Human Papillomarvirus (genital warts)

Genital warts are one of the most common sexually transmitted infections. There are over 70 strains of HPV (human papillomavirus). Certain strains of HPV are known to cause genital warts. It is estimated that less than 1% of men and women infected with HPV develop symptoms.
HPV Vaccination

* Four of the common types of HPV can be prevented through vaccination. These are types 6, 11, 16, and 18.
* Types 16 and 18 cause over 70% of cervical cancers.
* Types 6 and 11 cause 90% of anal and genital warts worldwide. Talk to your family doctor or nurse practitioner about your need for vaccination.

Who should be vaccinated?

* The vaccine has been approved for use in Canada for females 9-26 years of age.
* Ideally the vaccine should be given to females before they become sexually active in order to ensure maximum benefit.
* There is still a potential benefit from receiving the vaccine regardless of previous sexual activity, Pap abnormalities, cervical cancer, anogenital warts, or a known HPV infection.
* Although no recommendations were made for women older than 26 years, its use can be considered in individual circumstances.

How can I get vaccinated?

* The vaccine requires 3 doses to be given over the course of 6 months (0, 2, and 6 months).
* Make an appointment with your family doctor or nurse practitioner.

Do I need to pay for the vaccine?

* Yes, the vaccine costs about $160 per injection (~ $480 for all three).
* Some or all of the cost may be covered by private health plans.

Symptoms

Genital warts are highly infectious and are usually transmitted sexually. They may appear on the external and internal areas of the genitals and in the anal-rectal region. They may also appear on the buttocks, lower abdomen and upper thighs. Genital warts caused by HPV types 6 and 11 are believed to be benign (non-cancerous).

Warts may be pink, red or gray and can vary in size and shape. Sometimes they cluster together giving a cauliflower appearance. Genital warts are usually painless, but can cause some discomfort if they become large. Sometimes, although it is rare, genital warts can be itchy and have a foul-smelling discharge.
Transmission

The incubation period of the HPV virus is variable. This means that it might take longer for one person to develop symptoms than it takes another person (if symptoms develop at all). Most people develop symptoms within three to six months after infection, but in some cases symptoms occur years later. If you are infected with HPV but show no symptoms, you can still infect someone else.

Risk factors for genital warts include multiple sexual partners, unprotected sexual activity, early age of first sexual intercourse, smoking, low immunity and a history of other sexually transmitted infections.
Diagnosis

Visible warts are easy to diagnose. You or your doctor may see them on your genitals. Warts come in all different shapes and sizes: raised, bumpy, flat and even cauliflower-like. They can be small or large, single or multiple. If you have any lumps or bumps you are concerned about, get your doctor to have a look at them. Your doctor may use white vinegar and magnification to help locate the flat, smaller warts. Warts on the cervix may be difficult to see and may require a special technique called colposcopy. A microscope is used to visualize the cervix and tissue samples are taken as indicated.

Often there are no visible warts. This is called sub-clinical HPV infection. A Pap-smear test may inadvertently pick up sub-clinical HPV infection. Changes in the cells of the cervix found on a Pap test could be consistent with HPV and are an indication to look for the virus, possibly by colposcopy.No treatment guarantees cure of HPV infection. Visible genital warts are treated with chemicals or liquid nitrogen. This is thought to reduce transmission. The removal method will depend upon the clinical presentation of the warts and your doctor. Often, multiple treatments and possibly several removal methods will be required.

Pharmacologic treatment for external genital warts:

* Podophyllin – Cytotoxic agent used to treat dry warts. Administered by a physician and may require weekly treatments.
* Trichloroacetic Acid – Caustic agent used to treat moist warts. Administered by a physician.
* Imiquimod – A new drug, which stimulates the immune system to produce interferon and cytokines. Applied by the patient three times a week at bedtime.

Nonpharmacologic treatment for genital warts:

* Electrosurgery – Heat is used to destroy the abnormal growths.
* Cryotherapy – Abnormal growths are frozen and destroyed using liquid nitrogen.
* Conization – The abnormal tissue (in the form of a cone-shaped wedge) is removed from the cervix.
* Electrosurgical excision – Using electric energy and a wire loop, abnormal growths are destroyed.
* Laser treatment – A laser beam boils the water in the cells and vaporizes the tissue.

Although these treatments destroy existing warts, the virus may still exist in the body. Once diagnosed, an individual must continue looking for visible warts and receive annual medical checkups. Partners should also be checked and there should be no sexual activity until both are treated. It is possible that the virus may eventually leave the body although it is unclear how this happens.
Post-treatment

Your doctor will advise you of specific treatments. Generally, you are advised to

* avoid sexual intercourse until treated areas have been healed;
* avoid unprotected sex for six months;
* keep treated areas clean and dry—wear cotton underwear and consider blow-drying the treated area on a low setting;
* follow up with your doctor to ensure the wart lesions have gone; and
* return to your doctor if you suspect new wart lesions.