Genital Warts (HPV Infection)

Facts and Definition of Genital Warts (HPV Infection)

  • Genital warts are flesh-colored or gray growths found in the genital area and anal region in both men and women.
  • Genital warts are sometimes referred to as condyloma acuminata or venereal warts.
  • Genital warts is the most common sexually-transmitted disease (STD) caused by a virus. The warts are caused by the human papillomavirus (HPV).
  • Genital warts affect both men and women and can occur at any age.
    • Most people with genital warts are between the ages of 17-33 years. Genital warts are highly contagious. There is high risk of getting the infection from a single sexual contact with someone who has genital warts.
    • In children younger than three years of age, genital warts are thought to be transmitted by nonsexual methods such as direct manual contact. Nevertheless, the presence of genital warts in children should raise the suspicion for sexual abuse.
  • Up to 20% of people with genital warts will have other sexually transmitted diseases (STDs).

What Causes Genital Warts (HPV)?

Genital warts are caused by the human papillomavirus (HPV). Over 100 types of HPVs have been identified; about 40 of these types have the potential to infect the genital area.

  • Most genital warts are caused by two specific types of the virus (HPV-6 and -11), and these HPV types are considered "low risk," meaning they have a low cancer-causing potential. Other HPV types are known causes of premalignant changes and cervical cancers in women. HPV-16, one of the "high-risk" types, is responsible for about 50% of cervical cancers. HPV types 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 are other known "high risk" virus types. High-risk HPV types are also referred to as oncogenic HPV types. HPV is believed to cause 100% of cases of cervical cancer.
  • Common warts are not the same as genital warts and are caused by different HPV types that infect the skin.

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, during which there is no evidence of infection.

  • Generally, about two-thirds of people who have sexual contact with a partner who has genital warts develop them within three months.
  • Genital warts are indirectly associated with use of birth control pills due to increased sexual contact without the use of barrier protection, multiple sex partners, and having sex at an early age.

What Do Genital Warts Look Like (Pictures)?

Picture 1: Female patient with extensive labial venereal warts. Photo courtesy of Centers for Disease Control/Joe Millar.
Picture 1: Female patient with extensive labial venereal warts. Photo courtesy of Centers for Disease Control/Joe Millar.
Picture 2: Male patient with venereal warts in the anal region. Photo courtesy of Centers for Disease Control/Dr. Wiesner.
Picture 2: Male patient with venereal warts in the anal region. Photo courtesy of Centers for Disease Control/Dr. Wiesner.

What Are the Signs and Symptoms of Genital Warts (HPV)?

Although genital warts are painless, they may be bothersome because of their location, size, or due to itching.

  • The size may range from less than one millimeter (1 mm = 0.039 inches) across to several square centimeters (1 cm = 0.39 inches) when many warts join together.
  • Men and women with genital warts will often complain of painless bumps, itching, and discharge.
  • Rarely, bleeding or urinary obstruction may be the initial problem when the wart involves the urethral opening (the opening where urine exits the body.)
  • Warts in more than one area are common.
  • There may be a history of previous or concurrent sexually transmitted diseases (STDs).

Specific descriptions

  • In men, genital warts can infect the urethra, penis, scrotum, and rectal area. The warts can appear as soft, raised masses with a surface that can be smooth (on the penile shaft) or rough with many fingerlike projections (anal warts). Others may appear pearly, cauliflower-like, or rough with a slightly dark surface. Most lesions are raised, but some may be flat with only slight elevation above the skin surface. Sometimes lesions may be hidden by hair or in the inner aspect of the uncircumcised foreskin in males.
  • In women, genital warts have a similar appearance and usually occur in the moist areas of the labia minora and vaginal opening. Lesions visible on the outer genitals warrant a thorough examination of the vaginal canal, cervix, and anorectal area. Most vaginal warts occur without symptoms. Rarely, women may experience bleeding after sexual intercourse, itching, or vaginal discharge.

Is There a Vaccine to Prevent Genital Warts?

  • In 2006, an HPV vaccine (Gardasil) was approved by the FDA. It is currently recommended for both males and females aged 9 to 26 years. This vaccine has been shown to be safe and highly effective in preventing infection with the four most common HPV types (6, 11, 16, and 18) in women who have had no previous exposure to the virus. However, it is less effective in those who have already been infected with HPV, and it does not protect against all types of HPV infection. Studies are underway to determine whether the vaccine is safe and effective in older women.
  • Gardasil 9 has activity against the four viral types in the basic Gardasil, but also against virus types 31, 33, 45, 52, and 58 (for a total of 9 viral types, hence the name). It also is approved for both males and females aged 9-26 years of age.
  • Another vaccine against HPV types 16 and 18, Cervarix, was been approved by the FDA for females aged 10 to 25 years, but was withdrawn from the US market in 2016.
  • Because no treatment is 100% effective, it is important to prevent the spread of HPV, which causes genital warts and some cancers whenever possible. Transmission of genital warts can be decreased if condoms are used and the infected individual refrains from sexual activity until therapy is completed.

When to Seek Medical Care for Genital Warts (HPV)

If you have genital warts, see a health-care professional and discuss treatment options.

Bleeding warts that cannot be controlled with direct pressure should be seen by a health-care professional. Warts that obstruct the urethral opening and don't allow you to urinate are an emergency and should be treated as soon as possible.

STD Quiz: Sexually Transmitted Diseases Are On the Rise!

