Genital Warts

The virus that causes genital warts, is called the Human Papilloma Virus (HPV). There are more than one hundred types of HPV some of which cause warts on the hands or feet. Other types cause genital warts. These genital types affect the outer layers of the skin on, in or around the genitals — on the vulva, inside the vagina, on the cervix, around the anus, groin or thigh, on the penis, scrotum or inside the urethra. Genital warts are painless growths or bumps in the skin that can be raised or flat, single or multiple, small or large. Some cluster together to form a cauliflower-like shape.

What causes warts to grow?

Many sexually active people carry HPV. Evidence suggests that most people who have been sexually active have been exposed to HPV and will experience an HPV infection at least once in their lifetime. Not everyone infected with HPV develops warts. This seems to depend on the type of virus and the strength of a person’s immune system. Some people develop warts soon after sexual contact with someone who is infected. Others develop warts later when they become run down, stressed or pregnant. Once a person has been exposed to the virus, it usually takes between 3 weeks to a year or more before a wart develops, if at all. At present, there is no easy way to detect the virus other than by detecting the presence of a wart. Not all wart infections are visible (eg. if they are very small or out of sight on the cervix or anus).

How is HPV transmitted?

Untreated genital warts can be passed on to a sexual partner. The virus is transmitted by direct skin to skin contact. Genital to genital contact is enough to transmit the virus from one person to another though the most common form of transmission is through vaginal or anal intercourse. It is possible to transmit the virus through oral sex but this is uncommon.

Warts on other parts of the body are caused by different types of HPV. It is thought that contact with these warts cannot cause genital warts.

Some people are exposed to the virus at birth and the warts may occur before they become sexually active. However the presence of genital warts in children may indicate childhood sexual abuse.

After infection, the virus may lie dormant for twenty years or more, flaring at times such as when the immune system is not working well. The sudden appearance of warts in a person who is not currently sexually active or who is in a stable relationship does not mean that the person has been recently infected through sexual transmission.

Most people carrying the wart virus in their skin have no symptoms or signs of the infection and are unaware that they are infected. Infected people therefore may infect their partners unknowingly.

How is HPV infection detected?

There is no blood test for HPV or swab test for genital warts. Changes on a Pap smear may be the first indication that the virus is present.

Warts may not be visible (eg, if they are very small, or out of sight on the cervix or anus). If an unusual lump on the genitals is detected, or if a person has had sex with someone who has warts, they should see a doctor or a sexual health clinician. Sometimes, in women, a persistent itch or painful sex can be caused by wart virus infection around the vaginal opening.

People who learn that they have HPV often feel shocked, angry and upset and blame their partner. This can make the stress worse and may encourage the development of the warts. People may feel ashamed and/or embarrassed, especially when discussing their diagnosis with a partner or prospective partner. All of these reactions are common. It is important to discuss these feelings with someone such as a partner, doctor, sexual health clinician or a counselor.

How common is HPV?

It is estimated that the lifetime risk of being exposed to the virus is up to 85%. However, only about one percent of the population has an active infection at any one time. Most people have a strong immune system, which makes the virus inactive.

What factors influence immunity

Certain factors can affect the ability of a person to deal with viruses generally and with HPV specifically.
It is not only the presence of the virus that is important but also how the body reacts to the
presence of the virus. This reaction depends on the strength of the immune system. Factors, which affect
the immune system, include:

What can be done to prevent HPV transmission?

Using a condom protects a person from sexually transmissible infections including any warts in the area covered by the condom. Condoms do not protect against infection from warts that are not covered by a condom. There may be areas where HPV is present but not visible. The female condom does give more protection by partially covering the vulva.

The more sexual partners a person has, the higher the risk of coming into contact with HPV and other sexually transmissible infections. People who think they have been put at risk of exposure to a sexually transmissible infection should have a sexual health check.

Why is HPV a concern?

