Diagnosis & Management:

• Introduction

• Contents

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• Clinical assessment guidelines

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Diagnosis and management
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Genital warts
Diagnosis and management

Diagnosis

Management

Patient education

Follow-up

Diagnosis

Diagnosis is made on clinical grounds. Biopsy may be required for unusual presentations.

Management

The aim of treatment is to remove clinically evident warts. No treatment has been demonstrated to eradicate HPV. All treatment modalities are associated with high recurrence rates.

In some cases, genital warts may regress spontaneously.

Cryotherapy

Liquid nitrogen is applied to visible warts at weekly intervals until resolution. 

Podophyllotoxin

This is self applied treatment.  It is associated with a far lower rate of adverse reactions than treatment with podophyllin. 

podophyllotoxin 0.5% solution or 0.15% cream topical 12 hourly for 3 days followed by 4 days of no therapy.  This cycle may be repeated up to 4 times.  A maximum surface area of 4cm² can be treated (ADEC D).

The doctor should demonstrate the proper application technique and identify which warts should be treated.

Note:

• Do not use in pregnancy

• Do not use on cervical, rectal or urethral warts (because of difficulty in preventing damage to adjacent moist tissues and the potential for systemic absorption).

• Treat warts in the outer vagina or vestibular area with extreme caution. Only treat small isolated warts and allow to dry, to minimise contact with normal mucosa.

• Never use large volumes by treating extensive or very large warts. When large numbers of warts are present, discuss management with a consultant.

Imiquimod

This is self applied treatment.  It is more effective for women than men.

imiquimod 5% cream topical for 6-10 hours three times per week on alternate days for up to 16 weeks (ADEC B1).

Referral and investigation

Surgical removal, electrosurgery or laser therapy are used for warts resistant to the foregoing methods, for extensive warts or warts in certain locations, eg rectal warts.

Patients with cervical or extensive intravaginal warts should be referred for colposcopy.

Urethroscopy is indicated before treating recurrent meatal warts, and proctoscopy before treatment of perianal warts.

Patient education

The following points should be covered:

• The nature of the infection

• HPV is very common.  Most people will become infected with genital types during their sexual life

• Most infected people are asymptomatic with only a very small number developing visible wart

• The oncogenic types of HPV rarely cause visible genital warts

• HPV infection is often present in the absence of genital warts and is only of clinical significance if present on the cervix. It is impossible to diagnose subclinical HPV infection clinically 

• Side effects of treatment and their management. If podophyllotoxin has been used, stress the need to return immediately if a severe reaction results from treatment

• Cryotherapy may cause scarring or pigment changes

• HPV transmission is thought to be more likely in individuals with clinical warts. Condom use may be recommended until resolution of warts.

• Provide or recommend literature on warts and HPV.

Follow-up

Clinical assessment at one week, to assess response to therapy, and re-treatment as required.

For further information, see the South Australian Cervix Screening Program web site.

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