Genital Warts (Human Papillomavirus or HPV)

 Warts are caused by viruses and can appear anywhere on the body. Those that show up in the genital area are caused by the human papillomavirus, commonly called HPV, and are easily transmitted by sexual contact.

 HPV infection is the most common sexually transmitted disease (STD) in North America and certain forms of the virus can cause cervical and penile cancer. According to the Center for Disease Control and Prevention at least 50% of sexually active men and women will get a genital HPV infection at some point in their lives.

 After a person has been infected, it may take one to three months (or longer in some cases) for warts to appear. Some people who have been infected never get warts. If you think you have been infected, see your doctor, even if you cannot see warts.

 What Do Genital Warts Look Like?
 Genital warts look like small flesh-colored, pink, or red growths or bumps that appear on the vulva, in or around the vagina or anus, on the cervix, and on the penis, scrotum, groin, or thigh. The warts may be raised or flat, single or multiple, small or large, and look similar to the small parts of a cauliflower or they may be very tiny and difficult to see. They often appear in clusters of three or four, and may grow and spread rapidly. They usually are not painful, although they may cause mild pain, bleeding, and itching.

 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 are one of the most common forms of sexually transmitted diseases.

 Genital warts are caused by the human papillomavirus (HPV). HPV is a family of more than 80 extremely common viruses. Many types of HPV cause harmless skin warts, such as those on the fingers or feet. Only a few specific types of HPV are thought to cause genital warts.

 HPV is easily spread during oral, genital, or anal sex with an infected partner. About two-thirds of people who have sexual contact with a partner who has genital warts will develop them also, usually within three months of contact.

 Most people will be exposed to a form of HPV at some point in their lives, although not all will become infected or develop symptoms. Warts can appear within several weeks after sexual contact with an infected person, or they can take months to appear.

 How Do I Know If I Have Genital Warts?
 Like many STDs, HPV does not always have visible symptoms. But when symptoms do occur, warts may be seen around the genital area. In women, warts can develop on the outside and inside of the vagina, on the cervix (the opening to the uterus), or around the anus. In men, they may be seen on the tip of the penis, the shaft of the penis, on the scrotum, or around the anus. Genital warts also can develop in the mouth or throat of a person who has had oral sex with an infected person.

 Because there is no way to predict whether the warts will grow or disappear, people who suspect that they have been infected should be examined and treated, if necessary.

 What Tests Are Used to Detect Genital Warts?
 Your doctor may perform the following tests to check for genital warts:

  * An examination of visible growths to see if they look like genital warts
  * Application of a mild acetic acid (vinegar) solution to highlight less visible growths.
  * A complete pelvic exam and Pap smear (for women).
  * A specialized test for HPV, collected in a way similar to a Pap smear.
  * Biopsy of cervical tissue to make sure there are no abnormal cells that could develop into HPV-related cervical cancer. A biopsy involves taking a small sample of tissue from the cervix and examining it under a microscope.
  * Examination of the rectum.
  * A fluid sample test for gonorrhea and chlamydia.
  * A blood sample test for syphilis.

 Tests for gonorrhea, chlamydia, and syphilis are taken because STDs often occur together and share similar symptoms. Sometimes female patients are referred to a gynecologist (a doctor who specializes in female reproductive health) for further testing and biopsy.

 Complications of HPV:

 Cancer
 Most strains of HPV that produce genital warts do not cause cancer. But certain strains of HPV may cause cervical cancer, or less commonly, cancers of the vulva, anus, or penis. For this reason, it is important for women to have annual pap tests to detect any HPV-related abnormalities.

 Pregnancy/Childbirth Complications
 Genital warts may become larger during pregnancy, which may make it difficult to urinate. If the warts are in or near the vaginal opening, they may block the birth canal during delivery.

