Genital warts should not be confused with manifestations of other Sxually Transmitted Diseases such as condylomata lata of secondary syphilis. Condylomata lata are characterized
by large, white or gray, raised, moist, and flat lesions. In contrast, external genital warts are typically dry and cauliflower-like. If condylomata lata are suspected, serologic tests for syphilis (rapid plasma reagin [RPR], Venereal Disease Research Laboratories [VDRL], with confirmatory treponemal tests such as the Treponema pallidum particle agglutination assay [TP-PA]) will be positive, and surface scrapings of the lesion will reveal spirochetes under darkfield microscopy.
The lesions of the poxvirus, molluscum contagiosum, are shiny and umbilicated papules that may appear anywhere on the body except the palms and soles. These flesh-colored lesions are 2–5 mm, appear singly or in groups, and may sometimes be difficult to distinguish from genital warts. Unlike genital warts, however, molluscum contagiosum causes smooth and only rarely pedunculated lesions that may express cheesy material. Although most self-resolve in immunocompetent patients, the lesions can be particularly recalcitrant in AIDS patients with low CD4 T-cell counts.
A normal anatomic variant of the corona in men, pearly penile papules, can sometimes be mistaken for genital warts. Analogous lesions in women occur in the vulvar introitus. One clue to the diagnosis of these variants of normal anatomy is to look at the base of the lesions. In the normal variants, each normal papilla can be seen to arise from its own base; by contrast, in anogenital warts, multiple papillae typically arise from a single base. Lichen planus, nevi, and seborrheic keratoses may also be rarely confused with genital warts.
CAUSE
Human papillomavirus (HPV) is one of the most common sexually transmitted diseases (STDs) and is the cause of genital warts (condylomata acuminata), anogenital dysplasia, and invasive cancer. Oral warts may also occur as a direct consequence of HPV infection during sexual activity. At least 75% of sexually active men and women acquire one or more genital HPV types at some point in their lifetime.
The incubation period from HPV infection to condyloma is usually 3–4 months, with a range of 1 month to 2 years, but many infected persons have subclinical disease or have regression of disease before it becomes clinically apparent. HIV-infected patients have a higher prevalence of genital warts than HIV-uninfected patients. These may proliferate further during immune reconstitution following the initiation of antiretroviral therapy.
There are more than 100 different HPV types; 40 of these can cause anogenital lesions. HPV types 6 and 11 are most commonly associated with genital warts; these types have a low risk of malignant transformation. Other types (eg, 16, 18, 31, 33, and 35) have a strong association withcervical and other anogenital cancers. Thus, genital warts lie on one spectrum of a continuum of HPV-associated.
PATHOGENESIS
Most anogenital HPV is believed to be acquired via sexual transmission. Following acquisition of infection, HPV infection is established initially in the basal cells of the anogenital epithelium. As the basal cells differentiate and rise to the epithelial surface, HPV replicates and virions
form. A spectrum of disease occurs, depending on the degree of mitotic activity and replacement of the epithelium with immature basaloid cells. In the cervix, this ranges from genital warts or mild dysplasia (CIN 1) to moderate or severe dysplasia (CIN 2 and CIN 3).
SYMPTOMS AND SIGN
Genital warts appear as characteristic well-circumscribed, exophytic papules that may be pedunculated. Some warts may be flat. The adjacent skin usually appears normal. They range in size from a few millimeters to several centimeters, with some warts coalescing to form larger plaques. The median number of warts in an individual patient is seven although there is a large range from patient to patient.Most genital warts in circumcised men occur in the penile shaft. In uncircumcised men, they occur mainly in the preputial cavity where the penile shaft meets the glans. Other common locations for genital warts in men include the perianal area, particularly among men who have sex with men (MSM), and the urethral meatus. Less frequently, genital warts are seen on the scrotum and perineum.intra-anal warts can be very common as well. Among women, most lesions are found in the posterior introitus, the labia majora and minora , and the clitoris. Other less common locations in women are the perineum, vagina, anus, cervix, and urethra.
Symptoms of genital warts may include burning, itching, pain,
and fullness (urethra, vagina, or anus); however, many patients are asymptomatic.
Patients with genital warts may complain of itching, burning, bleeding, and pain. Patients with large genital warts may have a sensation of fullness and this may interfere with intercourse, vaginal delivery, and defecation. However, many patients have no symptoms.
Most genital warts are diagnosed by the characteristic appearance on clinical examination only. If lesions look atypical or have features that may be consistent with malignancy such as induration, ulceration, and pigmentation, biopsy with histologic evaluation should be
considered.
PREVENTION
The most reliable method of preventing HPV acquisition is abstinence from sexual activity, including skin-to-skin contact. However, there is strong evidence that male tion, as well as HPV-associated diseases such as genital warts, CIN 2 or 3, and invasive cervical cancer. Although not recommended by the US Centers for Disease Control and Prevention (CDC), partner evaluation may offer an opportunity to screen and provide education on HPV and other STDs.
Preventive vaccines are promising new options. A multivalent vaccine against four HPV subtypes (6, 11, 16, and 18) was approved by the Food and Drug Administration (FDA) for use in women and girls aged 9–26 years in June 2006. These immunizations use components of the major HPV capsid proteins that assemble into viruslike particles that contain no HPV DNA and thus are not infectious.
Vaccination with viruslike particles is designed to induce neutralizing antibodies prior to initial HPV exposure by the host. In large, randomized controlled trials, excellent
efficacy has been demonstrated against certain HPV types, including 6, 11 (which can cause anogenital warts), and 16 and 18 (which can cause invasive cervical and other
anogenital cancers). Future trials will test the efficacy of combined vaccines for additional types.
COMPLICATIONS
Genital warts have little risk of progression to invasive cancer. However, individuals with genital warts usually have shared risk factors for oncogenic HPV types that cause high-grade CIN and anal intraepithelial neoplasia.These are the true precancerous lesions and are the target of Pap screening programs.
In relation between Genital warts and pregnancy, it is know that genital warts may proliferate and increase in size during pregnancy and can obstruct the pelvic outlet during vaginal delivery. A rare complicationin children born to women with genital warts is recurrent respiratory papillomatosis. Warts develop in the infants’ throats, commonly the vocal cords, causing hoarseness or stridor. These warts are frequently removed, usually by laser surgery, to prevent the possibility of respiratory failure. Because the prevalence of recurrent respiratory papillomatosis is so low, cesarean delivery is not usually recommended as a preventive measure in pregnant women with genital warts.
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