What is Genital Warts?
Genital warts are a symptom of a sexually transmitted disease known as certain strains of Human Papillomavirus (HPV). Not everyone who gets infected with HPV will actually get genital warts- only 10% do. Most people, about 90%, who are exposed to the virus don’t develop these warts. The main cause of genital warts is the 6 and 11 types of HPV, out of over a hundred different known versions of the virus. You should know that HPV is typically spread via skin-to-skin contact, often during sexual activity. Although some types of HPV are known to cause cervical and anal cancer, these aren’t the same strains that lead to genital warts. It’s also possible to have concurrent infections with different types of HPV.
What Causes Genital Warts?
HPV, or the Human Papillomavirus, is mainly spread through sexual intercourse. It can also spread through other types of sexual activities without penetration, but this is less common.
There is some debate about whether condoms can help prevent the spread of HPV. Around 30% of genital warts, a common sign of HPV, disappear by themselves within four months of appearing. However, even after treatment, most genital warts come back within three months. How often they come back can depend on the person’s overall health, immune system, whether they’ve been vaccinated against HPV, the specific type of HPV, how often they have sex with an infected person, condom usage, and the amount of virus.
People who smoke are more likely to get genital warts. Three out of four people whose partners have warts get them within eight months. Even though 90% of the time the body clears the HPV infection within two years, sometimes the virus can lie dormant and cause the first occurrence or a recurrence of warts months or even years later. This dormant HPV can still spread. If a person has unprotected sex with a partner who has HPV, there is a 70% chance they will get infected.
In people who’ve had HPV before, any new warts are probably from a new exposure to the virus or a recurrence of the old infection. Warts in the anal or genital area can be passed on during birth and could mean sexual abuse. Genital warts can also appear due to self-infection, where warts from another part of the body are transferred to the genitals, such as from the hands.
Risk Factors and Frequency for Genital Warts
Genital HPV (Human Papillomavirus) infections are fairly widespread, affecting an estimated 10% to 20% of the population. However, only 1% show clinical symptoms. There has been an increase in the number of HPV infections, with about 80% of the people affected being 17 to 33 years old. The highest number of cases is seen in the 20 to 24-year age group. It’s calculated that about 2.9% of males in the US will carry the genital HPV DNA.
Although there are treatments to remove warts caused by the virus, they cannot eliminate HPV from the body. Sometimes, warts may disappear on their own. It’s traditionally thought that the virus remains in the body forever, but current views suggest that the body might fully get rid of it or suppress it to levels that tests can’t detect.
HPV is known to cause most cases of anal cancer (about 90%) and nearly all cases of cervical cancer in women. About half of these cases are caused by a particular type of HPV, known as HPV type 16. Cervical cancer is the fourth most common cancer seen in women. Other cancers, such as some vulvar cancers (29% to 43%) and vaginal cancer (70%), have also been linked to HPV. In men, HPV is associated with Bowen disease of the penis and about 35% to 40% of all penile cancers.
Risk factors that might make HPV stay in the body longer include age, smoking, immune system illnesses, and having multiple HPV types at the same time.
An HPV vaccine is available. The Centers for Disease Control and Prevention (CDC) suggests that adults aged 27 to 45 who haven’t been vaccinated before should get the vaccine. For kids, the CDC recommends the vaccine be given at ages 11 or 12 years, but it can be started as early as 9 years old.
Signs and Symptoms of Genital Warts
Genital warts are a type of sexually transmitted infection that can appear on different parts of the body. These warts can show up individually or in groups. They often appear in the genital or anal area, such as on the penis, scrotum, vagina, or outer labia. Genital warts can also occur on the internal surfaces of the vagina and anus. They range in size, with some being quite small (less than 5 mm in diameter), and others forming large clusters in the genital or anal regions. The color of the warts can differ, but they usually blend in with skin color or are darker. Occasionally, these warts may bleed on their own.
Besides the physical signs, genital warts can cause symptoms like itching, redness, or discomfort. They can also lead to emotional stress. Often, the presence of these warts is the only noticeable sign of a Human Papillomavirus (HPV) infection.
Testing for Genital Warts
Diagnosing genital warts primarily involves a visual inspection, but a more invasive confirmation method involving a small tissue sample (biopsy) might be necessary. Sometimes, small warts can be mistaken for a different skin condition called molluscum contagiosum. Genital warts are usually raised above the skin, display certain skin cell changes, and have specific traits related to an HPV infection.
Since genital warts are typically caused by low-risk HPV types, DNA testing is not usually used for diagnosis or in cases of low-risk HPV infections.
Some medical practitioners may apply a solution of vinegar-like compound (acetic acid) to the skin to help find small warts and affected areas. However, this method is not universally accepted as it is a topic of debate amongst experts.
A biopsy might be advised if the diagnosis is unclear or if the patient’s immune system is significantly weak. Lesions (wounds) that are colored or ulcerated should also be seriously considered for a biopsy.
If the genital warts have spread to the tip of the penis (glans), or if the patient has significant urinary symptoms, an internal examination of the bladder (cystoscopy) may be necessary. Also, even if a patient shows no symptoms, some specialists suggest observing the healing of any glans lesions prior to the test to avoid the possible spread of the HPV virus into the urinary tract.
Treatment Options for Genital Warts
Currently, there is no cure for HPV. Even though visible warts can be removed, it doesn’t stop the spread of the underlying HPV infection. In fact, about 80% of those with HPV will naturally get rid of the infection within 18 to 24 months.
