[Proven and new methods in the treatment of genital warts]

Anogenital warts are the most common clinical manifestation of human papillomavirus (HPV) infections. Although easy to recognize, asymptomatic anogenital warts (condylomata acuminata) may be overlooked, leading to unaware transmission to the sexual partner. On the other hand awareness of this sexually transmitted disease (STD) is largely associated with a great psychological and social burden, in men as well as women. Spontaneous regression of genital warts has been observed mostly within 2-5 years; however, persisting condylomata may prove refractory to all current treatment options. Because removal of the warts does not totally eliminate the underlying viral infection, treatment of genital warts can often be of long duration, of varying effectiveness and with high recurrence rates. Without a doubt only the patient's own immune system is capable of clearing HPV infections. Therefore, the solution to one of mankind's oldest health problems will depend on the future acceptability of HPV vaccines.

Management of external genital warts

Genital warts affect 1% of the sexually active U.S. population and are commonly seen in primary care. Human papillomavirus types 6 and 11 are responsible for most genital warts. Warts vary from small, flat-topped papules to large, cauliflower-like lesions on the anogenital mucosa and surrounding skin. Diagnosis is clinical, but atypical lesions should be confirmed by histology. Treatments may be applied by patients, or by a clinician in the office. Patient-applied treatments include topical imiquimod, podofilox, and sinecatechins, whereas clinician-applied treatments include podophyllin, bichloroacetic acid, and trichloroacetic acid. Surgical treatments include excision, cryotherapy, and electrosurgery. The quadrivalent human papillomavirus vaccine is active against virus subtypes that cause genital warts in men and women. Additionally, male circumcision may be effective in decreasing the transmission of human immunodeficiency virus, human papillomavirus, and herpes simplex virus.

Anal warts (condylomata acuminata) - current issues and treatment modalities

HPV infections are currently the most frequent cause of genital infections in the USA. Risk factors are early onset of sexual activity, multiple sexual partners, a history STDs, an early age of first pregnancy and tobacco use. In the past, HPV viruses were thought to be STDs, but it is now known that penetration is not necessary. Skin-to-skin or mucosa-to-mucosa contact is enough to transmit the virus, which presents high tropism for those tissues. The Papillomaviridae family includes over 120 viruses, some of which have high malignant transformation rates. The most common malignancy connected to HPV is uterine cervix cancer and anal canal cancer. The range of morphology of perianal lesions means that a thorough clinical examination is required, including an anoscopy. Therapeutic modalities often seek to eliminate macroscopic changes rather than focus on the cause of the infection, which leads to a high recurrence rate. Externally located changes can be eliminated with patient-applied treatments. Those located in the anal canal and distal end of the rectal ampulla require treatment by a qualified medical provider. Due to the high recurrence rate after standard treatment, special attention has been given to vaccinations. The polyvalent vaccine includes HPV viruses with both low and high malignant transformation risk. This has led to a decrease in the rate of malignancies.

Sexually transmitted and anorectal infectious diseases

Sexually transmitted diseases (STDs) are common and they can involve the anus and rectum in both men and women. In this article, the main bacterial and viral STDs that affect the anus and rectum are discussed, including their prevalence, presentation, and treatment.

Clinical features of external genital warts

External genital warts (EGWs) are a common sexually transmitted infection caused by the human papillomavirus (HPV). Although over 100 HPV types have been identified, some of which are associated with cancer, EGWs are caused by noncancerous HPV subtypes 6 and 11. This cutaneous manifestation of HPV infection can be asymptomatic or produce warty lesions that may assume a cauliflower-like, flat, papular, or keratotic appearance. Physical symptoms may also accompany warts, such as pruritus, burning, pain, and obstruction. EGWs typically appear in anogenital areas, such as the vulva, penis, groin, perineum, perianal skin, or mucosal surfaces. EGWs are typically a transient type of infection that often spontaneously regresses without treatment, but long-term remission rates are currently unknown. Treatment is determined according to the size and number of lesions, which can cluster or develop at multiple sites. Because of the individual variability in disease, treatment should be determined on a case-by-case basis. Further investigation, such as a biopsy, may be advisable in cases of atypical lesions, lesions that are unresponsive to therapies, and immunocompromised individuals, who are essentially more susceptible to HPV infections and less responsive to treatment. Although HPV testing is available, it is not currently recommended for detection and HPV typing. Differential diagnoses may include normal skin variations, other infectious or inflammatory diseases, and cancerous growths.

