warts%20-%20anogenital
WARTS - ANOGENITAL
Anogenital warts (condylomas) are caused by human papillomavirus (HPV) with >90% of the lesions caused by genotypes 6 & 11.
Patients who present with visible warts may also be infected with high-risk HPVs (eg types 16 & 18) which can cause subclinical lesions that are associated with intraepithelial neoplasia, cervical cancer and anogenital cancer.
Many HPV infections are subclinical, transient, and clear spontaneously within 12 months but may also remain latent and reactivate after several years.

Diagnosis

  • Diagnosis is usually made by clinical presentation
    • Naked eye exam is usually sufficient; visual exam may be aided by a magnifying glass

Classification

  • There are 4 types of genital warts:
    • Skin-colored filiform warts on moist mucosal skin (condyloma acuminata)
    • Skin-colored raised papules with rough warty surface on drier genital skin (verruca vulgaris)
    • Smooth, flat-topped papules that are pink, red, brown, or black on either dry or moist skin (carpet warts)
    • Red or pink giant condyloma with cauliflower surface on dry genital skin

Evaluation

  • Histology is necessary for:
    • Atypical and pigmented warts
    • Lesions fixed to underlying tissue or with bleeding tendencies
    • Presence of ulceration or induration
    • Lesions unresponsive to standard therapy 
    • Condition worsens during treatment
    • Uncertain diagnosis that may suggest intraepithelial neoplasia
    • Patients >35 years
  • Histology is usually unnecessary for patients <35 years, presenting with newly occurring multiple warts
  • Virological diagnosis of human papillomavirus (HPV) is through viral DNA detection, eg polymerase chain amplification (PCR)
    • Not routinely used for diagnostic purposes

Assessment

Assessment of Lesions

  • Examine the external anogenital region and surrounding skin
    • As most individuals with external anal warts also have intra-anal warts, evaluation of the anal canal by digital examination, standard or high-resolution anoscopy may be beneficial 
  • Proctoscopy is indicated if there is history of anal receptive sex, clearance of perianal warts or bleeding from anus
  • Meatoscopy is indicated if with history of distorted urine flow or bleeding from urethra
  • Urethroscopy is performed for more proximal warts
  • Classifying wart morphology and recording lesions on genital maps will be useful
  • Additional tests for females
    • Speculum exam of the vagina and cervix
    • Cervical cytology for high-risk patients
      • Not necessary for women <25 years and in patients with normal-smear intervals
    • Colposcopy with biopsy for cervical exophytic warts to exclude high-grade cervical intraepithelial neoplasia (CIN)

Screening

Other Sexually Transmitted Infections (STIs)

  • Many patients who present with anogenital warts may have other STIs and an appropriate screening for STIs is recommended
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