>Genital warts: HPV, symptoms and treatment

Introduction

Structure of HPV

Genital warts, caused by some types of HPV (human papilloma virus), can appear on the skin anywhere in the genital area as white or flesh-coloured, smooth, small bumps, or larger, fleshy, cauliflower-like lumps (see genital warts pictures). There are more than 100 different subtypes of HPV, and around 30 of them specifically affect the genitals. Other HPV subtypes cause warts to grow on different parts of the body, such as the hands.

Life cycle of HPV

Not everyone infected with HPV will develop genital warts. Some people will be infected with a strain that does not produce warts, or they will remain asymptomatic (i.e. no warts will appear), even though the virus is present in the skin or mucous membranes around the genital area, or on the cervix in women. Those who do go on to develop genital warts will usually notice them 1 to 3 months after initial infection.

Symptoms of genital warts

If symptoms do appear then the infected person may notice pinkish/white small lumps or larger cauliflower-shaped lumps on the genital area. Genital warts can appear on or around the penis, the scrotum, the thighs or the anus. In women genital warts can develop around the vulva or inside the vagina and on the cervix. If a woman has warts on her cervix, this may cause slight bleeding or, very rarely, an unusual coloured vaginal discharge. Warts may occur singly or in groups. The warts may itch, but they are usually painless. Sometimes genital warts can be difficult to spot. In severe cases, it is possible for genital warts to spread from the genitals to the area around the anus, even if anal intercourse has not occurred.
Occasionally, people can confuse skin problems caused by other STDs (such as genital herpes, syphilis or molluscum) with genital warts. Other people may become very worried because they mistake perfectly normal and non-infectious lumps and bumps for genital warts. Conditions that may be confused with genital warts include:

• Pearly penile papules - small white or skin-coloured bumps that, when numerous, appear in a ring around the edge of the head of the penis. More rarely, similar papules may be found on the vulva.
• Angiokeratomas - bright red or purple spots that look a little like blood blisters.
• Sebaceous glands (also known as 'Fordyce spots') - hard white, yellowish or skin-coloured little bumps that may be found all over the skin of the penis and scrotum in men, and the vulva in women. Sebaceous glands produce a substance called sebum, which keeps the skin healthy.
• Pimples or spots - caused by blocked sebaceous glands. Pimples and spots can form just as easily around the genital area as they do on the face, and may become sore and inflamed in a similar way.

All of the above are common, non-infectious skin manifestations that are not sexually transmitted.
Any doubt about lumps and bumps on the genitals can usually be resolved by a visit to a doctor or sexual health clinic.

How is HPV passed on?

Genital HPV is transmitted by genital skin-to-skin contact, or through the transfer of infected genital fluids. This is usually during vaginal or anal sex, but it is also possible to pass it on through non-penetrative sexual activity.
In rare circumstances, a woman can pass HPV on to her baby during vaginal child birth.

"I think I may have genital warts"

If you have any symptoms or are worried you may have been infected with an STD, there are a number of places you can go for help.

• You can visit your doctor, who may be able to tell whether you have genital warts just by looking closely at the affected area. If you would prefer, they will probably be able to refer you to a specialist clinic to get tested.
• Some countries also have specific sexual health clinics that can test for a range of STDs. Have a look at our help and advice page or your local telephone directory to see if you have a clinic near you.

If genital warts are suspected but are not obvious, the doctor or nurse may apply a weak vinegar-like solution to the genital area; this turns any warts white and makes them more visible. To check for hidden genital warts, the doctor may carry out an internal examination of the vagina, cervix and/or anus.
If a person suspects they have been exposed to HPV, but does not yet have symptoms, their doctor may be able to take a swab to test for high-risk strains of the virus (this isn't available in all countries). In women, this may be performed alongside a cervical Pap smear test (see below).
Not everyone diagnosed with HPV will develop warts, and patients may be asked to come back for another examination at a later date if nothing is yet visible.

Treatment for genital warts

There is no treatment that can completely eliminate genital warts once a person has been infected. Often outbreaks of genital warts will become less frequent over time, until the body naturally clears the virus and the warts disappear of their own accord. However, in some people the infection may linger.
A doctor can give patients various treatments to clear genital warts, but they may reappear even after treatment. Genital warts are caused by a virus, not a bacterium, so antibiotics will not get rid of them. Common treatments include:

• Podophyllin resin – a brown liquid that removes genital warts by stopping cell growth. Podophyllin resin and podofilox lotion is painted on to the wart(s) by a doctor or nurse and must be washed off 4 hours later (or sooner, if the area is irritated). It has to be applied by a medical professional to avoid damaging the healthy tissue around the wart and may have to be applied several times to work effectively.
• Podopfilox lotion/gel – can be applied to the wart(s) by the patient at home. The usual schedule is twice a day for 3 days, followed by 4 days without any lotion. This cycle is repeated for 4 weeks. It has few side effects and is well-suited for treatment at home.
• Cryocautery (also called cryotherapy) – uses liquid nitrogen to freeze more persistent warts every 1 to 3 weeks for a short period.
• Laser treatments – this approach, which uses an intense beam of light, can be expensive and is usually reserved for very extensive and tough-to-treat warts.
• Electrocautery – an electrical current is used to super-heat a needle which burns the wart cells and cauterises the blood vessels. A local anesthetic is used to prevent any pain and the procedure is usually carried out at a doctor's surgery. Electrocautery is used only after other treatments have failed.
• Surgical excision – the doctor will perform minor surgery to remove the wart under local anesthetic.

