Human Papillomavirus and Genital Warts

Human papillomavirus (HPV) is one of the most common causes of sexually transmitted infections (STI) in the world. According to the Centers for Disease Control and Prevention (CDC), approximately 6.2 million new cases of sexually transmitted HPV infections are reported every year. At least 20 million people in this country are already infected.

HPV is directly related to causing genital warts (formerly called venereal warts). It is also known to cause cervical cancer in women and recently, it is believed to play a role in various cancers of the anus, vulva, vagina, penis, and throat.

Genital warts
Genital warts (medically known as condylomata acuminata) are the most easily recognized sign of genital HPV infection. However, it is important to note that there are more HPV infected people where no genital warts can be seen.

Genital warts are typically non painful, soft, flesh colored growths that appear in the genital area. This includes the penis, the vagina, and the anus. Genital warts may also be found inside the vagina, on the cervix, and in the rectum. These warts may be raised or flat, large or small with a cauliflower-like appearance that may form in clusters.

Genital warts are easily recognized by your doctor with visual inspection. Although these warts are not dangerous to your health, many people may want to have them removed by the doctor for various reasons. One common reason is that large growths may be irritated by friction from clothing. Another common reason is for cosmetic purposes.

Cause
HPV (Human Papillomavirus) is a virus. More than 100 different types of HPV have been identified and we know that about 30 of them are spread through sexual contact. These types are further classified as either low risk or high risk. The types that cause genital warts are considered low-risk. The types of HPV linked to cause cancer and are classified as high risk types.

Transmission
Genital warts are very contagious. You can get them during oral, vaginal, or anal sex with an infected partner. You can also get them by skin-to-skin contact during vaginal, anal, or (rarely) oral sex with someone who is infected. About two-thirds of people who have sexual contact with a partner with genital warts will develop warts, usually within 3 months of contact.

If you are infected but have no symptoms, you can still spread HPV to your sexual partner and/or develop complications from the virus.

Symptoms
In women, genital warts occur on the outside and inside of the vagina, on the opening to the uterus (cervix), or around the anus.

In men, genital warts are less common. If present, they usually are seen on the tip of the penis. They also may be found on the shaft of the penis, on the scrotum, or around the anus.

Rarely, genital warts also can develop in your mouth or throat if you have oral sex with an infected person.

Like many STIs, genital HPV infections often do not have signs and symptoms that you can see or feel. One study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) reported that almost half of women infected with HPV had no obvious symptoms.

If you are infected but have no symptoms, you can still spread HPV to your sexual partner and/or develop complications from the virus.

Diagnosis
Your health care provider can usually diagnosed genital warts with just a thorough [[Physical Examination|physical examination.

If you are a woman with genital warts, you should also be examined for possible HPV infection of the cervix. In internal pelvic exam should be done to look for possible warts on the cervix and a Pap smear should be performed as well. Since HPV is directly linked to cervical cancer, it is very important to note look for any abnormalities on Pap smears.

Another test to diagnose HPV infection detects HPV DNA, which may indicate possible infection.

Your provider may be able to identify some otherwise invisible warts in your genital tissue by applying vinegar (acetic acid) to areas of your body that might be infected. This solution causes infected areas to whiten, which makes them more visible.

Treatment
Although there is no way to medically rid of the HPV infection, there are treatments for the removal of genital warts. Genital warts may disappear even without treatment but there is no way to predict this. It is also important to note that even after removal, genital warts can come back because the virus still remains in the body. Since genital warts are generally harmless, most decisions to have them removed are personal decisions.

There are basically two types of ways to remove genital warts. One way is to apply medication to the warts and the other is to physically have the doctor remove them.

Depending on factors such as the size and location of your genital warts, your doctor may offer one of the following treatment options.

Topical:

 * Imiquimod cream
 * 20 percent podophyllin antimitotic solution
 * 0.5 percent podofilox solution
 * 5 percent 5-fluorouracil cream
 * Trichloroacetic acid (TCA)

Caution: Podophyllin or podofilox should not be used during pregnancy because they are absorbed by your skin and may cause birth defects in your baby. 5-fluorouracil cream is also contra indicated during pregnancy.

Surgical:

 * Cryosurgery (freezing)
 * Electrocautery (burning)
 * Laser treatment
 * Excision (cutting)

One other option is to inject medicine (alpha interferon) directly into warts that have returned after removal by traditional means. The drug is expensive, however, and does not reduce the rate that the genital warts return.

Prevention
The best way to prevent getting an HPV infection is to avoid direct skin-to-skin sexual contact. It is important to know that HPV transmission can occur even if no genital warts are seen. It may be impossible to know if your sexual partner is infected HPV. Further, many people with the HPV infection may not even know they have it. Therefore, regular condom usage is the most effective way to prevent getting HPV. Recently, the Food and Drug Administration (FDA) approved a vaccine called Gardasil. Gardasil is highly effective in preventing persistent infection with HPV types 16 and 18, two "high-risk" HPVs that cause most (70 percent) of cervical cancers, and types 6 and 11, which cause virtually all (90 percent) of genital warts.Gardasil has not been proven to provide complete protection against persistent infection with other HPV types, some of which also can cause cervical canter. Therefore, about 30 percent of cervical cancers and 10 percent of genital warts will not be prevented by the current vaccine. In addition, Gardasil does not provide any protection against other sexually transmitted infections, nor does it treat HPV infection or cervical cancer.

Cancer
Some types of HPV can cause cervical cancer. Other types are associated with vulvar cancer, anal cancer, oral cancer, and cancer of the penis (a rare cancer).

Most HPV infections do not progress to cervical cancer. If you are a woman with abnormal cervical cells, a Pap smear will detect them. If you have abnormal cervical cells, it is particularly important for you to have regular pelvic exams and Pap smears so you can be treated early, if necessary.

Pregnancy and Childbirth
Genital warts may cause a number of problems during pregnancy. Because genital warts can multiply and become brittle, your health care provider will discuss options for their removal, if necessary.

Genital warts also may be removed to ensure a safe and healthy delivery of the newborn. Sometimes they get larger during pregnancy, making it difficult to urinate if the warts are in the urinary tract. If the warts are in the vagina, they can make the vagina less elastic and cause obstruction during delivery.

Rarely, infants born to women with genital warts develop warts in their throats (respiratory papillomatosis). Although uncommon, it is a potentially life-threatening condition for the child, requiring frequent laser surgery to prevent blocking of the breathing passages. Research on the use of interferon therapy with laser surgery indicates that this drug may show promise in slowing the course of the disease.

Research
In June 2006, FDA approved Gardasil, the first vaccine developed to prevent cervical cancer, precancerous lesions, and genital warts due to HPV types 6,11,16, and 18. FDA licensed the vaccine for use in girls and women aged 9 to 26 years.

Researchers continue to work on another vaccine for HPV to help protect against HPV types 16 and 18.

Government Links
National Cancer Institute [http://medlineplus.gov/ National Library of Medicine MedlinePlus] Centers for Disease Control and Prevention Food and Drug Administration

Non-government Links
American Social Health Association