Genital warts

Genital warts produce painless skin lesions or lumps in the genitalia and sometimes around the anus. Genital warts may be so small and flat that they can’t be seen with the naked eye. Sometimes, however, genital warts may multiply into large clusters.

They can be itchy or sore when they are growing fast, and occasionally may bleed.

Genital warts in men:

Men can experience genital warts in the following areas:

• Pubic area
• Penis
• Meatus (i.e. in the opening of the water pipe)
• Scrotum
• Perineum (i.e. the area between the external genitals and the anus)
• Anus
• Peri-anal area

Genital warts in women:

Women can experience genital warts in the following areas:

• Pubic area
• Vulval area
• Vaginal walls
• Cervix
• Perineum (i.e. the area between the external genitals and the anus)
• Anus
• Peri-anal area

Many people are perplexed to learn that they have anal warts even if they have not engaged in anal sex. This is because the HPV has a tendency to infect both anal and genital areas irrespective of its site of initial contact. Therefore, having anal warts does not mean that one has necessarily had anal sex.

Genital warts may cause discomfort and/or irritation. This can be due to inflammation produced by rubbing against clothing, or the rapid increase in size outstripping its blood supply.

Genital warts, especially those with a narrower base, can twist on its base cutting off its blood supply and can become painful and discoloured.

Occasionally, the warts can also be a site for another infection which may be responsible for the pain. Commonly encountered infections causing pain include:

• Anaerobic infections
• Herpes outbreak
• General bacterial infections

It is important to diagnose and treat these underlying infections before treatment for genital warts is considered.

Many patients report that the warts have resolved spontaneously without any treatment. Studies show that up to 50% of warts resolve on their own within 24 months of their occurrence.

However, it is hard to predict who will benefit from such spontaneous clearance, and many people do not like the idea of having on-going warts due to cosmetic and confidence reasons.

In the event that your warts don’t go away by themselves, or you’d prefer not to wait, effective genital wart treatment options are available.

Genital warts usually appear between 3 weeks to 8 months after exposure to HPV/Genital warts. However, it is entirely possible to develop genital warts after this time if the virus becomes active from its dormancy. This means that genital warts may appear on someone after years of being exposed to HPV.

In most people, genital warts do not lead to any medical complications. However, the following complications may sometimes arise:

• Squamous Cell Carcinoma: Sometimes High Risk HPV may be present in the warts and this can lead to development of cellular abnormalities which may lead to the development of cancer.
• Infection on the surface/base of the warts: Warts can sometimes get infected with secondary bacterial or fungal infections.
• Bleeding: Warts have got very rich blood supply, and tend to bleed heavily after being cut off accidentally.
• Difficulty in maintaining hygiene: Larger warts can have cauliflower like surface, and make it very difficult to maintain hygiene, especially those near the anal area.
• Buschke Lowenstein Tumors: Sometimes genital warts can be large enough to affect day to day activities. Buschke Lowenstein Tumors are very large warts which are treated surgically.
• Affect vaginal delivery in pregnant women: Sometimes genital warts can be large enough to interfere with a vaginal delivery.
• Blood in urine dipstick: Meatal warts (genital warts at the opening of the water pipe/urethra) can lead to blood in a urine dipstick.
• Laryngeal Papillomatosis in children: Warts in the larynx can occur in children before 5 years of age and can produce hoarseness of voice, noisy breathing and difficulty in breathing in more severe cases.
• Laryngeal Papillomatosis in adults: The papilloma in the Larynx (or voice box), can lead to hoarseness of voice.
• Concurrent skin conditions: Sometimes warts are present on the skin surface with another skin condition like lichen sclerosus. Treatment of this skin condition requires application of very strong steroid cream, which nourishes warts, and makes them worse.

Genital warts are caused by the Human Papilloma Virus (or HPV). There are more than 100 types of HPV and types 6 & 11 are accountable for more than 90% of genital warts. The transmission of HPV, and the development of genital warts, occurs as a result of the following:

• Having unprotected vaginal, anal or oral sex with someone with HPV infection (with or without warts)
• Very close contact with partners’ genitals
• (Rare) During childbirth from infected mother

You can’t get genital warts from kissing, hugging, sharing baths or towels, from swimming pools, toilet seats or from sharing cups, plates or cutlery.