 Risk Factors
 A risk factor is something that increases your chance of getting a disease or condition. Risk factors for contracting HPV and/or genital warts:

  *Age: 15-30 years old
  *Multiple sexual partners
  *Having sex without condoms
  *Skin-to-skin contact with an infected partner
  *Previous history of genital warts
  *Pregnancy
  *Smoking
  *Oral contraceptives
  *Having sex at an early age

 Symptoms
 Genital warts often look like fleshy, raised growths with a cauliflower shape. They often appear in clusters.

 In women, warts may be found in the following areas:
  *Vulva or vagina
  *Inside or around the vagina or anus
  *Cervix

 In men, genital warts are less common. If present, they are usually found in the following areas:
  *Tip or shaft of the penis
  *The scrotum
  *Around the anus

 The following symptoms may also be present:
  *Bleeding
  *Itching
  *Irritation
  *Burning
  *Secondary bacterial infection with redness, tenderness, or pus

 Diagnosis
 Evidence of genital warts may be diagnosed by the following:

 Visual Exam
 A doctor can diagnose genital warts by visual examination. If external warts are found, the cervix is usually checked for warts as well. Application of acetic acid may assist in identifying lesions that do not have classic features.

 Pap Smear
 Abnormal Pap smear results may indicate the presence of HPV. However, the Pap test is not the most accurate test for HPV. Further tests, such as a colposcopy, should be performed if Pap results are abnormal.

 Colposcopy and Biopsy
 Colposcopy is a test that enables the doctor to identify warts that might not be easily visible. A biopsy involves taking a sample of tissue to be tested.

 HPV Testing
 A swab of some cells from the affected area can be checked for specific types of HPV.

 Treatment
 Treatment for genital warts depends on the size and location of the warts. Treatment only alleviates the symptoms. It does not cure the virus. Since the virus remains, warts or other complications may recur later.

Treatments may include:
 Topical Treatments
 Your doctor may recommend one of the following treatments or solutions to be applied to the affected areas:
  *Imiquimod cream
  *Podophyllum resin
  *Podofilox solution
  *5-Fluorouracil cream
  *Trichloroacetic acid

 Cryosurgery, Electrocautery, or Laser Treatment
 Cryosurgery (freezing), electrocautery (burning), and laser are all methods that instantly destroy warts. These methods are used if the warts are small, or if the warts are large and have not responded to other treatment. Surgical removal is sometimes recommended for large warts. An antiviral drug, called alpha-interferon, can be injected directly into warts that keep recurring.

 Prevention
 The only way to completely prevent the spread of an HPV infection is to avoid physical contact with an infected sexual partner.

 Latex condoms may help reduce the spread of HPV infection and genital warts. However, they are not 100% effective because they cannot cover the entire genital area.

 Other preventive measures include:
  *Sexual abstinence
  *Monogamous sexual relationships
  *Regular check-ups for sexually transmitted diseases
  *Regular Pap smears for women starting at age 18 or at the onset of sexual activity, whichever comes earlier

  Vaccine
  A vaccine called Gardasil has been approved to prevent infection by some—but not all—of HPV strains that cause cervical cancer. Approved for use in females aged 9-26, the vaccine is given as a series of three injections over a 6-month period. There is a catch-up vaccination recommended for women between the ages of 13-26, regardless of their sexual history, who were never vaccinated or did not complete the recommended series.

 Gardasil is the first vaccine ever developed to primarily prevent a cancer. The vaccine reduces the risk of infection from four strains of HPV, including the two strains—16 and 18—that account for over 70% of HPV infections leading to cancer. In a recent large trial involving women aged 15-26, the vaccine effectively reduced the incidence of precancerous cervical lesions over a three year period.


 Special Considerations
 Anogenital warts are rare in children. Such a diagnosis should prompt consideration of sexual abuse and should be reported.
 

American Social Health Association
www.ashastd.org

Planned Parenthood
www.plannedparenthood.org

United States Centers for Disease Control and Prevention
www.cdc.gov/std

Health Canada
www.hc-sc.gc.ca/index_e.html

Sex Information and Education Council of Canada
www.sieccan.org