Genital warts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Genital warts is a highly contagious sexually transmitted infection caused by some sub-types of human papillomavirus (HPV). It is spread through direct skin-to-skin contact during oral, genital, or anal sex with an infected partner.

Genital warts are the most easily recognized sign of genital HPV infection. They can be caused by strains 6, 11, 30, 42, 43, 44, 45, 51, 52 and 54 of genital HPV; types 6 and 11 are responsible for 90% of genital warts cases. Most people who acquire those strains never develop warts or any other symptoms. HPV also causes many cases of cervical cancer; types 16 and 18 account for 70% of cases; however, the strains of HPV that cause genital warts are not linked to the strains that cause cancer.

Although treatments can remove the warts, they do not remove the HPV virus, so warts can recur after treatment. Traditional theories postulated that the virus remained in the body for a lifetime. However, new studies using sensitive DNA techniques have shown that through immunological response the virus can either be cleared or suppressed to levels below what PCR tests can measure. According to the Center for Disease Control‘s report on HPV to Congress in 2004, studies have shown that 70% of new HPV infections clear within one year, and as many as 91% clear within two years. The median duration of new infections is typically eight months. The gradual development of an effective immune response is thought to be the likely mechanism for HPV DNA clearance.

The state of the immune system determines the chances of removing the virus entirely and can be affected by factors such as HIV infection, certain medications, stress, or illness.[3] There is even some suggestion that effective treatment of the wart may aid the body’s immune response.

Genital warts often occur in clusters and can be very tiny or can spread into large masses in the genital or penis area. In women they occur on the outside and inside of the vagina, on the opening (cervix) to the womb (uterus), or around the anus. They are approximately as prevalent in men, but the symptoms may be less obvious. When present, they usually are seen on the tip of the penis. They also may be found on the shaft of the penis, on the scrotum, or around the anus. Rarely, genital warts also can develop in the mouth or throat of a person who has had oral sex with an infected person.

Genital warts may disappear without treatment, but sometimes eventually develop a fleshy, small raised growth. There is no way to predict whether they will grow or disappear.

Small warts can be removed by freezing (cryosurgery), burning (electrocautery), or laser treatment. Surgery is occasionally used to remove large warts that have not responded to other treatment.

Gardasil (sold by Merck & Co.) is a vaccine that protects against human papillomavirus types 16, 18, 6, and 11. Types 6 and 11 cause genital warts, while 16 and 18 cause cervical cancer. The vaccine is preventive, not therapeutic, and must be given before exposure to the virus type to be effective, ideally before the beginning of sexual activity. The vaccine is widely approved for use by young women, it is being tested for young men,^[1] and has been approved for males in some areas, such as the UK.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Genital warts are the most easily recognized sign of genital HPV infection. They can be caused by strains 6, 11, 30, 42, 43, 44, 45, 51, 52 and 54 of genital HPV; types 6 and 11 are responsible for 90% of genital warts cases. Most people who acquire those strains never develop warts or any other symptoms. HPV also causes many cases of cervical cancer; types 16 and 18 account for 70% of cases; however, the strains of HPV that cause genital warts are not linked to the strains that cause cancer.

• Genital warts often occur in clusters and can be very tiny or can spread into large masses in the genital or penis area. In women they occur on the outside and inside of the vagina, on the opening (cervix) to the womb (uterus), or around the anus.
• They are approximately as prevalent in men, but the symptoms may be less obvious.
• When present, they usually are seen on the tip of the penis. They also may be found on the shaft of the penis, on the scrotum, or around the anus. * Rarely, genital warts also can develop in the mouth or throat of a person who has had oral sex with an infected person.
• The viral particles are able to penetrate the skin and mucosal surfaces through microscopic abrasions in the genital area, which occur during sexual activity. * Once cells are invaded by HPV, a latency (quiet) period of months to years may occur. HPV can last for several years without a symptom.^[1]
• Having sex with a partner whose HPV infection is latent and demonstrates no outward symptoms still leaves one vulnerable to becoming infected. That causes the increase of HPV infectors and sometimes you cannot track down who was the source of the infection.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

It is a common misconception among men that hirsuties papillaris genitalis are genital warts. Hirsuties papillaris genitalis is not contagious and no treatment for it is necessary. Some may deem it unsightly and there are various methods of ridding the penis of the condition such as carbon dioxide laser treatment.

Genital warts (condylomata) should not be confused with Molluscum contagiosum (MC), which is often transmitted sexually, but does not occur internally as do condylomata. MC looks like small warts, which are much smaller than condylomata genital warts. It does not increase the risk of cervical cancer for women. Genital warts should not be confused with Fordyce’s spots, which are considered benign.