Managing external genital warts: practical aspects of treatment and prevention

Rising rates of human papillomavirus (HPV) infections in recent decades, including external genital warts (EGWs), underscore the need for effective management of this common sexually transmitted disease. Although treatment is a vital aspect that aims primarily to resolve physical symptoms, health care providers must also address the psychosocial burden that typically accompanies diagnosis, treatment, remission, and recurrence. Education and counseling are integral components of care to address the cascade of negative emotional reactions that follow diagnosis, which often include anger, shame, stigma, frustration, and fear. Health care providers should offer patient information that is clear and simple, both verbally and in written form. Research to date has shown that information is most helpful when it is conveyed in a supportive tone and avoids stigmatization. Treatment decisions should consider the patient's preferences and the clinician's ability to offer certain therapies. A locally relevant algorithm and an individualized treatment approach are recommended by various treatment guidelines to improve the chances of compliance and treatment success. Given that success rates are variable, monitoring treatment is also necessary to gauge the patient's response to treatment, local reactions, and the potential need to switch treatments. Patients diagnosed with EGWs should also be screened for other sexually transmitted diseases because coinfection is common. Vaccination is becoming an increasingly important aspect of prevention strategies for HPV infections and should be considered for eligible patients.

Therapeutic options for external genital warts

The primary goal of treatment for external genital warts (EGWs) is to eradicate visible lesions and address symptoms that may accompany them, but it does not address the underlying virus. Left untreated, warts may grow, remain the same, or spontaneously regress as a result of being cleared by the immune system. However, recurrence is common with or without treatment and may occur within 3 months of ending treatment in one-quarter to two-thirds of cases. Treatment options fall into two categories: provider or patient applied. Provider-based therapies include cryotherapy, trichloroacetic and bichloroacetic acid, electrocautery, surgical excision, and CO2 laser therapy. Patient-applied therapy choices include imiquimod and podophyllotoxin. Imiquimod 3.75% is a fairly new, patient-administered topical cream approved by Health Canada in 2011. Another recently approved patient-applied choice is sinecatechins, a green tea extract with immunomodulatory effects. Self-treatment options are attractive to patients because they offer privacy, convenience, and autonomy. In contrast, provider-administered therapies may boast increased precision (especially for areas that are hard to reach) and closer monitoring, which can be augmented by patient education and counseling. Available topical and surgical therapies vary widely in terms of cost, efficacy, adverse effects, dosage/frequency, and length of treatment. No one treatment is ideally suited to all patients or constitutes a gold standard. Treatment regimens must be tailored to each patient's needs and preferences. The health care provider's skills and experience will also factor into treatment decisions. In addition, the size, number, and location of lesions and whether the infection is new or recurrent will help guide the decision process toward the best treatment for a given patient.

[Treatment of recurrent large external genital warts in men]

The article presents the results of treatment of 51 men with recurrent genital HPV infection in the form of genital warts. Patients were divided into two groups depending on the treatment. Group 1 of patients has received the combination treatment--electrocoagulation + pharmacotherapy (panavir intravenously and topically in the form of a gel), Group 2 of patients--only electrocoagulation. According to the results of follow-up within 6 months, disease recurrence rate was significantly higher in Group 2--39.5% versus 9.6% in the Group 1. Postoperative complications were also more frequently recorded in the Group 2. These findings suggest that the combined treatment of reccurent forms of genital warts is preferred than just using destructive methods of treatment.

