Genital warts

Genital warts are small fleshy growths, bumps or skin changes that appear on or around your genital or anal area. They are the result of a viral skin infection caused by the Human Papilloma Virus. (HPV). Genital warts are very common. In England, they are the second most common type of sexually transmitted infection (STI) after chlamydia. Genital warts are most common in sexually active teenagers and young adults.

HPV is spread by skin-to-skin contact, so penetrative sex is not necessary for transmission. Genital warts are usually painless and do not pose a serious threat to a person’s health. However, they can appear unsightly and cause psychological distress. The Human Papilloma Virus (HPV) is not a single virus, but a family of over 100 different strains of viruses. Of these, 40 strains of HPV are known to cause genital warts. Other strains of HPV can cause cervical cancer.

Genital warts can be spread during vaginal or anal sex, and by sharing sex toys. Condoms do not provide complete protection because it is possible for the skin around your genital area (that is not covered by the condom) to become infected. HPV is most likely to be transmitted to others when warts are present, although it is still possible to pass the virus on before the warts have developed and after they have disappeared. The incubation period for genital warts (the time that it takes for symptoms to develop after developing an infection) can be as long as one year. Therefore, if you are in a relationship and you get genital warts, it does not necessarily mean that your partner has been having sex with other people.

Symptoms of genital warts

Genital warts usually appear within two to three months of developing an HPV infection, although incubation periods of up to a year have been reported. In women, genital warts usually begin as small, gritty-feeling lumps that become larger. A person can have a single wart, or clusters of multiple warts that grow together to form a kind of ‘cauliflower’ appearance. Warts are usually painless, although some people may experience symptoms of itchiness and irritation, particularly if warts develop around the anus (back passage). Warts that develop near or inside the urethra can disrupt the normal flow of urine. The urethra is the tube that is connected to the bladder, through which urine passes.

The most common places for genital warts to develop in women are:

• around the vulva (the opening of the vagina), which occurs in 2 out of 3 cases of genital warts
• inside the vagina, which occurs in 1 in 3 cases
• between the vagina and the anus, which occurs in 1 in 3 cases
• around the anus, which occurs in 1 in 4 cases
• on the cervix (the neck of the womb), which occurs in 1 in 10 cases
• at the opening of the urethra, which occurs in 1 in 25 cases

GENITAL WARTS (HPV) TRANSMISSION

Genital warts are caused by the human papillomavirus (HPV). HPV targets a type of tissue that is known as epithelial tissue, which is found on the skin, and on the lining of many of the body’s cavities, such as: the female genitalia, including the vagina, vulva and cervix, the anus and the mouth. In many cases, HPV does not cause any noticeable symptoms, so many people can be infected with HPV without realising it. The most common way that HPV can be passed from person to person is during sexual intercourse. Other forms of sexual activity where HPV can be passed from person to person include: oral sex, anal sex, non-penetrative genital to genital contact. Less commonly, a mother can pass HPV on to her newborn baby during birth.

Diagnosis of Genital Warts

Genital warts can usually be easily diagnosed by examining them. At a check-up, the doctor or nurse may use a magnifying lens to do this. Women will also have the inside of their vagina examined using a speculum, which is a specially designed instrument that incorporates a torch and a mirror.

Further testing may be recommended if: you have recently had anal sex and you were the passive partner, you have warts around your anus, you have experienced bleeding from your anus or urethra or if your normal urine flow has become distorted. The inside of the anus can be examined with a special metal instrument called a proctoscope. A proctoscope is a small metal tube that incorporates a torch and a magnifying lens. A similar tool called an endoscope (a thin, flexible tube with a camera at one end) may be used to examine the inside of your urethra.

Treatment of Genital Warts

There are two main types of treatment for genital warts:

• topical treatment, where a cream, lotion or chemical is applied directly to the wart or warts
• physical ablation, where the tissue of the wart is destroyed using external forces, such as lasers or electricity

Sometimes different people respond to treatments for genital warts in different ways. For example, one treatment can be very effective at treating one person’s symptoms, but fail to have much effect in someone else. However, topical treatments tend to work better on softer warts, and physical ablation tends to work better on harder and rougher feeling warts. Sometimes, a combination of topical treatment and physical ablation can be used. Either type of treatment can take several months to remove the warts, so it is important to be patient and persevere with the treatment.

Topical treatment of Genital Warts

There are several topical treatments that can be used to treat genital warts. These are:

Podophyllotoxin – Podophyllotoxin is usually recommended to treat clusters of small warts. It comes in liquid form and works by having a toxic (poisonous) effect on the cells of the warts. A special application stick is used to draw up the correct dosage of the liquid, which is then dripped onto the wart. You may experience some mild irritation when you apply the liquid to the wart. Treatment with podophyllotoxin is based on cycles. The first treatment cycle involves applying the medication twice a day for three days. This is then followed by a rest cycle where you have four days without treatment. Most people require four to five treatment cycles that are separated by rest cycles.

Imiquimod – Imiquimod is a type of cream that is usually recommended to treat larger warts. Imiquimod works by helping to stimulate your immune system into attacking the warts. You apply the cream to the warts and then wash it off after six to ten hours. This should be done three times a week. It can often take several weeks of treatment before you begin to notice an improvement in your symptoms. Common side effects of imiquimod include: hardening and flakiness of the skin, swelling of the skin, a burning or itching sensation after applying the cream, headache. These side effects are usually mild and should pass within two weeks of stopping treatment with imiquimod.

