Patients complain of perineal itching, burning, pain and tenderness or they may be asymptomatic, especially with cervical and vaginal involvement, but noticed distinctive fleshy warts of the external genitalia or anus. Lesions are pedunculated or borad based with pink to gray soft excrescences, occuring in clusters or individually.
What to do:
External warts seldom require biopsy for diagnosis. The differential diagnosis of anogenital warts includes molluscum cantagiosum, verruca vulgaris (common non-genital wart), secondary syphilis (condyloma lata), hypertrophic vulvar dystrophies and vulvar intraepithelial and invasive neoplasias. Consider atypical, pigmented, intravaginal cervical and persistant warts for referral for biopsy.
Prescribe podofilox 0.5% solution (Condylox) 3.5mL for self-treatment. Patients may apply podofilox with a cotton swab to warts twice daily for three days, followed by 4 days of no treatment. This cycle may be repeated as necessary for a total of 4 cycles. Total wart area treated should not exceed ten square centimeters and total volume of podofilox should not exceed 0.5mL per day. If possible, you should apply the initial treatment to demonstrate the proper application technique and identify which warts should be treated.
Alternatively, apply 25% podophyllin in tincture of benzoin (Podocon-25) 15mL using the above application technique and with the same dosage restrictions. Have the patient thoroughly wash off in 1-4 hours. This may be repeated weekly if necessary but if warts persist after six applications the patient should be referred for alternative therapy.
If the patient is pregnant, has severe involvement or has anal or rectal warts, she should be referred for cryotherapy, application of trichloroacetic acid, ablation with carbon dioxide laser, electrocautery or surgical extirpation.
If the patient's male partner also has visible lesions, he can be treated using the same regimens.
Counsel both about the unpredictable natural history of the disease and the possible increased risk of lower genital tract malignancy. Infected women should have an annual Pap smear.
What not to do:
Do not use podofilox or podophyllin during pregnancy. There have been a few cases of toxicity reported when large amounts of podophyllin have been used.
Do not mistake "pearly penile papules" for warts. These dome-shaped or hairlike projections around the corona of the glans penis are normal variants in up to 10% of men.
Genital warts are a result of infection with human papillomavirus (HPV). The virus is currently considered a leading candidate as a causative agent in squamous carcinomas of both the female and male genital tracts. The sexual transmission of HPV is well documented, with the highest prevalence in young, sexually active adolescents and acults. HPV types 6 and 11 are the most prevalent types associated with condyloma accuminata and are not considered to have malignant potential. HPV frequently coexists with other sexually transmitted diseases. HPV lesions are difficult to eradicate, with a very high recurrence rate, and still no definitive therapy.