Intralesional antigen immunotherapy for the treatment of warts: current concepts and future prospects

Many destructive and immunotherapeutic modalities have been used for the management of warts; however, an optimal treatment with high efficacy and absent or low recurrence has not been explored to date. Recently, the use of intralesional immunotherapy with different antigens has shown promising efficacy in the treatment of warts. We review the different aspects of this new modality, including candidates, types of warts treated, dosage, number and interval between treatment sessions, mode of action, efficacy, adverse effects, recurrence rate, advantages, disadvantages, current place and future prospects. A literature review revealed that healthy immune subjects are the best candidates, and a pre-sensitization test is usually done before the start of therapy. The dosage, the number and interval between sessions, and the success rates varied among the different studies. The mode of action is still uncertain, but is essentially mediated through stimulation of T helper-1 cell cytokine response. Adverse effects are mild and generally insignificant, and the recurrence rate is absent or low. Intralesional antigen immunotherapy seems to be a promising, effective and safe treatment modality for viral warts. Future well-designed and controlled studies would help to more clearly define its place in the challenging field of wart therapy.

New approach to managing genital warts

OBJECTIVE

To summarize and determine the appropriate use for the new and old management tools for genital warts.

SOURCES OF INFORMATION

The following databases were searched: MEDLINE, PubMed, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ACP Journal Club, and Trip. The bibliographies of retrieved papers were also reviewed. Clinical trials, qualitative review articles, consensus reports, and clinical practice guidelines were retrieved.

MAIN MESSAGE

Symptomatic warts are prevalent in at least 1% of the population between the ages of 15 and 49, with estimates of up to 50% of the population being infected with human papillomavirus at some point in their lifetime. Imiquimod and podophyllotoxin are 2 new treatments for external genital warts that are less painful and can be applied by patients at home. In addition, the quadrivalent human papillomavirus vaccine has been shown to be efficacious in preventing genital warts and cervical cancer. There is still a role for the older treatment methods in certain situations, such as intravaginal, urethral, anal, or recalcitrant warts; or for pregnant patients.

CONCLUSION

The new treatments of external genital warts can reduce the pain of treatment and the number of office visits. Other treatment methods are still useful in certain situations.

Update on the treatment of genital warts

This review summarizes new treatments from the last seven years employed for the treatment of genital warts caused by human papillomavirus (HPV). Imquimod 3.75% is a new agent with fewer side effects and perhaps a better dosing schedule than imquimod 5%, but is not more effective. Sinecatechins/Polyphenon E 15%, a novel extract from green tea can be effective against genital warts but requires three times a day dosing and is not more effective than existing treatments; the treatment course is 12-16 weeks. Photodynamic therapy combined with other destructive modalities might increase the cure rate for genital warts. The quadrivalent vaccine against HPV 6, 11, 16, 18 is decreasing the incidence of warts in the western world but the evidence does not support vaccination as a treatment for those already infected by HPV. Hyperthermia and immunomodulators might be positive additions to the armamentarium of clinicians. In sum, there are new tools that physicians can use but none is really a great advance over what was available a decade ago.

HPV and genital warts among Peruvian men who have sex with men and transgender people: knowledge, attitudes and treatment experiences

Background

Several studies have assessed the epidemiology of HPV infection among MSM, but no qualitative studies have specifically assessed how HPV and genital warts (GW) affect South American men who have sex with men (MSM) and male-to-female transgendered women (TG). This study explored the knowledge, attitudes and experiences of Peruvian MSM and TG regarding HPV and GW.

Methods

We performed a qualitative study consisting of fifteen in-depth interviews and three focus groups carried out in Lima, Peru with diverse MSM and TG groups, including sex workers. Resulting data were analyzed by applying a systematic comparative and descriptive content analysis.

Results

While knowledge of HPV was limited, awareness of GW was common, particularly among TG persons and sex workers. Still, few participants recognized that GW are sexually transmitted, and many had problems differentiating between GW and other STI/anogenital conditions. Stigmatizing experiences were common during sexual encounters with people who had visible GW. Shame, emotional and physical troubles, and embarrassing sexual experiences were reported by individuals with GW. Search for treatment was mediated by peers, but stigma and apparent health services’ inability to deal with GW limited the access to effective medical care.

Conclusions

In Peru, public health interventions should strengthen services for HPV/GW management and increase accurate knowledge of the transmission, treatment, and sequelae of HPV/GW in MSM and TG populations.

[Epidemiology of genital warts in female population of Czech Republic]

OBJECTIVE

The aim of study was to evaluate prevalence of genital warts in Czech Republic.

SUBJECT

Multicentric prospective observation study.

