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Genital warts (HPV) - Dr Deac Pimp


  • Benign papular epithelial proliferative growth(s) on or around the genital region caused by HPV (human papilloma virus), sexually transmitted
  • Also called anogenital warts


Risk factors

  • Sexual contact with someone with warts
    • Condoms do not provide full protection
  • Many sexual partners
  • MSM
  • Anoreceptive/rough sex/genital trauma increases likelihood of transmission
  • Early age at first sexual encounter
  • Other STIs
  • Fisting and fingering
  • Immunosuppression
  • Smoking


Differential diagnoses

  • Molluscum contagiousum
  • Skin tags
  • Pearly penile papules
  • Sebaceous glands
  • Epidermoid cysts
  • Herpes simplex
  • Syphilis – condyloma lata (secondary syphilis)
  • Neoplasia/malignancy



  • Around 63,000 cases in England in 2016
  • Has been dropping for the past 5 years
    • Likely result of cross-protection from first HPV vaccine (Cervarix: bivalent for HPV 6 and 11))
    • Is expected to drop as girls who received the new HPV vaccine (Gardasil: quadrivalent for HPV 16 and 18) begin sexual activity (first cohort is age 16 in 2017)
    • No drop in MSM population, possible rise over last 5 years
  • 35% incidence in 15-24 year olds undergoing chlamydia screening in 2008 (before new HPV vaccine)
  • 12% incidence in women in sexual health clinics in 2007, down to 0.85% in 2011



  • Infection with HPV virus
  • Over 95% of warts are caused by strains 6 and 11
    • No risk of malignancy (types 16 and 18)
  • Easily transmissible
    • Sexual transmission: 60% transmission rate to partner
    • Vertical transmission during pregnancy
    • Autoinnoculation to other parts of body
    • Non-sexual transmission eg on fingers


Clinical features

  • Papules of varying size. May join together, and can grow massive, especially in immunocompromised patients
    • Resemble cauliflower, especially when grow together
  • If on moist, non-hairy skin warts are generally soft and non-keratinised
  • If on normal hairy skin warts are generally firmer and keratinised
  • Can be pedunculated or not
  • Often skin coloured, can be pink, grey, white, red or brown
  • Warts can be found anywhere in the anogenital region, or outside this area, but common sites include:
    • Males: frenulum, corona, glans, inner foreskin, urethral meatus, shaft, scrotum, perianal, perineum, pubis, anal canal
    • Female: labia, clitoris, urethral meatus, introitus, vagina, cervix, perineum, perianal, pubis, anal canal
  • Symptoms may relate to position, eg urinary obstruction if on urethral meatus



  • Double stranded DNA virus, HPV 6 and 11



  • Examination
  • 20% have concurrent STI, so investigate symptoms and swab test is necessary
  • Rule out other causes
  • Biopsy is not usually necessary unless recurrent, atypical or there is high risk of malignancy



  • Warts can be left, and 1/3 will disappear within 6 months
  • Podophyllotoxin (‘Warticon’) 0.15% cream (vulval) or 0.5% solution (penile) can be used for non-keratinised warts only. Apply twice a day for 3 days, then 4 rest days. Repeat for 5 weeks. Not suitable in pregnancy.
    • 43-83% success rate
  • Imiquimod 5% cream for keratinised or non-keratinised, applied 3 times a week until warts are gone for up to 16 weeks. Not suitable in pregnancy.
    • 35-68% clearance rate
  • Ablation:
    • Cryotherapy
    • Excision
    • Laser
    • Electrothermy
    • All of these options may leave scars, especially on those with darker skin
    • Have much higher clearance rates
  • Recurrence in 20-30% of patients, regardless of type of management
  • Cervical warts require referral to gynaecologist and colposcopy
  • Intra-anal warts require referral to proctoscopy and possible surgery



  • Lifelong subclinical infection may occur
  • Warts may increase in size if left
  • May be co-infection with high risk HPV (16 and 18), which increase risk of malignancy
HPV Genital Warts.docx
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