Genital warts should be differentiated from syphilis, which commonly presents with generalized systemic symptoms such as malaise, fatigue, headache and fever. Skin eruptions may be subtle and asymptomatic. It is classically described as 1) non-pruritic bilateral symmetrical mucocutaneous rash; 2) non-tender regional lymphadenopathy; 3) condylomata lata; and 4) patchy alopecia.^[1]

Anogenital wars must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoids, anal fissure and perianal abscess.

Disease	History	Physical exam findings	Sample image
Hemorrhoids	External hemorrhoids External hemorrhoids are painful as the skin below the punctate line is sensitive to pain.[1] Blood clots may form in external hemorrhoids. Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus. When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch. Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse. Internal hemorrhoids The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement. Internal hemorrhoids that are not prolapsed are usually not painful. Prolapsed hemorrhoids often cause pain, discomfort, and anal itching	Skin examination Inspection of the anal verge may show scratch marks and skin tags. Inspection also may reveal external hemorrhoids or prolapsed internal hemorrhoids. Digital rectal examination Digital rectal examination reveals the size and location of hemorrhoids. Thrombosed hemorrhoids are tender to palpation. Internal hemorrhoids are not palpable by digital rectal examination and the use of anoscope is mandatory.
Anal fissure	Anal fissure usually presents with tearing pain with every bowel movement.[2] Pain usually lasts for minutes to hours after every bowel movement. Patient is typically afraid of going to the bathroom to avoid the pain, which leads to a viscious cycle. The fissure worsens the constipation and the constipation (hard stool) aggravates the fissure. About two-thirds of the patients present with bright red blood streaks on toilet papers or on the surface of stools. May be accompanied by pruritis and discharge.	Most fissures occur in the posterior midline of the anal canal.[3] Skin tags in the perianal area may accompany chronic anal fissures.
Rectal prolapse	Rectal prolapse most commonly occurs in multiparous females over 40 years old.[4] Appears as a progressive mass protrusion from the anus. The protrusion first appears with straining and defecation, then progresses to the degree when it is no longer replaced back. It presents with abdominal discomfort and incomplete defecation. Fecal incontinence and anal discharge. Pain is not usually present.	Mass protruding from the anus.[5] Concentric mucosal rings are characteristic of rectal prolapse.
Perianal abscess	Perianal abscess presents with severe, continuous, dull, aching pain in the perianal area.[6] Pain is exacerbated with bowel movements, but is not exclusive to it. Constipation due to fear of bowel movements. Fever, headache, and chills may accompany the pain. If the abscess starts to drain, discharge of purulent or bloody fluid may be noticed.	Flatulent, erythematous, and tender area of skin overlying the abscess. If abscess is deep, tenderness is elicited with digital rectal examination.
Anal cancer	Rectal bleeding is the most common presentation.[7] Mass sensation in the anus. Mucoid discharge may occur. Patient may give a history of anal condyloma (especially homosexual men).[8] Fecal incontinence.	On digital rectal examination, solid hemorrhagic mass that is firmly fixed to the surrounding structures is noted. Femoral and inguinal lymph nodes may show lymphadenopathy secondary to spread of cancer.
Condylomata acuminata	Patient may give a history of unprotected anal sex with an infected partner. Having multiple sexual partners is a risk factor and should be investigated.[9] Condyloma acuminata presents with painless warts that vary in size, shape, and color. Pruritis and discharge may accompany the warts.	Anal condyloma acuminata may be accompanied by cervical, vaginal, or even ororpharyngeal warts, so the patient should be examined thoroughly.[10]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Although treatments can remove the warts, they do not remove the HPV virus, so warts can recur after treatment. Traditional theories postulated that the virus remained in the body for a lifetime. However, new studies using sensitive DNA techniques have shown that through immunological response the virus can either be cleared or suppressed to levels below what PCR tests can measure. According to the Center for Disease Control‘s report on HPV to Congress in 2004, studies have shown that 70% of new HPV infections clear within one year, and as many as 91% clear within two years. The median duration of new infections is typically eight months. The gradual development of an effective immune response is thought to be the likely mechanism for HPV DNA clearance.

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Please help WikiDoc by adding content here. It’s easy! Click here to learn about editing.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The state of the immune system determines the chances of removing the virus entirely and can be affected by factors such as HIV infection, certain medications, stress, or illness. There is even some suggestion that effective treatment of the wart may aid the body’s immune response.

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Please help WikiDoc by adding content here. It’s easy! Click here to learn about editing.

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