Genital warts is one of the most common STDs, and STDs in general are on the rise from last year. Are you taking the necessary precautions to prevent catching an STD? See how STD smart you are!

  1. Can condoms protect you from contracting STDs?
  2. How many people in the US are living with HIV?

Is There a Test to Diagnose Genital Warts (HPV)?

Diagnosis is often based on findings from the history and appearance of the genital warts.

  • Sometimes, lesions are only visible with an enhancing technique called acetowhitening. This technique involves the application of 5% acetic acid solution to the area of suspicion for about 5-10 minutes. Infected areas will turn white.
  • Magnification of the area (colposcopy) using a scope may be necessary to see the lesions. In females, a colposcope may be used to look for lesions in the vaginal canal and on the cervix.
  • A routine Pap smear should always be done in order to look for evidence of HPV infection and abnormal cells on the cervix.
  • A biopsy can be performed if the lesion appears unusual or recurs after treatment.
  • Special laboratory tests can also be used to confirm the presence of HPV infection.

What Natural or Home Remedies Treat Genital Warts (HPV)?

Because genital warts essentially have no symptoms other than their appearance, there is little need for home treatment. It is important, however, to recognize that the warts exist.

  • Take the necessary precautions to prevent trauma to the area, which can result in bleeding.
  • Be careful to prevent transmission to a sexual partner.
  • Because the warts themselves are infectious, avoid touching them. Do not pick or squeeze the warts.

What Is the Treatment for Genital Warts (HPV)?

There is no single effective cure for removal of genital warts. A number of treatment options exist; however, no treatment is 100% effective in eliminating warts and preventing them from coming back in all patients. It also is not possible to eliminate infection with human papillomavirus once it has occurred. Genital warts may go away on their own in about 10% to 20% of people over a period of three to four months.

  • Cryotherapy: This technique freezes the wart using liquid nitrogen or a "cryoprobe." It is an excellent first-line treatment because response rates are high with few side effects.
  • Laser treatment: This treatment is used for extensive or recurrent genital warts. It may require local, regional, or general anesthesia. The laser physically destroys the HPV-induced lesion. Disadvantages include high cost, increased healing time, scarring, and potentially infectious viral particles in the air caused by the laser plume.
  • Electrodesiccation: This technique uses an electric current to destroy the warts. It can be done in the office with local anesthesia. Of note, the resulting smoke plume may be infectious.

What Medications Treat Genital Warts (HPV)?

Several medications exist for treating genital warts and can be used as an alternative to other treatments.

  • Podophyllum resin (Pod-Ben-25, Podofin) is topically applied by a health-care professional.
  • Podofilox (Condylox) can be topically applied at home and has a higher cure rate than podophyllum resin. Podofilox also is useful for prevention.
  • Trichloroacetic acid or bichloracetic acid is topically applied; however, the response is often incomplete and recurrence is higher and it may cause pain and burning.
  • 5-Fluorouracil (Efudex) is applied as a cream, has a long treatment time, can cause burning and irritation, and has many side effects.
  • Interferon alpha-n3 (Alferon N) is an injection used for warts that do not respond to other therapies; however, it has many side effects.
  • Imiquimod (Aldara) is applied as a cream and local skin irritation is a common side effect.

What About Surgery to Cure Genital Warts (HPV)?

Cutting the warts away can be done as an office procedure with local anesthesia. It is usually done when the warts are small in size and number. Surgical destruction or excision has been more effective in eradicating genital warts than medical therapies, but it carries a relatively high recurrence rate.

What Is the Outlook for a Person with Genital Warts (HPV)

  • Complete the necessary treatment as outlined by your health-care practitioner.
  • Women with genital warts should see their doctor for a routine Pap smear and investigation for HPV infection of the vaginal canal and cervix. If the genital warts are not successfully treated with the initial therapy, the individual will need to follow-up with a doctor or a dermatologist to discuss options for alternative treatment.
  • In many cases, genital warts fail to respond to treatment or come back even after a removal.
  • Reappearance of abnormal cells on the cervix of women is not altered by treatment of their sexual partners.
  • Recurrence rates of genital warts are greater than 50% after one year and have been attributed to the following factors:
    • Recurrent infection from a sexual partner; infection with multiple HPV types is possible
    • Potentially long incubation time of HPV
    • Persistence of the virus in the surrounding skin, in the hair follicle, or in sites that are missed by the treatment used
    • Deep lesions or lesions that cannot be detected
  • Genital warts often appear or increase in number during pregnancy. Dormant infections may also become activated. The presence of genital warts may make vaginal delivery difficult if they are in the cervix or vagina, and warts in these locations tend to bleed easily. The warts often disappear without treatment after pregnancy. The real danger, however, is that newborns may become infected during passage through an infected birth canal. HPV can cause a very serious condition in children called recurrent respiratory papillomatosis (RRP). This is a life-threatening disease of the respiratory tract. The papillomas or warts appear and spread quickly, sometimes dangerously blocking the child's airway.
Reviewed on 11/21/2017

REFERENCES:

CDC. 2015 Sexually Transmitted Diseases Treatment Guidelines. Updated: Jan 25, 2017.
<https://www.cdc.gov/std/tg2015/default.htm>

Gearhart, PA. Human Papillomavirus. Medscape. Updated: Jan 05, 2017.
<http://emedicine.medscape.com/article/219110-overview>

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