Often people who have always been meticulous in protecting themselves with condoms are distraught when they learn that they have genital warts. This is because the virus is shed from a much wider genital area than a condom can cover.

Often people seek an explanation as to when they first got exposed to the virus and from which partner. It is very difficult to pin-point the exact moment when you come in contact with HPV because the virus has a habit of laying dormant without causing any symptoms but being contagious at the same time.

Furthermore, most people will have developed genital warts after being with someone who did not have them. This can make it even harder to determine who gave you the infection.

• You come into contact with someone with genital warts present
• You have sex with someone of the same gender
• Increased number of sexual partners
• Unprotected vaginal or anal sex
• Weaker immune system

In rare cases, one might develop warts in the mouth, throat or on the lips from oral sex, or pass warts on the hands to the genitalia. If you’re pregnant and have genital warts at the time, it’s possible to pass the virus to the baby at birth in rare cases.

• Immunosuppressive drugs: Drugs to suppress the immune system are used in patients with kidney transplant and conditions such as psoriasis, rheumatoid arthritis and lupus.
• Steroids: Steroids have a well-established effect of suppressing the immune system, especially when taken orally, but can also produce a similar effect when used topically on the genital skin.
• Diabetes: Poorly controlled diabetes, especially type 1 diabetes mellitus, is associated with more severe cases of genital warts, poor response to treatment and higher chances of recurrence.
• Smoking: More severe cases of genital warts have been noted amongst heavy smokers.

• A full course of HPV vaccination
• Having protected vaginal, oral and anal sex with new partner(s)
• Using a condom, femidom and/or dental dam with a new partner
• Recommend your partner to get treated for genital warts

Genital warts are commonly diagnosed by a physical examination from an experienced professional. Occasionally, the use of a magnifying glass, dermatoscope or colposcope helps in this diagnosis.

In cases where it is difficult to diagnose genital warts, we use the aid of two diagnostic tools:

• Cryotherapy: A cold spray of liquid nitrogen is applied directly to the lesion, and brings up its finer details.
• Dilute acid: We apply the acidic solution directly onto the lesions, and it makes them more prominent and easier to see. This in turn makes them easier to diagnose.

Histopathological examination of a biopsy specimen from the suspected lesion is rarely needed to confirm the diagnosis.

In trying to diagnose genital warts, there are other kinds of lesions we have to make sure it is not. These may include:

• Molluscum Contagiosum
• Skin tags
• Seborrhoeic Keratosis
• Lichen Sclerosus
• Chronic herpetic lesions in those with underlying immunosuppression
• Blocked sebaceous glands
• Localised cysts
• Scarring

Sometimes patients may have lesions due to more than one cause. This can result in a multiple diagnosis.

Your partner does not need to get tested for HPV or receive any treatment if they have no signs or symptoms of genital warts. This is where HPV and genital warts are managed very differently from other classical STIs like Chlamydia, Gonorrhoea and Syphilis.

Therefore, it’s not necessary for you to tell your partner that you have been diagnosed with genital warts. However, your relationship may be such that you may feel it is necessary to share your diagnosis with your partner to help with your inner well-being.

Genital warts can recur after treatment because the treatment only eradicates the symptoms of HPV, but not the HPV infection itself.

There is no cure for the HPV infection, you will still have the infection in your body despite any treatment you may have had for genital warts. The main way of clearing the infection is via a natural process, although it can be a chronic and long lasting infection for others.

Although warts are very common and treated widely, accurate statistics do not exist to make precise predictions. Therefore, it’s difficult to predict the likelihood of warts recurring after the treatment in an individual patient.

However, the presence of underlying health conditions including diabetes, use of immunosuppressive drugs and the use of steroids can increase the likelihood of warts coming back after treatment.

The warts can come back after successful treatment, months or even years later. More often than not, recurrence of warts is likely to be due to activation of existing HPV type, rather than getting exposed to a new HPV type.

There is no validated way to prevent genital warts from recurring. General advice to reduce the chances of warts coming back include:

• Stopping smoking
• Avoid shaving areas affected by genital warts
• Tighter control of diabetes (in those with diabetes)
• Treatment of HIV /AIDS (in those with underlying infection)

In rare cases, agents to boost immune system to fight HPV more effectively can be used.