HPV is an important health concern in particular for women. The virus has been linked to an increased risk of developing cancer of the cervix. Some types of HPV can cause the cells of the cervix to develop abnormally. Having abnormal cells of the cervix does not mean that a person has cancer. These abnormal cells sometimes turn to cancer. However this takes time, usually years for this to occur. Therefore if a woman has a regular Pap smear every two years, abnormal cells should be detected before cancer has had time to develop. If the Pap test detects abnormal cells on the cervix, treatment can reverse the changes. Doctors will advise their patients of the frequency of Pap smears or follow up tests if required.

A doctor or sexual health clinician should be consulted if bleeding between periods or after sexual intercourse occurs.

While HPV is very common and there is a link between HPV and cervical, anal, penile and some vulva cancers, it is important to realise that very few women and men with HPV develop cancer. There are many factors that can influence the development of cancer and HPV is just one such factor. Other implicated co-factors include smoking and a weakened immune system.

What are the treatment options for genital warts?

There is no cure for HPV though genital warts can be managed through a range of treatments. The goal of any treatment should be to remove visible warts, trigger the immune system to fight the infection and get rid of any annoying symptoms. Options for treating genital warts are:

   •Painting with podophyllin which is an extract of the May Apple plant. The liquid is applied directly to the wart/s by a doctor or sexual health clinician. Podophyllin affects the cells of the wart causing a chemical destruction of the lesion. Treatment must be washed off after 4 to 6 hours. It can cause skin irritation, local pain or blistering. It must not be used during pregnancy.

   • Cryotherapy is a common treatment for genital warts occurring both internally (eg. on the cervix) and externally and involves the freezing of the wart using liquid nitrogen or nitrous oxide. Cryotherapy is usually recommended during pregnancy as there are little side affects beyond the initial blistering of the treated area. There are usually no long-term scarring effects. Treatment is usually carried out on a weekly basis and can be painful.

   • Patients can apply podophyllotoxin solution directly on to visible warts. Podophyllotoxin is a purified extract of podophyllin. It is not suitable for difficult to reach places and must not be used during pregnancy. Because this treatment can be self- administered it may require fewer visits to a clinic. This treatment is done over about 4 to 6 weeks, applying the paint twice a day for 3 days and then resting for 4 days.

   • Another self-applied treatment is imiquimod cream marketed as Aldara. It has been used successfully to clear genital and perianal warts particularly those located in moist areas and in uncircumcised men. There may be irritating side-effects associated with this treatment such as a burning sensation, pain or tenderness. This treatment results in a low recurrence rate compared with other treatments. It can take up to i6 weeks to clear the warts. The treatment is not subsidised by the Pharmaceutical Benefit Scheme and is therefore expensive.

   • Laser therapy involves the removal of the wart by burning with a precise, high intensity light. This procedure is usually performed through a hospital facility. The precision of the treatment makes it suitable for delicate removal work and there is a very low risk of scarring. This treatment is not generally available.

   • Other options include electrosurgery/diathermy (removal with electrified blade, wire or needle) and scissor excision (scissors or scalpel) under local anaesthetic.

Genital warts on the cervix can be viewed with a special microscope (colposcope) and small sample (called a biopsy) taken to check for abnormalities of the cervix. Treatment to the cervix is usually carried out by a gynaecologist where the abnormal area is removed by laser, diathermy or surgery. Follow-up colposcopy and Pap smear are important.

Warts can recur despite these treatments. Treatment should be continued until all warts have gone. A final check three months later is recommended.

Your sexual partner(s) should also be checked for warts, and both you and your partner should be checked for other sexually transmissible infections (STIs).

Does HPV affect pregnancy?

The presence of warts will not usually affect pregnancy or delivery. Women with HPV who previously have not had visible warts may develop warts during pregnancy. This is because pregnancy can affect the body’s natural immunity. These warts often disappear soon after the birth when the immune system returns to normal function (about 6 weeks). Uncommonly, the warts may become so large that they need to be treated so as not to interfere with childbirth. Pregnancy does affect the choice of treatment — for example, podophyllin and podophyllotoxin should not be used. Only in very rare cases will HPV be transmitted to babies during birth resulting in wart growth in the baby’s throat or on the genitals.

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