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

2. Cases of genital warts/year in UK

3. 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

4. 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)

5. 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

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

7. 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

8. But first…
….what’s a normal lump?

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

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

14. Parafrenular glands Symmetrical, small and smooth surface
No treatment required

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

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

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

22. And now…
other differentials

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

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

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

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

30. 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

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

32. 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

33. Source: Sandyford Protocols- External Anogenital Warts.33

34. 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, (BASHH) 34

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

38. Non-keratinised warts
Warticon
Cryotherapy or imiquimod if not improving

40. 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

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

43. 20 week pregnant female

44. 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

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

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

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

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

53. Single wart at fourchette
Cryotherapy
Surgical excision

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

57. 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

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

61. 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

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

63. Sandyford contacts

64. Some final points…

65. Chlamydia/Gonorrhoea NAAT test

66. PREFERRED SAMPLE
VULVOVAGINAL SWAB

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

68. 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