Anogenital Warts - Human Papillomavirus (HPV) Infection - CDC

Anogenital warts are a common disease, and 90% are caused by nononcogenic HPV types 6 or 11. These types can be commonly identified before or at the same time anogenital warts are detected (1206). HPV types 16, 18, 31, 33, and 35 also are occasionally identified in anogenital warts (usually as infections with HPV 6 or 11) and can be associated with foci of high-grade squamous intraepithelial lesion (HSIL), particularly among persons who have HIV infection. In addition to anogenital warts, HPV types 6 and 11 have been associated with conjunctival, nasal, oral, and laryngeal warts.

Anogenital warts are usually asymptomatic; however, depending on the size and anatomic location, they can be painful or pruritic. They are usually flat, papular, or pedunculated growths on the genital mucosa. Anogenital warts occur commonly at certain anatomic sites, including around the vaginal introitus, under the foreskin of the uncircumcised penis, and on the shaft of the circumcised penis. Warts can also occur at multiple sites in the anogenital epithelium or within the anogenital tract (e.g., cervix, vagina, urethra, perineum, perianal skin, anus, or scrotum). Intra-anal warts are observed predominantly in persons who have had receptive anal intercourse; however, they also can occur among men and women who have not had a history of anal sexual contact.

Prevention

Anogenital warts have decreased among adolescents, young women, and heterosexual men with use of HPV vaccination in multiple countries, including the United States (1203,1207–1216).

Diagnostic Considerations

Diagnosis of anogenital warts is usually made by visual inspection but can be confirmed by biopsy, which is indicated if lesions are atypical (e.g., pigmented, indurated, affixed to underlying tissue, bleeding, or ulcerated lesions). Biopsy might also be indicated in the following circumstances, particularly if the patient is immunocompromised (including those with HIV infection): the diagnosis is uncertain, the lesions do not respond to standard therapy, or the disease worsens during therapy. HPV testing is not recommended for anogenital wart diagnosis because test results are not confirmatory and do not guide genital wart management. Some anogenital lesions can resemble anogenital warts (condyloma accuminata), but do not respond to anogenital wart treatment. Condyloma lata, a manifestation of secondary syphilis, can be diagnosed by serologic tests or through direct detection from serous fluid from the lesions (see Syphilis, Diagnostic Considerations).

Treatment

The aim of treatment is removal of the warts and amelioration of symptoms, if present. The appearance of warts also can result in considerable psychosocial distress, and removal can relieve cosmetic concerns. For most patients, treatment results in resolution of the warts. If left untreated, anogenital warts can resolve spontaneously, remain unchanged, or increase in size or number. Because warts might spontaneously resolve in <1 year, an acceptable alternative for certain persons is to forego treatment and wait for spontaneous resolution. Available therapies for anogenital warts might reduce, but probably do not eradicate, HPV infectivity. Whether reduction in HPV viral DNA resulting from treatment reduces future transmission remains unknown.

Treatment of anogenital warts should be guided by wart size, number, and anatomic site; patient preference; cost of treatment; convenience; adverse effects; and provider experience. No definitive evidence indicates that any one recommended treatment is superior to another, and no single treatment is ideal for all patients or all warts. Shared clinical decision-making between a patient and a provider regarding treatment algorithms has been associated with improved clinical outcomes and should be encouraged. Because all available treatments have shortcomings, clinicians sometimes use combination therapy (e.g., provider-administered cryotherapy with patient-applied topical therapy between visits to the provider). However, limited data exist regarding the efficacy or risk for complications associated with combination therapy. Treatment regimens are classified as either patient-applied or provider-administered modalities. Patient-applied modalities are preferred by certain persons because they can be administered in the privacy of their home. To ensure that patient-applied modalities are effective, instructions should be provided to patients while in the clinic, and all anogenital warts should be accessible and identified during the clinic visit. Follow-up visits after weeks of therapy enable providers to answer any questions about use of the medication, address any side effects experienced, and facilitate assessment of the response to treatment.