SETTING

HPV College.

METHODS

During 6 month (February 2010 - July 2010) 20 private gynaecological centers in all Czech Republic were counting up the number of genital warts cases. Risk factors, therapy and knowledges about genital warts were evaluated.

RESULTS

There were 637 patients with genital warts in cohort of 70 980 patients. The prevalence of genital warts was 0.89%. The most frequent risk factor was cigarette smoking in 37%. Main strategy for treatment were podophyllin local application and cold knife excision.

CONCLUSION

The prevalence of genital warts in our study has shown importance for its prevention by rules of safety sex and HPV vaccination against HPV type 6 and 11.

[Liquid nitrogen freezing combined with 5-aminolaevulinic acid-photodynamic therapy for condyloma acuminatum in men]

OBJECTIVE

To investigate the efficacy, adverse reaction and prognosis of liquid nitrogen freezing combined with 5-aminolaevulinic acid-photodynamic therapy (ALA-PDT) in the treatment of condyloma acuminatum in men.

METHODS

We collected medical histories and conducted physical examinations for 35 male patients with condyloma acuminatum in the outpatient department, and treated them by liquid nitrogen freezing combined with ALA-PDT every 7-10 days. We recorded the skin lesions and adverse events each time and followed up the patients at 4 and 24 weeks after treatment.

RESULTS

The 35 patients were aged 17-71 (median 31) years, and their average course of disease was 30-180 (mean 60) days. The skin lesion area was reduced remarkably after 3 times of liquid nitrogen freezing combined with ALA-PDT, 16-140 (median 38) mm2 for the first time, 6-63 (median 13) mm2 for the second, and 0-10 (median 3) mm2 for the third, with statistically significant differences (P < 0.01). Two cases (5.7%) relapsed at 4 weeks and 4 cases (11.4% ) at 24 weeks.

CONCLUSION

Liquid nitrogen freezing combined with ALA-PDT is better than either liquid nitrogen freezing or ALA-PDT alone for the treatment of condyloma acuminatum in men.

Management of genital warts in pregnancy

Genital warts are the most prevalent form of viral genital mucosal lesions. In pregnancy they may proliferate and become easily irritated due to the increased vascularity and altered immunity. This case highlights the importance of a multidisciplinary approach and exact planning to ensure good outcome in the management of genital warts in pregnancy.

[Genital warts and HPV vaccination]

OBJECTIVE

To present and overview of incidence of, and cost of care for, genital warts.

SUBJECT

Review.

SETTING

Department of Obstetrics and Gynecology, Palacky University and Faculty University, Olomouc; Office gynecology and primary care centre, Brno; Department of Obstetrics and Gynecology, Charles university in Prague-First Faculty of Medicine and General Faculty Hospital, Prague.

METHOD

Literature review of incidence of, and cost of care for, genital warts in some european countries, North America and Australia.

CONCLUSION

Genital warts exert a considerable impact on health services, a large proportion of which could be prevented through immunisation using the quadrivalent human papillomavirus vaccine.

[Comparative assessment of the methods of treatment of Condylomata acuminata]

The treatment of Condylomata acuminata often causes disappointment to both the physician and the patient since most of the current medical approaches require multiple examines while on the other hand success rates are low and recurrence rates remain high. The treatment approaches include surgical as well as non-surgical methods. The non-surgical treatment includes the application of local agents such as imiquimod, podophyllotoxin, and 5-fluorouracil. Other local agents, used in outpatient treatment settings, include trichloroacetic acid (TCA), podophyllin, or the intralesional application of agents such as interferon and bleomycin. The surgical methods include cryotherapy, electrosurgery, excision and laser therapy. Their major goal is the removal of the visible lesions. The development of the laser systems and the new HPV vaccines are a significant progress in the treatment and prevention of the HPV infections.

[A 32P application device for the treatment of condyloma acuminatum in the rectum]

OBJECTIVE

To investigate the use of a 32P application device (AD) in the treatment of condyloma acuminatum (CA) in the rectum, and to compare its clinical effect with that of the microwave therapy.

