Genital warts

Definition

Genital warts or anogenital condylomatosis is an overgrowth of acute condylomas in the anus, perineum, and genital area. It is manifested by sensations of discomfort and foreign body in the area of the anus, anal itching, a feeling of wetness, and pain during defecation. Pathology becomes a source of psychological and sexual problems. There is a risk of traumatization of formations with bleeding and subsequent infection. Malignant degeneration is possible. Diagnosis is made on the basis of examination data, laboratory, and instrumental studies. Treatment includes the removal of condylomas and measures to stimulate immunity.

Causes

Anogenital condylomatosis occurs due to infection with human papillomavirus types 6 and 11. This very common virus causes various types of skin and mucous membrane diseases. More than 100 varieties of the virus have been identified, provoking a variety of pathologies (various types of warts, condylomas, papillomas).

Human papillomavirus (HPV) is one of the most common sexually transmitted infections. More than half of all sexually active people are carriers of the virus (often several types). In most cases, virus carriage is asymptomatic. The appearance of condylomas is observed in no more than 1-2% of cases of carriers of the respective virus type. It is assumed that the appearance of acute condylomas in people infected with HPV types 6 or 11 also requires a general and local weakening of immune defenses.

Symptoms of condylomatosis

The disease is manifested by the appearance and growth of papillary formations in the anus, a feeling of discomfort, and the presence of a foreign body in the perineal area. Often in the area of the anus, there is maceration of the skin. Large condylomas can be mechanically damaged, resulting in soreness and bloody discharge.

Large condylomas can secrete a fluid with an unpleasant odor or contain fistula-like passages. The occurrence of inflammation contributes to the development of symptoms of general intoxication (fever, weakness, headache). Perianal condylomas can grow at a fairly high rate, but pronounced painfulness is not characteristic of this disease. If there is intense pain in the anus, it is necessary to assume any associated pathology (hemorrhoids, anal fissures, paraproctitis, etc.).

Diagnosis

The clinical picture of anogenital condylomatosis is quite characteristic. The diagnosis is made based on the examination and detection of acute perianal condylomas. In addition, a thorough examination of the genitals is performed, as there may also be overgrowths.

To detect condylomas in the anal canal, a proctologist performs a finger examination. The indication for this is the detection of even small formations in the perianal area. When examining the anal canal, acute condylomas are palpable as small nodules of dense consistency. Giant perianal condylomas are quite often accompanied by lesions of the anal canal mucosa. Anoscopy is performed for the same purpose (detection of acute condylomas in the anal canal).

In HIV-infected individuals with a developing immunodeficiency syndrome, condylomas tend to proliferate to a giant size, forming cauliflower-like clusters (Buschke-Löwenstein tumor). Such tumors are a risk factor for squamous cell cancer, particularly in patients with HIV infection. Histologic examination may reveal invasive cancer components in large nodules of this tumor. In patients with suspected malignant neoplasm, sigmoidoscopy is necessarily performed. Often during this study, hyperemia (sometimes granularity) of the rectal mucosa is noted. Acute condylomas are not noted in the rectum (above the anorectal line).

When anogenital condylomatosis is diagnosed, all patients are tested for HIV and syphilis (RPR test). The diagnosis is confirmed by cytologic and histologic examination of condyloma biopsy specimens. In addition, antibodies to human papillomavirus may be detected in the blood by ELISA. The virus DNA is also isolated from the cells of the affected tissue by PCR diagnostics.

If acute condylomas are detected, HIV and other sexually transmitted infections are examined. In the differential diagnosis of condylomatosis and malignant neoplasms, cytologic examination plays a major role.

Treatment of anogenital condylomatosis

Modern medicine does not know how to destroy the human papillomavirus permanently, so treatment is aimed at eliminating symptoms and preventing the development of relapses or complications. Surgical removal of condylomas does not exclude subsequent transmission of the virus to a partner because the patient remains a carrier, and the superficial location of infected cells in the skin can be a source of infection. The development of recurrences after treatment of perianal condylomas occurs in 30% of patients.

Treatment tactics are chosen individually depending on the size, number, localization of acute condylomas, concomitant urogenital infections, and general body condition. Conservative treatment is subject to small perianal condylomas that do not merge into conglomerates. Condylomas are cauterized with a solution of podophyllotoxin (applying it to the affected skin with a special stick that comes with the drug). The drug should be avoided on unaffected areas of skin. Local antiviral agents (podophyllotoxin) should be prescribed to suppress the multiplication of the virus and prevent relapses. Local agents are combined with general immunostimulatory therapy.

The most radical method of getting rid of perianal condylomas is their surgical removal. The growths are excised within the unchanged tissue and removed with the help of a hydrocarbon laser, and chemical cytodestruction methods are used (concentrated solutions of caustic acids and cytotoxic drugs). However, methods of removing condylomas in most cases do not prevent their re-development because the human papillomavirus continues to develop in the deep layers of the surrounding tissues. In addition, cauterization of condylomas in the anal canal with chemical reagents is inappropriate because it is not compelling enough and leads to the development of complications (local inflammation, itching, wetting, and erosion of the mucosa).

Regular courses of general therapy with interferon and its inducers and other immunostimulants help prevent the development of perianal condylomas after their removal. Immediately after the end of the treatment course of combined immunotherapy, the number of patients with a positive DNA test for HPV is reduced by one and a half to two times. Of particular note is the positive role of immunotherapy in preventing high carcinogenic risk overgrowths. The risk of oncogenicity in patients receiving immunotherapy treatment is also reduced almost twice.

Treatment of anogenital condylomas is prescribed both directly to the person applying and to his sexual partner. For the duration of treatment, it is recommended to refuse sexual contact. Combined therapy, combining methods of cytodestruction of existing overgrowths with the prescription of immunostimulating agents of general action, is the most effective treatment regimen, which contributes to improving the quality of life and reducing the likelihood of recurrence of clinical manifestations of the disease.

Surgical removal of perianal condylomas is usually carried out under local anesthesia and refers to low-traumatic interventions. General anesthesia and prolonged postoperative observation are required if extensive growths need to be removed. Multiple condylomas, as well as giant growths, can be removed surgically in several stages. One-stage excision of large condylomas is usually not used in practical proctology because the resulting extensive tissue defects are challenging to heal and can lead to deformities of the perianal area.

All these treatment options are available in more than 700 hospitals worldwide (https://doctor.global/results/diseases/genital-warts). For example, Loop electrosurgical excision procedure (LEEP) can be performed in these countries at following approximate prices:

Turkey$1.0 K  in 25 clinics

China$2.4 K in 7 clinics

Germany$2.7 K in 32 clinics

Israel$3.9 K in 15 clinics

United States$10.6 K in 13 clinics.

Prognosis and prevention

Regardless of the method of removal of condylomas, the probability of recurrence of anogenital condylomatosis in all cases is almost the same. Prevention of recurrence of pathology is a comprehensive treatment with antiviral agents and immune therapy, as well as maintaining immunity and regular courses of therapy under the supervision of a specialist. If the morphological structure of condylomas is detected as malignant cells, the prognosis is unfavorable.