.

Overenthusiastic initial treatment can result in intense inflammation and discomfort that lasts for days. The procedure is simple.

WARNING.

Systemic toxicity occurs from absorption of podophyllum. Paresthesia, polyneuritis, paralytic ileus, leukopenia, thrombocytopenia, coma, and death.

Podofilox.

Podofilox, also known as podophyllotoxin, is the main cytotoxic ingredient of podophyllin. Podofilox (Condylox) is available for self-application. Patients are instructed to apply the 0.5% solution.

Trichloroacetic acid.

Application of trichloroacetic acid (TCA) is effective and less destructive than laser surgery, electrocautery, or liquid nitrogen application. This is an ideal treatment for isolated lesions.

Electrosurgery.

A limited number of warts on the shaft of the penis are best treated with conservative electrosurgery rather than by subjecting the patient to repeated sessions with podophyllum. Large, unresponsive masses of warts around the rectum or vulva may be treated by scissor excision of the bulk.

Cryosurgery.

Liquid nitrogen delivered with a probe, as a spray, or applied with a cotton applicator is very effective for treating smaller genital warts. Warts on the shaft of the penis and vulva respond very well.