Genital warts, also known as condyloma acuminata, are benign growths that appear in the genital, anal, or perianal regions, and are caused by the human papillomavirus (HPV). These warts can present in various forms, ranging from flat to raised, single or multiple, small or large, and can be pink to dark brown in color. In some cases, they may cluster together to form a cauliflower-like appearance. HPV is a family of viruses that includes over 70 different types, with some types causing common warts on the hands and feet, while others specifically cause genital warts. In this context, types 6 and 11 are most commonly associated with the formation of genital warts.

Etiology and Pathophysiology
HPV is a highly contagious virus that is primarily transmitted through direct skin-to-skin contact, most commonly during vaginal, anal, or oral sex with an infected individual. Although genital warts are the most visible manifestation of HPV infection, the virus can also exist in a subclinical form, causing no visible warts. This asymptomatic or “clinically inapparent” infection is believed to be less contagious, although its exact transmission dynamics are not well understood. Some individuals infected with HPV may never develop visible warts, but the virus can remain latent in the skin or mucosal tissue, potentially activating later under certain conditions, such as a weakened immune system.

HPV infections are widespread among sexually active individuals, affecting both men and women of all ages and sexual orientations. While genital warts are primarily associated with sexual transmission, infants can be infected during childbirth, though this is rare. Infections with high-risk HPV types (16, 18, 31, 33, etc.) are also linked to an increased risk of certain cancers, including cervical, anal, and oropharyngeal cancers. These associations highlight the importance of HPV screening, especially in women, through Pap smears and other HPV detection tests.

Clinical Presentation
Genital warts can appear as small bumps or growths that vary in shape and size. They may be raised, flat, or cauliflower-like, and typically appear in the genital or anal areas. The warts may be pink, flesh-colored, or dark brown and may present as single or multiple lesions. In some cases, the warts can be difficult to detect without magnification. Warts can appear weeks, months, or even years after exposure to the virus, making it challenging to determine the exact timing or source of infection. In many cases, genital warts are painless, but they may cause discomfort, itching, or bleeding, particularly during sexual activity.

Diagnosis
The diagnosis of genital warts is typically made through a clinical examination. In some cases, a healthcare provider may use special magnifying instruments to visualize subclinical or microscopic warts that are not visible to the naked eye. Although a Pap smear is not designed to detect HPV, abnormal results may suggest HPV-related cellular changes, such as dysplasia or precancerous changes, especially in the cervix. Testing for HPV’s genetic material can provide additional information, helping to identify the presence of high-risk HPV strains associated with cancer.

Treatment Options
The treatment of genital warts focuses on removing visible lesions and managing symptoms. While no treatment can cure HPV infection, effective treatments can help reduce the symptoms and improve the quality of life by removing warts and preventing their spread. The choice of treatment depends on factors such as the number, size, and location of the warts, as well as patient preferences.

• Cryotherapy involves the application of liquid nitrogen to freeze off the warts. This method is effective and relatively inexpensive, making it a common treatment for small, localized warts. Cryotherapy can be performed in a clinical setting and may require multiple sessions for complete resolution.
• Topical Treatments:
  • Imiquimod (Aldara): This immune-modulating cream stimulates the body’s immune response to help clear HPV infection. It is applied topically and can take several weeks to show results. Imiquimod is expensive, and its use can cause mild irritation.
  • Podofilox (Condylox): Podofilox is a topical chemical that works by destroying wart tissue. It is applied directly to the warts and is often effective for treating external genital warts. However, it can cause irritation and should not be used on mucosal surfaces.
  • Trichloroacetic Acid (TCA): Applied by a healthcare provider, TCA is a chemical agent that can burn off warts. It is effective for treating smaller lesions but may require repeat applications.
• Electrocautery and Laser Therapy: Electrocautery, which uses electric currents to burn off the warts, and laser therapy, which uses focused light to destroy wart tissue, are options for larger or more resistant warts. These methods are effective but are often more expensive and may be reserved for cases that do not respond to other treatments.
• Surgical excision involves physically removing warts and is used for large or persistent lesions that do not respond to other treatments. This procedure may require local anesthesia and can result in scarring, making it less favored for cosmetic reasons.
• Interferon is an antiviral drug that can sometimes be used as an adjunct treatment, either before or after other therapies. It can be effective in clearing warts, but it is costly and may cause side effects such as flu-like symptoms.
• HPV Vaccination: The HPV vaccine, such as Gardasil, has been shown to be effective in preventing infection with high-risk HPV types (16, 18) and low-risk types (6, 11), which are responsible for genital warts. Vaccination is recommended for both males and females, ideally before the onset of sexual activity, to provide protection against future infections. The vaccine is administered as a series of three injections over a six-month period and is most effective when given prior to exposure to the virus.

Prevention
Preventing the spread of HPV and genital warts involves practicing safe sex by using condoms and dental dams, although these methods do not completely eliminate the risk of transmission. Vaccination remains the most effective means of prevention, particularly when administered before exposure to the virus. For individuals who are pregnant, certain treatments for genital warts, such as imiquimod, should be avoided due to potential risks to the fetus.

Conclusion
Genital warts are a common manifestation of HPV infection and can significantly impact quality of life due to their appearance and associated discomfort. Although there is no cure for HPV, a variety of treatments are available to manage symptoms and reduce the visibility of warts. Prevention through vaccination and safe sexual practices remains crucial in reducing the burden of HPV and its complications, including genital warts and HPV-related cancers. Regular screenings, such as Pap smears for women, are essential for detecting precancerous changes linked to high-risk HPV strains.

References

1. Centers for Disease Control and Prevention (CDC). (2021). Genital HPV infection – Fact sheet. https://www.cdc.gov/std/hpv/stdfact-hpv.htm
2. Farthing, R. A., & Rosenthal, S. L. (2020). Management of genital warts: Treatment strategies and prevention. American Journal of Obstetrics and Gynecology, 223(1), 11-20. https://doi.org/10.1016/j.ajog.2020.01.019
3. Markowitz, L. E., Toh, P., & Liu, G. (2019). HPV vaccination and prevention of cervical and other cancers. Cancer Journal, 25(6), 327-336. https://doi.org/10.1097/PPO.0000000000000403