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Warty growths on the vulva, perianal area, vaginal walls, or cervix are caused by various types of HPV. Pregnancy and immunosuppression favor growth. Ninety percent of genital warts are caused by HPV 6 and 11. With increasing use of the HPV vaccine in the United States, the prevalence of HPV types 6, 11, 16 and 18 decreased from 11.5% in 2003–2006 to 4.3% in 2009–2012 among girls aged 14–19 years, and from 18.5% to 12.1% in women aged 20–24 years. Vulvar lesions may be obviously wart-like or may be diagnosed only after application of 4% acetic acid (vinegar) and colposcopy, when they appear whitish, with prominent papillae. Vaginal lesions may show diffuse hypertrophy or a cobblestone appearance (eFigure 18–18).

eFigure 18–18.

Condylomata acuminata of vulvar and perineal skin. (Reproduced, with permission, from DeCherney AH, Nathan L, Laufer N, Roman S. Current Diagnosis & Treatment: Obstetrics & Gynecology, 12th edition. McGraw-Hill, 2019.)

Recommended treatments for vulvar warts include podophyllum resin 10–25% in tincture of benzoin (do not use during pregnancy or on bleeding lesions) or 80–90% trichloroacetic or bichloroacetic acid, carefully applied to avoid the surrounding skin. The pain of bichloroacetic or trichloroacetic acid application can be lessened by a sodium bicarbonate paste applied immediately after treatment. Podophyllum resin must be washed off after 2–4 hours. Freezing with liquid nitrogen or a cryoprobe and electrocautery are also effective. Patient-applied regimens, useful when the entire lesion is accessible to the patient, include podofilox 0.5% solution or gel, imiquimod 5% cream, or sinecatechins 15% ointment. Vaginal warts may be treated with cryotherapy with liquid nitrogen or trichloroacetic acid. Extensive warts may require treatment with CO2 laser, electrocautery, or excision under local or general anesthesia. Intralesional injection of interferon may be used as adjunctive therapy, particularly in patients with refractory lesions. Routine examination of sex partners is not necessary for the management of genital warts since the risk of reinfection is probably minimal and curative therapy to prevent transmission is not available. However, partners may wish to be examined for detection and treatment of genital warts and other sexually transmitted infections. Consistent and correct condom use can decrease the chances of HPV acquisition and transmission.

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Grennan  D. JAMA patient page. Genital warts. JAMA. 2019;321:520.
[PubMed: 30721297]  
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Meites  E  et al. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68:698.
[PubMed: 31415491]  

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