Anogenital Warts

Condyloma acuminatum, otherwise known as anogenital warts, are caused by nononcogenic or low-risk human papillomavirus (HPV). The warts thrive inside and around the anus and on parts of the male and female genitals. HPV is spread through skin-to-skin contact with an infected area of the body. It is most commonly spread during sexual activity, although it does not require genital-to-genital contact to be passed from one person to another.1

Anogenital warts are one of the most commonly diagnosed sexually transmitted infection (STI) in the United States.2 In fact, most people who are sexually active contract HPV at some point in their lives.3 There are more than 200 varieties of HPV and their symptoms can range from skin growths to cancer. Of low-risk anogenital warts, 90 percent are caused by HPV-6 and HPV-11.4 These strains of HPV can remain latent for months or years after being contracted, so many patients often unknowingly transmit these diseases to their partners. There is no known cure for anogenital warts although there are many different types of treatments that can remove and reduce the appearance of the warts. Preventative measures such as vaccines and barrier contraceptive methods can also decrease the likelihood of transmission.

Transmission

HPV is highly contagious and around 14 million Americans are infected with HPV every year. A person can contract genital HPV infections through vaginal, anal, and oral contact with an infected partner. Other types of sexual skin-to-skin contact (as in foreplay or manual stimulation) and sharing sex toys with an infected person can also lead to the spread of HPV. Although rare, it is possible for a mother to pass HPV to an infant during childbirth. It is not common for kissing to lead to transmission, but oral HPV infections can occur as a result of oral sex. The virus can be contracted even if the infected person does not have any symptoms.

Anyone who is sexually active is at risk for contracting HPV, regardless of the individual’s number of sexual partners. In fact, people are most likely to become initially infected with HPV is right after they first become sexually active.5 The Center for Disease Control (CDC) recommends any patient with untreated anogenital warts refrain from sexual activities with new partners until the warts are treated and removed. Although the warts are usually asymptomatic, some growths can become pustular and pruritic (become filled with pus and irate). These developments can create additional risks while engaging in sexual activity.

Symptoms

Anogenital warts first appear as tiny blemishes, sometimes as small as the head of a pin, and may grow larger than the size of a pea. Warts may vary in appearance from large cauliflower-like growths to small pink bumps that can be difficult to see. They may be raised or flat and may grow and spread rapidly. Typically, the warts are not painful, although, in some cases they may cause pain, bleeding, and itching.​​

Anogenital warts can also spread to other areas of the body. For females, warts can develop on the inner and outer labia, on the lower area of the vagina, and on the cervix. For males, warts may appear on the shaft or on the tip of the penis, and on the scrotum. HPV-6 and HPV-11 can also spread to the mouth or the throat of a person who has performed oral sex on an infected person. Patients with visible symptoms of HPV may suffer psychological distress from the appearance of anal warts. Nonetheless, anal warts are extremely common. The CDC reports that about 360,000 people infected with HPV per year experience warts as a symptom. Anal warts can be treated or removed by a doctor. If left untreated, the warts may grow, stay the same, or go away over time.1

Treatment

Although anogenital HPV is not curable, there are many different treatment methods to mitigate its symptoms. Application of a mild acetic acid solution highlights any existing warts that are less visible to the naked eye, allowing physicians to further diagnose symptoms. Since many persons with external warts also have intra-genital or intra-anal warts, a doctor may perform either a Pap test or an internal anal exam (also known as anoscopy) to inspect the vaginal or anal canal to determine the sites of infection.6 Currently, there is no HPV test recommended for men besides a visual diagnosis by a trained medical profession. The type of treatment for HPV depends on the size, appearance, and location of the warts. Doctors may recommend different types of treatments including ointments, cryotherapy, and electrocautery to remove or reduce the size of the warts.

Ointments

Small warts located on the surface of the anus may be treated with topical medications and can be self-administered directly to the surface of the warts. This method usually requires several applications of medications performed at various intervals over several weeks. The current patient-applied topical medications on the market are Imiquimod, Podofilox, and Sinecatechins.

These medications all have limitations depending on the lifestyle and condition of the patient. For example, Imiquimod and Sinecatechins have active ingredients that can weaken latex condoms and vaginal diaphragms. Some side effects of these medications can also cause complications for females who are pregnant or persons with immunocompromised conditions like Human Immunodeficiency Disease (HIV). It is important to consult your doctor prior to applying medications for anogenital warts.

Cryotherapy

Larger warts or warts that are located on the inside of the vaginal or anal canal require more aggressive medical attention. A trained healthcare provider may freeze off larger warts with liquid nitrogen or cryotherapy. Cryotherapy can sometimes be more invasive than other treatments as it can cause blistering and necrosis of the skin around the treated area. Use of a cryoprobe in the vagina or anal canal can also increase the risk of vaginal perforation or fistula formation.2

Electrocautery

More severe cases might require electrocautery or laser treatment. Surgical therapy has the advantage of eliminating most warts at one time. Since most warts are present on the upper dermis, surgical procedures don’t usually require extensive treatments.2 These procedures provide immediate results but may require the use of local or general anesthesia. Nearly all patients can go home the same day of the procedure.

