Chapter 139: Genital Warts

PATIENT STORY

An 18-year-old woman presents with a concern that she might have genital warts (Figure 139-1). She has never had a sexually transmitted disease (STD) but admits to two new sexual partners in the last 6 months. She has not been vaccinated against human papillomavirus (HPV). The patient is told that her concern is accurate and she has condyloma caused by HPV (an STD). The treatment options are discussed and she chooses to have cryotherapy with liquid nitrogen followed by imiquimod self-applied beginning 2 weeks after cryotherapy. A urine test for gonorrhea and Chlamydia is performed and the patient is sent to the lab to have blood tests for syphilis and HIV. Fortunately, all the additional tests are negative. Further patient education is performed and follow-up is arranged.

INTRODUCTION

More than 100 types of HPV exist, with more than 40 that can infect the human genital area. Most HPV infections are asymptomatic, unrecognized, or subclinical. Low-risk HPV types (e.g., HPV types 6 and 11) cause genital warts, although coinfection with HPV types associated with squamous intraepithelial neoplasia (e.g., HPV types 16, 18, 31, 45) can occur. Asymptomatic genital HPV infection is common and usually self-limited.¹

SYNONYMS

Condyloma acuminata.

EPIDEMIOLOGY

• Anogenital warts are the most common viral STD in the United States. Incidence can vary, as there is no requirement to report the disease. Current data suggests that there are approximately 350,000 new cases of genital warts diagnosed per year in the United States, although that can range up to 1 million.¹ Worldwide, incidence may vary from 100 to 200 new cases (per 100,000 general population), with peak incidence in young males and females.^2,3

• Some warts are transient and may clear within 1 year. There appears to be a time delay when patient first notices warts and seeks a healthcare opinion—on average, 76 days for men and 30 days for women.^1,2

• Infections may persist and recur, causing much distress for the patient.

ETIOLOGY AND PATHOPHYSIOLOGY

• Genital warts are caused by HPV infection. HPV encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure is variable and ranges from 3 weeks to 8 months.

RISK FACTORS

• Penetrative intercourse (penis-vaginal, digital-vaginal, digital-anal)⁴.

• Oral intercourse (oral-vaginal and oral-anal).

• Immunosuppression, especially HIV (Figure 139-2).