Warts%20-%20anogenital Diagnosis

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

• 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

• 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 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)

Other Sexually Transmitted Infections (STIs)

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