Since anogenital warts may reappear repeatedly after successful treatments, follow-up screenings are necessary for long-term prognoses. Very rarely, post-surgical complications may result in chronic pain syndromes such as vulvodynia, painful defecation, or fistulas.2

Recovery

The recovery time and the potential pain or discomfort resulting from anal wart removal depends on each individual situation and the number of warts that are removed. Most people are moderately uncomfortable for a few days after treatment and may receive prescription pain medication, while others may experience only slight discomfort. Depending on the extent of the case, some people are back on their feet the next day, while others may need to refrain from physical activity and laborious tasks for up to several weeks.3

Typically, more than one or two treatments is necessary to completely eradicate anal warts. Even with electrocautery and surgical treatments that immediately destroy existing warts, many patients develop new warts after treatment. This occurs because the virus that causes the warts can live under the surface of the skin, allowing the skin to appear normal for up to six months or longer before another wart develops. In this way, the virus “hibernates” and pops up later during another outbreak.

Subsequent warts can typically be treated in the physician's office, using either a chemical solution or the electrocautery procedure. These treatments may be performed every few weeks initially, then less frequently as new warts become smaller and less numerous. Follow-up appointments are recommended (and oftentimes necessary) to ensure that the warts are kept under control.

Prevention

HPV can cause chronic symptoms that have lifelong consequences. However, with modern technology, there are many preventative methods to that can help you avoid contracting HPV or to treat HPV once contracted. These methods include getting vaccinated, getting tested, and practicing safe sex.

  • Vaccines: The Food and Drug Administration (FDA) has approved three vaccines, Gardasil®, Gardasil® 9, and Cervarix®, for the prevention of anogenital HPV infections. All three vaccines prevent infection with HPV-16 and HPV-18, two high-risk HPVs that cause about 70 percent of cervical cancers and an even higher percentage of other HPV-caused cancers.7 Gardasil also prevents infection with HPV-6 and HPV-11. Gardasil 9 prevents infection with the same four HPV types plus five additional cancer-causing types.8
  • STI testing: Getting tested regularly can help people who are sexually active avoid contracting unwanted infections or help identify an existing infection at its earliest stage. HPV can be difficult to detect without clear symptoms; therefore, doctors can help diagnose or treat early signs of growths that may still be asymptomatic. Getting tested can also help youprotect your partners and prevent the spread of STIs.
  • Safe sex practices: You can lower your chances of contracting HPV by practicing safe sex with your partner and future partners. While HPV can still be transmitted while using barrier contraceptive methods like condoms or dental dams, using a barrier method still safer than using no protection at all. Other safe practices include thoroughly cleaning your sex toys each time you use them and communicating effectively with your partner about getting tested regularly.

While it may seem impossible to avoid contracting HPV when nearly 80 million Americans are currently affected by it, you can take precautionary measures to protect yourself and others from ever dealing with HPV by getting vaccinated and practicing safe sex.

Concluding Remarks

Anogenital warts are a symptom of HPV that can cause both mental and physical discomfort. While they can be benign and asymptomatic, anogenital warts are dangerous when left untreated. Clusters of warts can create high-risk lesions that have a high chance of developing into different forms of gynecologic cancers.4 Nevertheless, despite the existing negative associations one may have with anogenital warts, it is important to understand that with proper treatment and care, anogenital warts can be controlled and maintained and those experiencing them can still lead a healthy and fulfilling sex life.

References

  1. “Risk Factors for Anal Cancer.” American Cancer Society, 13 Nov. 2017.
  2. “Anogenital Warts - 2015 STD Treatment Guidelines.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 4 June 2015.
  3. Parenthood, Planned. “What Is HPV & How Do You Get It?” Planned Parenthood.
  4. McCutcheon, Tonna. “Anal Condyloma Acuminatum.” Gastroenterology Nursing : the Official Journal of the Society of Gastroenterology Nurses and Associates, U.S. National Library of Medicine, 2009.
  5. "Human Papillomavirus (HPV) and Cervical Cancer." World Health Organization. World Health Organization, n.d. Web. 20 Apr. 2016.
  6. “Anal Warts.” American Society of Colon and Rectal Surgeons.
  7. Chaturvedi, Anil K, et al. “Human Papillomavirus and Rising Oropharyngeal Cancer Incidence in the United States.” Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, American Society of Clinical Oncology, 10 Nov. 2011.
  8. “Human Papillomavirus (HPV) Vaccines.” National Cancer Institute, 16 May 2018.

Last Updated 14 May 2019.

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