Dr Daniela Brawley ST4 Genitourinary medicine 23rd November 2010 Warts and All Dr Daniela Brawley ST4 Genitourinary medicine 23rd November 2010

Cases of genital warts/year in UK

Human Papilloma Virus > 100 sub-types of HPV HPV 6 and 11 cause 90% of genital warts Most clear the infection in 9 months HPV 16 and 18 risk for malignant change Persistent infection with oncogenic sub-types increases risk of malignant change

Prevalence 1% of population have visible warts 10% have active HPV infection 60% have cleared HPV However can have long latent or lifelong phase ? Missed opportunity with quadrivalent HPV vaccine (6/11/16/18)

Transmission Sexual in majority of cases Female to male 71% at 3 months Male to female 54% at 3 months Condoms can reduce risk but don’t eliminate Increased risk if immunocompromised and/or smoker

Diagnosis Diagnosis is by examination under good light Consider referral/biopsy if atypical or unsure STI screening Partner notification not necessary

STI screening 10-20% have co-existing STIs Extensive warts – HIV indicator disease BHIVA 2008 HIV testing guidelines Chlamydia/ Gonorrhoea Urine in males Vulvovaginal/cervical swab in females HIV/Syphilis

But first… ….what’s a normal lump?

Pearly penile papules Normal anatomy No treatment Common presentation in young men Reassure strongly that are normal

Vulval papillomatosis Smooth and symmetrical Easily confused with HPV Don’t progress review at 1 month No treatment

Parafrenular glands Symmetrical, small and smooth surface No treatment required

Fordyce spots or sebaceous follicles Glands in clusters Prepuce, shaft of penis and vestibular area of vulva More obvious when skin is stretched Reassurance

Sebaceous cysts No treatment necessary unless become too large or get infected Reassurance In men scrotal sebaceous cysts may occur

Lymphocoele Hard swelling behind coronal surface No treatment required Usually resolves over time Reassurance

And now… other differentials

Molluscum contagiosum Pox virus Skin to skin contact, most likely sexual Cryotherapy STI screening including HIV especially if extensive

Condyloma Lata of Secondary Syphilis Refer GUM Syphilis PCR and serology Dark ground microscopy STI screening Penicillin and GUM follow-up

Now for warts…. Site, distribution and number Morphology- keratinised or non keratinised Patient features Experience and equipment Availability of cryotherapy

Treatments Podophyllotoxin (warticon) Cryotherapy Imiquimod (aldara) Smoking cessation Excision

Warticon Purified extract of podophyllin Solution (0.5%) or cream (0.15%) Non-keratinised warts, not perianal 3 days BD then 4 days rest for 4 weeks Soreness and ulceration NOT used in pregnancy

Cryotherapy Necrosis of dermal-epidermal junction Keratinised warts and intrameatal warts Weekly application with “Halo” and “Freeze and thaw” techniques Safe in pregnancy

Aldara Immune response modulator Non formulary and expensive (£50/month) Used for resistant/extensive warts 3 times a week for maximum 16 weeks NOT used in pregnancy

Source: Sandyford Protocols- External Anogenital Warts. 33

Clearance rates TREATMENT END OF TREATMENT >3 MONTHS RECURRENCE RATES (%) Cryotherapy 63-88 (75) 63-92 0-39 (20) Imiquimod (Aldara) 50-62 (58) 50-62 13-19 (16) Podophyllotoxin (Warticon) 42-88 (65) 34-77 10-91 (50) Surgical excision 89-93 (91) 36 0-29 (15) Source: United Kingdom National Guideline on the Management of Anogenital Warts, 2007. (BASHH) 34

Keratinised Warts Cryotherapy first line Imiquimod if not improving Warticon less likely to be effective but can try for 4 weeks

Non-keratinised warts Warticon Cryotherapy or imiquimod if not improving

Perianal warts Cryotherapy first line Imiquimod if not improving Warticon can be used but not licensed Proctoscopy not indicated unless immune suppressed, or symptoms in anal canal

Extensive Sub-preputial warts GUM referral Imiquimod and cryotherapy Surgical referral

20 week pregnant female

Warts in pregnancy Cryotherapy Warticon and Imiquimod contraindicated Improve/resolve 6-8 weeks after delivery Not an indication for Caesarean Section Small risk of transmission both genital and laryngeal papilloma 1 in 400 No reduction with c-section

Warts and Bowen’s Disease Referral for biopsy of suspicious areas Cryotherapy/ electrocautery Circumcision

Warts and VIN Referral for biopsy of suspicious areas Localised surgical excision Referral to Gynaecology

Features indicating biopsy Atypical Pigmentation Flat warts Older age groups Immunosuppression including HIV Heavy smokers

Extensive warts Trial of imiquimod +/- cyrotherapy Referral to Gynaecologist for surgical removal STI screening

Single wart at fourchette Cryotherapy Surgical excision

Extensive anal warts HIV positive gay man GUM referral Syphilis PCR and serology Cryotherapy and/or Imiquimod Proctoscopy Surgical referral Risk of AIN

Meatal Warts Cryotherapy Concern about causing urethral stenosis If can see extent of warts Concern about causing urethral stenosis Warn about symptoms of urethral obstruction

Vaginal warts Usually resolve with treatment of external warts Cryotherapy if not improving

Cervical warts Usually resolve with treatment of external warts Ensure has had recent smear No need for additional smears If no external warts or no improvement with treatment of external warts refer to colposcopy

Summary points Treat the patient in front of you Offer STI testing Smoking cessation Refer if unsure, not improving or suspicious features

Sandyford contacts www.sandyford.org 0141 211 8130 dbrawley@nhs.net

Some final points…

Chlamydia/Gonorrhoea NAAT test

PREFERRED SAMPLE VULVOVAGINAL SWAB

Tests for ulcers Syphilis Herpes type 1 and 2 Combined PCR test Confirm with syphilis serology

PRIMARY CARE VAGINAL DISCHARGE PROTOCOL History Low risk STI Typical BV or VVC history No symptoms of PID Examination and pH pH < 4.5 Treat for VVC pH > 4.5 Treat for BV High risk STI Pregnant Requests testing Examination, pH and CT/GC NAAT Await CT/GC NAAT Recurrence Symptoms of PID Postpartum Gynaecological instrumentation Exam HVS CT/GC NAAT GUM referral if GC positive or unresolved CT/GC NAAT BV- bacterial vaginosis VVC- vulvovaginal candida CT/GC NAAT- Chlamydia/Gonorrhoea molecular test GUM- genitourinary medicine clinic