condyloma acuminata (anogenital wart)
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Etiology
- all warts are caused by human papilloma virus (HPV)
- HPV types 6 & 11 generally cause genital warts (90%)[7]
- HPV types 16,18.30,31,33,34,35,39,40,42,43,44,45,51,52,53, 54,55,56,57,58,59,66,68 also associated with genital warts
- sexually transmitted disease
- children may acquire condyloma acuminata by
- vertical transmission (born to infected mothers)
- laryngeal papillomatosis, oral & skin condylomas
- generally manifested in 1st year of life
- horizontal transmission raises question of sexual abuse
- typical condyloma in anogenital region
- generally manifested after 1st year of life
- vertical transmission (born to infected mothers)
- risk factors for HPV infection
- sex with an infected partner
- multiple sexual partners
- previous sexually transmitted disease
- cigarette smoking
- oral contraceptives
Pathology
- HPV types 6 & 11 (genital warts) not associated with a malignant potential[7]
- cervical intraepithelial neoplasia (CIN) associated with HPV 16, 18, 31, 33, 35
- benign HPV lesions may become associated with neoplasia in immunosuppressed hosts
- lesions may regress spontaneously, recur or persist after therapy, or undergo malignant transformation
- majority of persons whose sexual partner has condyloma acuminata will develop condyloma acuminata within 3 months
- area of clinically apparent disease may represent only a small part of infection
Clinical manifestations
- most frequently asymptomatic
- average incubation period is 3 months, but may be as long as 6 months
- painless exophytic lesions[2]
- lesions occur on anogenital mucosa
- papillomatous, pedunculated or sessile lesions
- may appear as soft, pedunculated moist lesion
- occur singly or in clusters which may become confluent ('cauliflower' mass)
- skin-colored or hyperkeratotic (leukoplakia)
- on cervical epithelium, HPV may induce subclinical changes noted only on Pap Smear, colposcopy, or biopsy
- males develop condyloma on the penile shaft, coronal sulcus, frenulum, prepuce, glans & less commonly on the scrotum meatus & anus
- females develop condyloma on the posterior introitus, fourchette, labia minora & less commonly on the clitoris, vagina, urethra & anus
* images[6]
Laboratory
- no serologic or culture methods available
- histology & cytology confirm the diagnosis
- DNA hybridization
- in situ hybridization
- dot blot
- electron microscopy
- immunoperoxidase staining
- Pap smear to document HPV-associated histology of cervix
- colposcopy with biopsy if cervical squamous cell changes
- atypia
- intraepithelial lesions
- viral typing may be used to identify individuals at risk for developing cancer
Diagnostic procedures
- diagnosis generally made clinically
- a magnifying glass may assist in detecting small lesions
- colposcopy provides better visualization of the genital tract
- anoscopy may be helpful in identifying internal condyloma & anal cancer[8]
- skin biopsy if diagnosis is in question &/or lesions are refractory to therapy[2]
Differential diagnosis
- verruca vulgaris (another subtype)
- molluscum contagiosum
- seborrheic keratoses
- condyloma latum
- perly penile papules
- vestibular papules
- bowenoid papulosis
- Bowen's disease
- hemorrhoids
Management
- see verruca vulgaris (wart)
- cytology
- biopsy
- suspicious lesions before treatment
- lesions refractory to treatment
- examine entire anogenital tract
- anoscopy for internal condyloma & anal cancer[8]
- consider testing for other sexually transmitted diseases
- treatment indicated for symptomatic lesions or cosmetic reasons[2]
- genital warts often resolve without therapy[2]
- treatment does not prevent papillomavirus transmission[2]
- pharmacologic agents
- podophyllin 25% resin solution applied weekly
- podophyllotoxin 0.5% solution (podofilox): home application
- cantharidin, 0.7% colloidin solution
- 5% 5-fluorouracil cream, apply qweek for 8 weeks
- topical imiquimod 5%[2]: home application
- sodium nitrite, 6%, with citric acid, 9%, twice daily (complete resolution in 31% vs 14% placebo)[5]
- cryotherapy: repeat every 1-2 weeks until clear
- surgery
- excision
- electrosurgery
- laser vaporization
- HPV vaccine may reduce the burden of genital warts[2][4]
- treatment does not prevent transmission of papillomavirus[2]
More general terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 958, 965-967
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Anderson, Advance/Laboratory June 2001, pg 91
- ↑ 4.0 4.1 Fairley CK et al Rapid decline in presentations of genital warts after the implementation of a national quadrivalent human papillomavirus vaccination programme for young women. Sex Transm Infect 2009 Oct 16 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19837728 <Internet> http://dx.doi.org/10.1136/sti.2009.037788
- ↑ 5.0 5.1 Ormerod AD et al Evaluation of the Efficacy, Safety, and Tolerability of 3 Dose Regimens of Topical Sodium Nitrite With Citric Acid in Patients With Anogenital WartsA Randomized Clinical Trial. AMA Dermatol. Published online April 29, 2015 http://archderm.jamanetwork.com/article.aspx?articleid=2280394
- ↑ 6.0 6.1 Ghadishah D, Brenner BE (images) Medscape: Condyloma Acuminata http://emedicine.medscape.com/article/781735-overview
- ↑ 7.0 7.1 7.2 Hawkins MG, Winder DM, Ball SL et al. Detection of specific HPV subtypes responsible for the pathogenesis of condylomata acuminata. Virol J. 2013 May 1; 10: 137. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23634957
- ↑ 8.0 8.1 8.2 NEJM Knowledge+
- ↑ World Health Organization. Human papillomavirus. http://www.who.int/biologicals/areas/human_papillomavirus/en/
- ↑ Centers for Disease Control and Prevention. Human papillomavirus (HPV) infection. http://www.cdc.gov/std/treatment/2010/hpv.htm