The treatment for warts varies based on how many there are, their size, and where they’re located. It’s important to note that treatment can lead to permanent changes in skin color, itching, pain, and scarring. Warts located at the opening of the urethra are best treated with surgery to prevent long-term complications. The American Urological Association does not advise treating invisible warts.
There are essentially two types of treatments – physically removing or destroying the wart (known as ablative) or applying topical agents. Physically removing the wart is more effective, but many people prefer to start with topical treatments, especially for smaller warts.
One type of topical treatment is Podophyllotoxin, a gel or cream applied directly to the warts. Side effects can include burning, itching, pain, inflammation, and it should not be used during pregnancy. Another topical treatment is Imiquimod, a cream that increases the body’s immune response but may cause symptoms like a fungal infection or the flu. Sinecatechins, an extract from green tea, have also been found to effectively clear warts, though they take longer to work. They are applied as an ointment and can cause redness, inflammation, and pain.
There are other treatments that are usually prescribed by a healthcare provider. An acne medication called Isotretinoin, for example, has shown significant efficacy when used in tandem with standard treatment for genital warts. Trichloroacetic acid, however, is not as effective and can cause injury to surrounding tissues, so it’s best to avoid using it on certain areas of the body, like the vagina, cervix, or urinary opening.
Genital warts can also be physically removed or destroyed, an approach that’s especially effective on larger, keratinized warts. Common methods include using a small surgical procedure under local anesthetic, applying liquid nitrogen, electrocauterization, or laser vaporization. More extensive warts may require surgical removal under general anesthesia. Additionally, there have been successful tests using photodynamic therapy with a photosensitizing agent like aminolevulinic acid.
However, some types of treatment, like 5-fluorouracil 5% cream and interferon intralesional injections, have been discontinued because of their side effects. And it’s important to note that treatments such as Podophyllin, podofilox, and especially Isotretinoin should be avoided during pregnancy.
What else can Genital Warts be?
- ‘Condyloma lata’ or a form of syphilis
- A non-dangerous, inherited skin condition called ‘familial benign pemphigus’
- Infection from the herpes simplex virus
- Non-cancerous skin growths called ‘benign nevi’
- A condition affecting the nerve tissue in the vulvar area known as ‘vulvar neurofibromatosis’
What to expect with Genital Warts
Many genital wart cases don’t respond to treatment and often come back. This is especially true if there are repeated infections through sexual contact or a long incubation period of the HPV virus. Strategies to improve treatment include making sure patients follow their treatment plan, trying a different medicine, and adding a drug called isotretinoin.
Genital warts can cause itching, bleeding, and emotional distress because of the presence of genital lesions. Sometimes these warts can become malignant and turn into a type of skin cancer called squamous cell carcinoma.
People with weakened immune systems are more likely to have genital warts that are harder to treat and that come back more frequently. There’s also a greater chance for these warts to turn into squamous cell carcinoma. Usually, these patients benefit from using a mix of different treatments, adding isotretinoin early in the treatment process, longer treatment times, and performing surgery sooner.
Possible Complications When Diagnosed with Genital Warts
The main issue people encounter with this disease often involves changes to their physical appearance. If the disease isn’t treated and progresses, it can turn into cancer, which is a serious concern. Today’s standard care approach works to prevent such terrible outcomes through different treatment methods and primary prevention strategies.
Complications of this disease may include:
- Physical disfigurement
- Risk of cancer in severe or untreated cases
Prevention and treatment strategies include:
- Regular medical treatment
- Vaccination
Preventing Genital Warts
Gardasil is a vaccine designed to safeguard against certain types of the human papillomavirus (HPV) – specifically types 6, 11, 16, and 18. These types are notable because types 16 and 18 are responsible for around 70% of cervical cancers while types 6 and 11 cause about 90% of genital warts. It’s important to understand that this vaccine is preventative and won’t treat an existing infection – it must be given before you’re exposed to these types of the virus to work.
The vaccine got a thumbs up from the U.S. Food and Drug Administration (FDA) in 2006, and it’s appropriate for children as young as nine years old. Its primary aim is to act as a defensive shield against cervical cancer. In 2014, we saw the emergence of Gardasil 9, another FDA-approved vaccine. This one not just protects against the four HPV types covered by the original Gardasil but also five additional strains (HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58) that cause around 20% of cervical cancers.
All vaccines, including this one, are aimed at preventing the disease, not treating it. Medical professionals generally prefer vaccines that protect against more types of the virus – these are known as quadrivalent or 9-valent vaccines.
The Advisory Committee for Immunization Practices (ACIP) recommends routine HPV vaccination for women between the ages of 9 and 26. However, it can be effective up to the age of 45. As for adults over 26 and up to 45 who haven’t been vaccinated, the CDC suggests having a talk with their healthcare provider about getting the vaccine.
When it comes to males, the ACIP recommends quadrivalent HPV vaccination at ages 11-12. If not administered earlier or if the course wasn’t completed (the vaccines are given as a series of three doses), males can get the vaccine up to age 21. Between the ages of 22 and 26, the vaccine is optional, meaning males can choose if they want to receive it. So, ideally, males should get the HPV vaccination between the ages of 11 and 12, but it’s available up to age 45.
It’s not yet clear if the growing use of these vaccines will decrease the number of people exposed to HPV, as well as the number of infections and resulting complications. Research on this continues.