Genital warts, or anogenital warts, are soft, moist and flesh-colored benign lesions caused by certain strains of the human papillomavirus (HPV). Although they often appear around or inside the genitalia of both males and females, they can also appear on other parts of the body, including the thighs, groin and around or inside the anus, either as a single bump or in clusters. They are a type of a sexually transmitted disease, meaning you can get genital warts if you have any form of close sexual contact, including vaginal, anal or oral sex, with an infected person.
HPV is the most common sexually transmitted disease in the UK. In 2008, for example, the number of new infections and recurrent cases of genital warts in England was 80,531 and 68,259 respectively, according to a 2011 study that evaluated data from genitourinary medicine and general practice clinics for that period. Moreover, prior to the introduction of national HPV vaccination programme in the UK in 2008, infection rates in sexually active 14- to 24-year-olds undergoing chlamydia screening was about 35%, according to a 2012 study appearing in the Vaccine journal. It is worth noting that anogenital warts are more prevalent in women than in men. Below is a detailed look at genital warts.
Causes of Genital Warts
According to a 2009 study published in the Journal of Infectious Diseases (JID) and cited by the Centers for Disease Control and Prevention (CDC), human papillomavirus (HPV) types 6 and 11 account for about 90% of all genital warts infections. At this point, it is worth noting that there are over 100 strains of HPV. That said, the study also found other strains of HPV including types 16, 18, 31, 33 and 35 usually occur in visible anogenital warts as coinfections with HPV types 6 or 11. When they occur together, these HPV types may cause foci of high-grade intraepithelial neoplasia, particularly among HIV patients. Other growths associated with HPV types 6 and 11 include laryngeal, nasal, conjunctival and oral warts.
Signs and Symptoms of Genital Warts
Genital warts are often asymptomatic, which means most patients show no symptoms. In fact, studies involving female college students found that, despite nearly 50% of the participants testing positive for HPV, only 1% to 2% had visible warts and additionally, fewer than 10% had ever had visible warts. This means that most of the people who have genital warts may not even know they are carriers of the virus. Still, some patients do develop visible warts and depending on the anatomical location and size of the lumps, may cause physical discomfort including itching and a burning sensation. The lesions may also bleed and cause abnormal virginal discharge.
The growths are usually flat, smooth or slightly bumpy to the touch and their tops resemble a cauliflower. The lesions may be pedunculated or broad-based. Some of the colors associated with these genital warts include red, pink, white, brown and grey. However, they can also be unpigmented. When they develop on warm, moist and non-hairy skin, such as the vulva, they tend to be soft. On the other hand, when they appear on dry and hairy skin, they tend to be firm. In men, they usually occur at certain anatomic sites including the penis, scrotum, groin, thighs and around or inside the anus. In women, they usually appear around or inside the vagina, around or inside the anus and the cervix. If you have oral sex with an infected person, the growths may also appear on your tongue, lips, or throat.
Transmission of Genital Warts
According to a 2012 study published in the March 2012 edition of the Journal of the European Academy of Dermatology and Venereology, genital warts are primarily spread by skin-to-skin contact, including oral, genital and oral sexual contact, with an infected person. Additionally, genital-hand-genital contact can also spread the virus. In other words, you can catch the virus if you touch the genitals of an infected sexual partner and then touch your own with the same hand. It is important to remember that the strains of HPV that cause anogenital warts are different from the strains that cause warts on other parts of the body including the feet and hands.
For this reason, you are unlikely to develop these growths on your hands by touching an infected partner’s genitals. However, it is also important to remember that even people who do not exhibit any symptoms of genital warts may be carriers of HPV. In fact, according to a 2007 study titled “Management of anogenital warts,” from the British Association for Sexual Health and HIV (BASHH), genital warts have a 60% transmission rate between sexual partners. Besides sexual contact with an infected person, genital warts can also be spread by hetero-inoculation or auto-inoculation from non-genital warts, as well as prenatally, says the BASHH.
