Genital Warts — Recognise, Treat & Counsel
Genital warts (also called anogenital warts) are skin growths caused by human papillomavirus (HPV); most are due to types 6 and 11, which are low-risk types that do not usually cause cancer (BASHH)
They spread by skin-to-skin contact during vaginal, anal or oral sex, and by sharing sex toys; not by towels, baths, toilet seats or swimming pools
Warts may appear weeks, months or years after infection (average 3 to 11 months), so the time of infection and the source usually cannot be known
About 10 to 20% of patients have another sexually transmitted infection, so test for HIV, syphilis, chlamydia and gonorrhoea (Sandyford)
The diagnosis is made by looking; acetic acid testing for hidden infection is not recommended
Treatment clears the visible warts; no treatment is 100% effective and warts often return; some clear without treatment
Skin-coloured, pink or brownish lumps; soft, rough or cauliflower-like, or flat and slightly raised
On the labia, around the vaginal opening and perineum, and around the anus; sometimes inside the vagina, at the urethral opening or on the cervix
Usually painless; some women have itching, soreness or bleeding, and many have no symptoms and notice a lump
They often grow and multiply during pregnancy
Document the site, number, size, whether the surface is keratinised, and any pigment; note pregnancy and whether she can return for treatment (Sandyford)
| Look-alike | How it differs |
|---|---|
| Vestibular papillae (normal) | Tiny, even, finger-like projections in a symmetrical band at the vaginal opening; no treatment needed (from memory) |
| Molluscum contagiosum | Smooth, firm, dome-shaped papules, often with a central dimple (from memory) |
| Condylomata lata (secondary syphilis) | Broad, flat, moist, grey-white plaques; send syphilis serology (from memory) |
| Skin tags | Soft, smooth and often on a thin stalk (from memory) |
| Vulval pre-cancer or cancer | Pigmented, raised, ulcerated or bleeding; persistent; older women and smokers; biopsy (from memory) |
Examine in good light; use a speculum only if internal warts are suspected, and a proctoscope only for anal symptoms
Offer HIV, syphilis, and chlamydia and gonorrhoea tests
Check for pregnancy before choosing treatment (from memory)
Do not do HPV typing of the warts; warts do not change the usual cervical screening schedule, because the types that cause warts differ from those that cause cervical cancer
Ask about distress: a diagnosis can be upsetting, and support can be arranged
| Treatment | How it is used | Key points |
|---|---|---|
| Podophyllotoxin 0.5% solution or 0.15% cream (she applies it) | Twice a day for 3 days, then 4 days rest; up to 4 cycles; review at 4 weeks | Clears 40 to 70%; irritation is common; avoid on broken skin and in pregnancy |
| Imiquimod 5% cream (she applies it) | Three nights a week; wash off after 6 to 10 hours; until clear, at most 16 weeks | Skin reactions are common; avoid in pregnancy; caution with autoimmune disease or transplant |
| Green tea extract (sinecatechins) ointment (she applies it) | Three times a day, up to 16 weeks | Not for the vagina, urethra or anus; wash off before sex; avoid in pregnancy and breastfeeding |
| Cryotherapy (liquid nitrogen) (clinic) | Freeze, thaw, freeze again, 10 to 20 seconds each; every 1 to 2 weeks | Treatment of choice in pregnancy and for warts at the urethral opening; not suited to large or clustered warts |
| Trichloroacetic acid 80–90% (specialist) | Applied sparingly once a week; consider another option if under half have cleared after 4 applications | Specialist-applied; usually accepted in pregnancy (from memory) |
| Surgery or laser (specialist) | For large, extensive or resistant warts | Done under anaesthesia where needed; consider early if she is immunosuppressed |
Warts may appear or grow during pregnancy; treatment is possible but she should not use podophyllotoxin, imiquimod or green tea ointment; cryotherapy is preferred
HPV and warts cannot pass to the baby before birth; rarely a baby is infected during delivery
Warts alone are not a reason for caesarean section; she should tell the antenatal team (BASHH; caesarean is considered only if they block the birth canal, from memory)
Warts are very common; the virus often clears by itself; having warts does not by itself mean a weak immune system
She cannot tell when or from whom she was infected, and the position of the warts does not show how they were caught
Her partner needs treatment only if he or she has warts; partners may attend for a check or sexual health screening; treating partners does not change the course of her warts
Condoms cut the chance of catching HPV and warts by about 30 to 60%, but only cover the skin they touch; warts are most infectious when visible, so waiting until they clear lowers the risk
Warts can come back, especially in smokers, in pregnancy, and in immunosuppressed women
HPV vaccines that include types 6 and 11 prevent warts well when given before exposure; it is not yet known whether they clear existing warts; ask which vaccine is available in your area (from memory)
Vaccination, ideally before first sex
Condoms from the start of every sexual relationship
Not smoking, which makes HPV infection more likely and treatment less effective
Keep to the national cervical screening schedule (VIA every 5 years from age 30 to 65 in India)
Treating without testing for other infections
Giving podophyllotoxin, imiquimod or green tea ointment in pregnancy
Treating a pigmented, ulcerated or bleeding lesion without a biopsy
Putting creams inside the vagina, urethra or anus when the product is not meant for it
Home remedies such as acids, caustic pastes or cutting the lumps, which burn and scar (from memory)
Telling her that warts mean cancer, or that her partner has been unfaithful
Saying she is cured for life, or forgetting cervical screening
Missing the possibility of abuse when a child has warts