The doctor or nurse should give the patient advice about having sex whilst receiving treatment.
There are some non-prescription treatments available for genital HPV, but it is advisable to always seek medical advice. Never try to treat genital warts by yourself.
It is important that a woman who is pregnant, or trying to become pregnant, informs her doctor. Podophyllin treatment could harm the developing baby and an alternative treatment should be used.

Follow-up

It is important to return regularly for treatment until all of the genital warts have gone so the doctor or nurse can check progress and make any necessary changes in your treatment. Sometimes treatment can take a long time.
The majority of people whose genital warts initially disappear will get a recurrence.
In the majority of cases, the immune system keeps the virus under control and eventually destroys it a few years after the initial infection.

Taking care of yourself and your partner

If you have genital warts, following these suggestions will make an outbreak easier to deal with, and will help protect your partner.

• Use condoms when having sex. But remember that condoms will only prevent the transmission of genital warts if they cover the affected areas. Talk to your doctor or nurse for more advice on safer sex.
• Make sure that your partner has a check-up too, as they may have warts that they haven't noticed.
• Keep your genitals clean and dry.
• Don't use scented soaps and bath oils or vaginal deodorants, as these may irritate the warts.

HPV and cervical Pap smear tests

Some types of the human papilloma virus (notably types 16 and 18) have been linked to changes in cervical cells that can lead to cancer. This is why it is important that all sexually active women have a regular cervical Pap smear test.
A smear test is performed by opening the vagina using a speculum (a metal instrument that gently stretches the entrance and the walls of the vagina) and taking a small sample of cells from the cervix with a special swab. The cells will then be looked at under a microscope. If any changes to the cells are noted, the woman may be asked to repeat the test or will be referred for treatment that can prevent the cells from developing into cervical cancer. It is important to note that cell changes (also called cervical dysplasia) DO NOT indicate that a woman already has cancer. Most of these changes will go away on their own, or with treatment. However, it is very important to monitor the cell changes closely, as there is a risk that they may turn precancerous if they do not clear.
A woman who has received an abnormal Pap smear result may sometimes be given a colposcopy to look at cells on the cervix. A colposcope is a kind of small microscope with a light which is used to view the cervix. The scope magnifies the cervix so the doctor can see any changes or problems. The doctor may take a small sample of cells (called a biopsy), which will be looked at in a laboratory. The colposcopy may feel slightly uncomfortable. If the patient has a biopsy taken then they may have a dull ache like a mild period cramp, with slight bleeding.
Treatment to remove abnormal cells on the cervix will usually consist of cryocautery (freezing the cells using a special cold probe), electrocautery (heating the cells with electricity) or using laser treatment to 'zap' the cells. None of these procedures should be painful, but they may lead to dull aching (like period pains) and watery vaginal discharge that may last several weeks.
A woman who has had visible genital warts in the past is not necessarily at any greater risk of cervical cancer, as genital warts tend to be linked to non-cancer causing subtypes of HPV.

Pap smear tests of the anus and rectum

The subtypes of HPV that can lead to cervical cancer may also pose a risk for men and women who have regular anal sex. Though few countries offer regular screening for anal and rectal cancer, many doctors recommend that people who have frequent anal sex (such as gay or bisexual men) should still receive a regular Pap smear test of the rectum and anus. As with cervical cell changes, early detection and treatment can help to prevent cancer from developing.

Is there a vaccine against genital warts?

Two vaccines are currently used to prevent cervical, vulvar and vaginal cancers, and genital warts caused by some of the major subtypes of HPV.
Gardasil®, marketed by Merck, was first approved by the Food and Drug Administration (FDA) for use in the United States of America in June 2006.¹ The vaccine is now approved in over 100 countries. Gardasil® has also been found to provide protection for men against anal disease caused by some types of HPV.²
The other FDA approved vaccine, Cervarix® (marketed by GlaxoSmithKline), is used in the UK's HPV vaccination programme for girls run by the National Health Service.
The vaccines are not recommended for pregnant women and a very small number of people may not be able to have the vaccine due to specific medical reasons. The vaccines may also be less effective in women who are already sexually active, as they may have already been infected with HPV.
HPV vaccines do not protect against all cervical cancers, so it is important for women to continue attending cervical Pap smear tests.