Risk Factors for Genital Warts
Although virtually any sexually person can develop this sexually transmitted infection, studies by various health organizations including NICE CKS and BASHH indicate some individuals are at a greater risk of genital warts due to certain risk factors. These risk factors include stress, poor nutrition, smoking, multiple sexual partners and immunodeficiency caused by concurrent viral infections such as HIV, flu and herpes. Additionally, individuals with a history of other sexually transmitted infections are more susceptible to genital warts. In fact, according to the BASHH, up to 20% of genital warts patients have other STIs. Certain sexual practices including penetrative anal intercourse, fisting and fingering are risk factors for anal warts, according studies published in the Journal of the European Academy of Dermatology and Venereology and the Current Problems in Dermatology journal.
Potential Complications of Genital Warts
If left untreated, genital warts can cause serious health problems. Some of the potential complications of genital warts include:
Cancer – According to research, HPV infection is the main cause of cervical cancer and cervical dysplasia. Other types of cancer associated with genital warts include cancer of the penis, vulva and anus.
Pregnancy problems — Hormonal changes during pregnancy could cause genital warts to increase in number, grow bigger or bleed. Additionally, when a pregnant woman infected with genital warts gives birth, she could potentially spread the virus to her baby and cause the baby to develop laryngeal papillomatosis.
Diagnosis of Genital Warts
The diagnosis and treatment of genital warts usually takes place at a sexual health or genitourinary medicine (GUM) clinic. In essence, you should visit a GUM or sexual health clinic for an examination if your current or recent sexual partner develops anogenital warts, you have another STI, you’ve recently had unprotected sex with a new partner, or your partner has recently had sex with someone else. The same goes if you are pregnant or planning a pregnancy. The diagnostic process typically involves visual inspection of the potential infection sites. To make the lesions more visible, physicians usually apply mild acidic solution, such as 3% to 5% acetic acid, on the affected sites. The solution causes genital warts to turn white and therefore become more visible. Your doctor may also use a colposcope to magnify the lesions. To examine the area inside your anus, your physician will use a proctoscope.
For women, pelvic exam, Pap test and HPV test are necessary to check for genital warts. Pelvic exams and Pap tests help detect the presence of genital warts in the cervix. A Pap test is essentially a biopsy procedure that entails collecting and examining cervical cells for genital warts. To perform a Pap smear, your doctor will use a speculum to hold open your vagina. Next, using a long-handled tool, your doctor will collect cervical cellular samples from your cervix. Finally, your doctor will examine the samples under a microscope for genital warts. If you are 30 or older, your doctor many perform an HPV test on your cervical cellular samples to check for HPV types that cause cervical cancer. HPV test is unnecessary for women under the age of 30 because younger women generally have robust immune systems that can kill the strains of HPV that cause cancer.
Prevention of Genital Warts
You can use several strategies to prevent catching genital warts. For starters, you can practice abstinence, which the only completely effective solution. This means that even if you are disease-free and get into a monogamous relationship with a disease-free partner, you may still catch the virus. The second most effective way to prevent catching genital warts is to use a condom every time you have sex, whether oral, vaginal or anal sex. However, condoms are not completely effective because the unaffected area left uncovered by a condom can become infected. Besides condoms, you can also use a dental dam, which is essentially a plastic or latex square, to cover female genitals or the anal area. If you use sex toys, you should avoid sharing such toys.
If you do share, ensure you disinfect them thoroughly or cover them with a new condom before you use them. Thirdly, HPV vaccines can help prevent genital warts. In the UK, these vaccines are specifically aimed at young women. For this reason, girls ages 12 and 13 in the UK receive HPV vaccination for free through the national HPV vaccination programme. The programme has been using Gardasil vaccine, a quadrivalent vaccine that protects against four strains of HPV, since September 2012.
Gardasil is particularly effective in combating HPV types 6 and 11, which account for over 90% of the genital warts infections in the UK, as well HPV types 16 and 18, which are responsible for over 70% of the cervical cancer infections in the UK. Cervarix® , a bivalent vaccine that protects against HPV types 16 and 18, is also a popular HPV vaccine in the UK. It is important to note that HPV vaccines cannot fight all types of HPV.
This means that even women who have received HPV vaccinations should undergo Pap tests (cervical screening) regularly. Additionally, these vaccines are designed to protect you against certain HPV types. For this reason, you should receive all doses before you engaging in sexual intercourse. In terms of dosage, recent research from the Boston University Medical Center and the CDC show that two doses of HPV vaccine are sufficient to protect preteens and teens against genital warts.
Treatment Options – Can You Get Rid Of Genital Warts?