Trichloroacetic acid (TCA) – Trichloroacetic acid (TCA) may be recommended to treat small warts that are very hard. TCA is also recommended for use by women who are pregnant because it is thought to be the safest of all the topical treatments to use during pregnancy. TCA works by destroying the proteins inside the cells of the wart. However, if it is not applied correctly, TCA can damage healthy skin. Therefore, it is recommended that you do not apply TCA yourself. Instead, you will be asked to visit your local GUM clinic once a week so that a doctor or nurse can apply the medication. After TCA is applied, some people experience an intense burning sensation for around five to ten minutes.

Ablation Treatment of Genital Wart

There are four main methods used in the physical ablation of genital warts. They are: cryotherapy, excision, electrosurgery and laser surgery. These are described in more detail below.

Cryotherapy – Cryotherapy is usually recommended to treat multiple, small warts, particularly those that develop on the vulva. Cryotherapy involves freezing the wart using liquid nitrogen. Freezing helps to kill the cells of the wart by splitting their outer membranes. After being frozen, the wart is allowed to thaw out and, if necessary, it can be frozen and thawed again. During cryotherapy treatment, you will experience a mild to moderate burning sensation. Once the treatment has finished, it is likely that you may develop skin irritation, blistering and pain at the site of the wart. Your skin will take between one and three weeks to heal. Avoid having sex until the area of skin around the wart has fully healed.

Excision – Excision is sometimes recommended to treat small, hardened warts, particularly where this is a combination of smaller warts that have joined together to form a sort of cauliflower shape. At the start of the procedure you will be given a local anaesthetic to numb the area of skin around the wart. The wart will then be cut away with a surgical scalpel, and the remaining incision will be sealed with stitches. Excision can cause scarring so it may not be suitable for very large warts. The area of skin from where the wart was removed will be sore and tender for around one to three weeks.

Electrosurgery – Electrosurgery is often combined with excision to treat large warts that develop around the anus or vulva that have failed to respond to topical treatments. First, excision is used to remove the outer bulk of the wart. A metal loop is then pressed against the wart. An electric current is passed through the loop in order to burn away the remaining part of the wart.

Laser surgery – Laser surgery may be recommended to treat large genital warts that cannot be treated using other methods of physical ablation because they are located in a difficult position to access, such as deep inside your anus or urethra (the tube that connects the bladder to the penis or vulva, through which urine passes). Laser surgery may also be recommended for pregnant women who fail to respond to treatment with trichloroacetic acid (TCA). During the procedure, the surgeon will use a laser to burn away the warts. Depending on the number and size of the warts, laser surgery can be performed under either a local or general anaesthetic. As with other types of ablation treatment, you should expect soreness and irritation at the site where the warts were removed. This should heal within two to four weeks.

Genital warts and sex

It is recommended that you do not have sex, including anal and oral sex, until your genital warts have fully healed. This will help prevent you passing the infection on to others. It will also help speed up your recovery time, as skin friction that occurs during sex can cause treated skin to become irritated and inflamed. Even after the warts have gone, there may still be traces of human papillomavirus (HPV) in your skin cells. Therefore, it is recommended that you use a condom during sex for the first three months after the warts have cleared up.

Smoking

For reasons that are still unclear, many of the treatments discussed here are more effective in non-smokers than in smokers. Therefore, if you are a smoker, quitting smoking may help to speed up the time that it takes for the warts to heal. Quitting smoking will also bring a range of other important health benefits, such as significantly reducing your risk of developing lung cancer and heart disease.

Prevention Of Genital Warts

Condoms – Using condoms (male or female) every time you have vaginal or anal sex is the most effective way to avoid getting genital warts, other than being celibate (not having sex) or getting vaccinated (see below). If you have oral sex, cover the penis with a condom. A dental dam, which is a latex or polyurethane (plastic) square, can be used to cover the anal area or female genitals. Dental dams are usually only available at sexual health clinics clinics, although your local pharmacist may be able to order some for you.

Avoid sharing sex toys. However, if you do share them, wash them or cover them with a new condom before anyone else uses them. Following these measures will also help to protect you from getting a number of other sexually transmitted infections (STIs), such as HIV, chlamydia and gonorrhoea.

HPV vaccinations – There are currently two HPV vaccinations that are available for the virus:

• Cervarix, which provides protection against some strains of HPV that are known to cause cervical cancer, but does not provide protection against the strains that cause genital warts
• Gardasil, which provides protection against cervical cancer (in women) and genital warts (in men and women)

Cervarix was recently introduced as part of the routine vaccination schedule for girls, and is usually given to girls who are 12 or 13 years of age. Gardasil is not part of the routine vaccination schedule and it is not usually available on the NHS. It is likely that you will have to pay to have the vaccine privately if you want yourself, or your child, to be vaccinated against genital warts using Gardasil. The vaccine is estimated to be 99% effective in preventing genital warts in young men and women.

However, after being vaccinated, it is thought that a person’s immunity will gradually start to reduce after six years. The cost is around £140 to £180 a dose and three doses are required. There is a specific schedule for vaccination with Gardasil. The second dose should be given at least one month after the first dose. The third dose should be given at least three months after the second dose. All three doses should be given within a 12-month period.

The vaccination is injected directly into the muscles, either into the upper arm or the thigh. Common side effects of Gardasil include: pain, redness, bruising and swelling at the site of the injection , flu-like symptoms, such as a high temperature and joint and muscle pain