Genital Warts (Condylomata Acuminata) - a Sexually Transmitted Infection

Introduction:

Condyloma, a Greek word that means round tumor, has been recognized as a distinct entity since ancient times. Mucosal HPV (Human Papillomavirus) infections are regarded to be the most common sexually transmitted infections (STIs). It can occur in the anogenital region, oral mucosa, or skin. HPV present in the birth canal can be transmitted to a newborn during vaginal delivery, and it may persist for years in a dormant state and become infectious intermittently. Most commonly, people of the young and sexually active age group are affected.

Which Causative Organism Is Responsible for HPV Infection?

The causative organism is the human papillomavirus. The most common subtypes are 6, 11, 16, and 18. Less common subtypes are 31, 33, 35, 39, and 51 to 59.

How Does the Infection Get Transmitted?

Genital HPV infections are transmitted chiefly through sexual contact such as genital-to-genital, oral-to-genital, or genital-to anal, but digital and perinatal transmission can also occur. Non-sexual transmission occurs through skin-to-skin contact and skin-to-mucous contact. But sexual transmission is the most common one. The incubation period is several weeks to months.

What Are the Risk Factors of Genital HPV Infection?

The risk of developing genital HPV infection increases with,

• Increased number of sex partners.

• Smoking.

• Human immunodeficiency virus infection (HIV).

• History of chlamydia and gonorrhea.

• Indulging in sex at an early age.

• Oral contraceptives.

What Are the Clinical Features of HPV Infection?

The most common sites affected are the frenulum, coronal sulcus, the inner surface of the prepuce, urethral meatus, cervix, vagina, and vulva. It can also affect the anal region of homosexuals. It is usually asymptomatic, single or multiple, soft, pink or whitish, sessile tumor (immobile) with fine papillary projections. It may bleed on friction or slight trauma. These lesions may either subside, progress, or prevail in the same condition. There may be abnormal discharge, and pruritus may also be present. Some experience bleeding with sex and during pregnancy. Two-thirds of the population having sex with sex partners having HPV-induced genital warts are known to acquire the infection within three months of exposure.

What Are the Clinical Variants of Genital Warts?

1. Small papular.

2. Cauliflower-like floret.

3. Sessile.

4. Flat-topped papules or plaques.

5. Giant condyloma (Buschke-Lowenstein tumor).

What Complications Does Condylomata Acuminata Cause?

• It may enlarge to an enormous size and hamper the physiological function.

• Sometimes, there will be bleeding, ulceration, and secondary infection.

• Local malignancy (oncogenic - type 16 and 18) is associated with oncogenic atypia and less frequently with invasive carcinoma in HIV.

• Anogenital warts flourish in pregnancy. The size, as well as the number, will increase, maybe due to the influence of increased hormone levels, vascularity, and immune deficiency.

• Genital warts in children may result from the perinatal route (mother to newborn during delivery), autoinoculation from finger warts, and non-sexual transmission from a family member or through sexual abuse. Genital warts present at delivery are associated with a risk of juvenile laryngeal papilloma.

What Investigations Help Diagnose HPV-Induced Genital Warts?

Clinical examination is sufficient to diagnose most of the external genital warts. Sometimes, to visualize warts clearly, a specialized instrument called a colposcopy can also be used, which helps view warts in a magnified version. Laboratory examinations are also used in a few cases.

They are as follows:

1. Acetowhite test for subclinical genital HPV (5 % acetic acid for 5 minutes).

2. Pap smear.

3. Skin biopsy for koilocytes, mature squamous cells with a large clear perinuclear zone, and smudged nuclei.

4. Detection of HPV DNA (deoxyribonucleic acid).

5. Serology test.

In people with HPV genital infection, additional tests to look for the presence of other sexually transmitted infections like syphilis, gonorrhea, chlamydia, HIV/AIDS, etc., are also done.

What Other Lesions Imitate Condylomata Acuminata?

• Molluscum contagiosum.

• Sebaceous cysts.

• Buschke-Lowenstein tumor.

• Psoriasis.

• Lichen planus.

• Condyloma lata.

How Is Condylomata Acuminata Treated?

• Spontaneous regression may happen in 10 % to 15 % of cases.

• 20 % Podophyllin (a resin extracted from Podophyllum peltatum) in alcohol or tincture Benzoin is applied to the lesion with an applicator, covering the surrounding area with petroleum jelly. It is left on the surface for 4 to 6 hours and then cleaned. It may be repeated every third day till lesions are completely cured. This is contraindicated in pregnancy as it can lead to fetal death and abortion.

• Trichloroacetic acid of 50 % to 70 % can be used.

• Podophyllotoxin cream 0.5 % solution or 0.15 % cream twice daily for three days, followed by a four day gap. This has to be given for three cycles.

• 5 % 5-Fluorouracil cream was applied locally to the lesion for three to seven days.

• Immunomodulator: Treatment with 5 % Imiquimod cream three times per week every other night for a maximum of 16 weeks will help.

• Surgical methods such as cauterization, excision under local anesthesia, cryocautery or carbon dioxide laser, electrodessication, and curettage are also beneficial.

• Prophylactic and therapeutic vaccines are available. Gardasil and Cervarix three doses over six months.

Counseling:

Clear information and counseling must be given to accomplish proper management. Female individuals who have an HPV infection should get counseling about regular participation in cervical cytology screening programs. He or she should be encouraged to use barrier protection with new sexual contacts until successful treatment has been completed.

How Is HPV Infection Prevented?

The spread can be prevented by following the below-mentioned measures.

• Limit the number of sexual partners.

• Get the vaccine.

• Get routine checkups.

• Practice safe sex.

• Avoid douching.

Can Genital HPV Infections Recur?

20 % to 30 % of the time, genital warts due to HPV infection can recur even after successful treatment. They also can become cancerous. Hence follow-up with the treating doctor is necessary. Keep a close look at the affected regions and look for signs of bleeding, pigmentation, and ulceration, which indicate malignant transformation.

Conclusion:

If HPV infection is confirmed, inform the sexual partners regarding it and refrain from having sex until getting treated successfully. Otherwise, it unnecessarily gets transmitted to the partners. Condom usage can prevent the transmission of such sexually transmitted diseases; hence if planning to have sex other than for getting pregnant, condoms are worth using.