In most cases, anogenital warts pose no serious health risk. In fact, some of the visible lesions tend to disappear over time even without any medical intervention. However, if left untreated, genital warts can increase in size and number. Additionally, genital warts tend to be unsightly and in some cases, can cause serious health complications, including cancer. For this reason, it is best to seek treatment for anogenital warts. Treatment will not only help you manage the infection, but also ensure you do not infect your partners.
According to the CDC, some of the key factors to consider when choosing a treatment regimen include anatomic site of the wart wart size, wart number, wart morphology, patient preference, convenience, adverse effects, provider experience and cost of treatment. Some of the factors that might affect how you respond to therapy include the presence of immunosuppression and compliance with therapy, which can consist of either a complete course of treatment or a single treatment. Of course, if you fail to see substantial improvement after a complete course of treatment, you should change to a different treatment regimen. You should also change your treatment regimen if you experience severe side effects. In most cases, genital warts respond to treatment within three months.
When choosing a treatment option, it is important to note that ablative techniques and imiquimod therapies often cause hypopigmentation or hyperpigmentation. Additionally, if you rush treatment, you are likely to develop depressed scars. Fortunately, treatment rarely causes disabling chronic pain syndromes, such as hyperesthesia and vulvodynia of the treatment site, or painful defecation in the case of anal lesions. Additionally, you are unlikely to experience any complications if you administer treatment properly.
Treatment regimens fall into two categories: chemical treatments and physical treatment. The former involves the use of chemicals to destroy genital warts. Examples of such chemicals include:
Podofilox — This is an antimitotic drug is available either as a cream or lotion. It is relatively inexpensive, safe and easy to use. For these reasons, it is suitable for patient-applied modalities (home use). For Podofilox to be effective, you should apply it to visible lesions twice daily for three consecutive days and then skip four consecutive days without applying it. Then, repeat this cycle up to four cycles (about four weeks). Possible side effects of Podofilox include mild to moderate pain and irritation. It is important to note that this chemical has not been determined safe for pregnant women, so you should avoid it if you are pregnant.
Imiquimod cream — This cream boosts the immune system by stimulating the production of cytokines such as interferon. For the best results, you should apply the cream topically to external genital warts once per day, preferably at bedtime, thrice per week for about four months. Additionally, you should wash it off when you wake up in the morning. The potential side effects of using Imiquimod cream include irritation, ulceration/erosions, induration, vesicles and hypopigmentation. Additionally, this cream tends to weaken vaginal diaphragms and condoms. Similar to Podofilox, pregnant women should avoid Imiquimod cream.
Sinecatechin ointment — Formulated with green tea extracts, this ointment is rich in catechins, a natural flavonoid with significant immune-stimulatory, antioxidative and antiviral properties. You should apply the ointment on the infected sites three times daily until the infection clears. However, the treatment regimen should not exceed 16 weeks. Ensure you wash off the medication after use and avoid sexual contact while the medication is on your skin. Some of the potential side effects associated with this ointment include vesicular rash pruritis/burning, ulceration, induration, edema and pain. The ointment may be unsafe for HIV patients, persons with clinical genital herpes, immunocompromised persons and pregnant women.
The aforementioned treatment regimens are suitable for home use — patient-applied regimens. If these regimens prove ineffective, you can try provider-applied regimens. Typically, a health professional administers provider-applied regimens at a health facility. Examples of such regimens include:
Surgical therapy — surgical therapy is highly effective in eradicating genital warts, especially a large number of genital warts or lesions spread over a large area. A surgeon can use various surgical techniques, both invasive and non-invasive, to destroy or remove lesions. Examples of non-invasive surgical techniques include laser surgery and electrocautery. Invasive surgical procedures involve the use of scissors, scalpel or curettage to remove genital warts.
Cryotherapy — This therapy uses liquid nitrogen to destroy genital warts. Possible side effects include pain and blistering. This procedure is safe for pregnant women.
Caused by HPV types 6 or 11, genital warts are the most prevalent sexually transmitted disease (STD) in the UK today. They usually affect the anogenital region and are spread through skin-to-skin sexual contact. They are usually asymptomatic but some patients do develop symptoms. The main symptoms include the presence of warts, itching, burning sensation and abnormal virginal discharge. Prevention strategies include condoms and HPV vaccines. Treatment options include medication, cryotherapy and surgical therapy.