What are Genital Warts?
Genital Warts are caused by the HPV Virus of which there are over 100 types. Types 6 and 11 cause most genital warts. The original cervical cancer HPV vaccine given in schools targeted only the cervical cancer types 16 & 18. Later HPV Vaccines include types 6 & 11. This vaccine has been included in Queensland Schools year 7 or 8 for a number of years now. The vaccine has roughly halved the number of young people with genital warts.
Genital warts take several weeks or months to develop following exposure to the virus although it can take as long as 18 months¹.
Most people exposed to HPV do not develop genital warts. For example, around 1% of young adults in the USA have genital warts yet around 15% of young adults have been exposed to HPV. This means that people can be carriers without knowing they carry HPV, and pass on the virus without realising it.
What are the Symptoms of Genital Warts?
The lesions do not usually cause symptoms other than their appearance. On occasion they can be itchy or bleed when irritated.
Genital Warts are usually multiple. They are commonly found near moist genital surfaces. They are often found on dry surfaces such as the shaft of the penis and sometimes teh scrotum. Raised lesions may be smooth or look like classical warts with a rough bumpy surface (under a magnifying glass the surface looks a bit like a cauliflower). The lesions are less commonly flat.
The diagnosis is usually straightforward although conditions like genital molluscum contagiosum may cause a similar appearance. There are alternative rare diagnoses that need to be considered when warts look “funny” or are very persistent. Secondary Syphilis can be ruled out with a simple blood test or swab, and Intra-epithelial neoplasia ruled out with a biopsy. Women with genital warts will need an initial speculum examination and referral to a specialist if warts are found in the vagina or on the cervix.
There are some normal variations that men and women often confuse with genital warts.
It’s not surprising perhaps that year 12’s don’t get to see slide shows of these normal variations though it would save a lot of heartache if they did!
It is also important with genital warts to look at more general STD Testing which is nowadays normally done on self-testing samples taken at home.
What are the Treatment options?
There are three broad treatment options:
- No Treatment. Warts do usually go on their own, and no treatment is therefore a guideline option. In the real world, most people don’t want to hang around with their warts for another 6-12 months.
- Topical creams or solution which are described below. These have the advantage that they may be applied at home when the warts are external and can be seen.
Treatments carried out in the clinic include:
- liquid nitrogen (cryotherapy). Freezing may be performed at the time of your appointment if this is the option you choose. Cryotherapy may be repeated weekly. May cause short term soreness, irritation or blister.
- Trichloroacetic acid (TCA)* which is corrosive. TCA is applied weekly at the clinic at scheduled appointments. It’s not a ‘soft option’ because it tends to cause a marked burning sensation for up to 10 minutes!
- Surgical Excision for a small number of accessible raised warts*
(Referral is required for large numbers or very large warts because this sedation is usually required)
* Please note that TCA, Electrocautery and Surgical excision require an initial consultation.
Please ensure you request a long appointment for the initial consultation regarding genital warts.
Podophyllotoxin which comes as a 0.15% cream (eg. Wartec®) or 0.5% solution. The minimum amount of solution or cream is applied to cover the lesion and is left to dry thoroughly. Do not apply to normal skin. A cycle of treatment lasts one week, with applications twice per day for three consecutive days followed by a four day break. The weekly cycles may be repeated every week for around 4 weeks. Wartec is normally well tolerated when applied correctly. Side effects may include soreness, itching, redness or ulceration.
Imiquimod 5% Cream is another option (Aldara®). Apply in thin layers to the affected areas and rub in until the cream is no longer visible. Apply three times per week (eg. Monday / Wednesday / Friday) at night and leave on for 6 to 10 hours. Wash the cream off in the morning with mild soapy water. Continue treatment until the warts have cleared (maximum treatment 16 weeks). Local skin reactions are also common and can sometimes require a reduced number of applications. Latex condoms may be weakened with Aldara® cream.
You may have noticed that the duration of Wartec treatment is around a month whereas a course of Aldara will last around 4 months. Unprotected sex is should be avoided soon after application of either cream. You can see that treatment is likely to have an impact on your sex life.
Which treatment is best?
There are a lot of treatment options, hey! The choice can be bewildering. However, The Doctor will guide you to the most appropriate treatment for you. Decisions are based on any previous treatments, location,, number, and type of warts.
This partly reflects that lack of evidence for one being superior to another. For those who want to see the figures, check out table 1 of the 2015 BASHH guideline on treatment of genital warts. The first column of figures gives the clearance rates, and the last column gives the recurrence rate. It’s not possible to say which treatment is definitely ‘best’. However, cryotherapy is so easily available with results within a week or two that it’s a common starting point. TCA is also a good clinic treatment. Home treatments would usually be with Wartec® or Aldara®.
Should my partner attend a clinic?
It is best to let partners know, and to suggest that they do make an STD appointment. There will be a natural fear of not wishing to let the partner know and there is likely to be embarrassment but remember that 15% of young people have been exposed to HPV with only 1% having a wart.
The issues for the Partner are that they have warts they are unaware of (eg. in the vagina or cervix) or another STD. Around 90% of genital warts are caused by HPV types 6 and 11 and these are not the HPV types that cause cervical cancer. However, other HPV subtypes are linked with cervical cancer and it is important for females to have regular pap smears. In summary, it is sensible for partners to make an appointment to discuss these issues and consider examination for warts, STD testing and pap smears..