METHODS

This study included 107 cases of CA in the rectum, 99 males and 8 females, aged 21-58 (33.6 +/- 9.4) years. Forty-six of the patients (the AD group) were treated with a self-made 32P application device, which, as a tube-shaped carrier of radionuclide 32P colloid, was fixed in the rectum at the diseased part for medication at 4.9-8.2 Gy for 3-5 hours once and 1-2 times a week. The other 61 (the microwave group) were treated by microwave burning under local anesthesia. Both groups of patients were followed up for over 3 months for comparison of the therapeutic results and observation of the stability and reliability of the 32P application device.

RESULTS

The rates of cure, reoccurrence and adverse reaction were 84, 8%, 13.0% and 8.7% in the AD group, compared with 40.3%, 55.7% and 75.4% in the microwave group, with statistically significant differences between the two groups (P < 0.01).

CONCLUSION

The 32P application device, with its advantages of low cost, easy operation, good effect, high safety and reliability, low recurrence, fewer adverse events and good acceptability, is highly valuable for the treatment of CA in the rectum.

[Epidemiology and management of patients with ano-genital warts in Italy]

PURPOSE

Overview of the impact of ano-genital warts in Italy.

COMMENTS

In Italy, the HPV infection is not subject to mandatory reporting, the available epidemiological data come from sentinel surveillance of STIs and show a high spread among young people under 25 years and an increase in reports after 2004. Although ano-genital warts are a benign disease, nonetheless they are characterized by a big relational and psycho-sexual impact, due also to high recurrence rates.

CONCLUSIONS

It is extremely useful to promote information activities, education in safe sex, early diagnosis and treatment of genital warts. In this context, primary prevention through vaccination represents a valid tool of protection.

Current therapy for condyloma acuminata of the patients attending female STD Unit, Siriraj Hospital

OBJECTIVE

To describe the treatment pattern of condyloma acuminata in female.

MATERIAL AND METHOD

The 5-year medical records of 449 women treated for genital condyloma acuminata at the Gynecologic Infectious Diseases and Female Sexually Transmitted Disease (GID-FSTD) unit were reviewed. Data included the distribution of age, client by category, anatomical site and size, serologically coexisting sexually transmitted infection (STI), and treatment modalities.

RESULTS

About half, 50.1%, of treatment was the application of topical trichloroacetic acid; followed by podophylline in the proportion of 35.5%. While the electric cauterization and imiquimod applications were uncommon therapy. Two-fifth ofthe subjects, 40.7%, was completely cured, and the remaining cases required additional management.

CONCLUSION

The present setting, the wide range of treatment available is reflection of the fact that there is no ideal management.

Sexually transmitted diseases and anorectum

Sexually transmitted diseases (STD) are a major public health problem because their incidence is increasing worldwide despite prevention campaigns and because they raise the risk of HIV infection. Anorectal localisations of STD are common among men who have sex with men (MSM) but can also be seen among heterosexuals (men or women). Transmission of such infections is due to anal sex or to other sexual behaviours like "fisting". Although some pathogens (like Human Papillomavirus-HPV) are common in gastroenterologist/proctologist consultations, others are not so well-known. Furthermore during the last years, sexual risky behaviours have led to resurgence of old affections (like syphilis) or to emergence of unknown diseases (like lymphogranuloma venereum) in our countries. This presentation tends to focus on clinical manifestation, diagnosis and treatment of different STD: HPV, Herpes Simplex Virus, Neisseria gonorrhoeae, Chlamydia trachomatis (in particularly lymphogranuloma venereum) and Treponema pallidum.

Treatment of genital warts in males by pulsed dye laser

OBJECTIVE

To determine the safety and efficacy of the flashlamp-pumped pulsed dye laser for the treatment of uncomplicated genital warts in adult males.

METHODS

This was a prospective observational study set in the outpatient clinics of the Department of Andrology and Sexually Transmitted Diseases, National Institute of Laser Enhanced Sciences, the Dermatology Clinic, Cairo University, and the Department of Dermatology and Venereology, Suez Canal University. A total of 174 adult male patients with 550 uncomplicated anogenital warts were included. Selective photothermolysis and photocoagulation of the lesions with the flashlamp-pumped pulsed dye laser was carried out. A pulsed dye laser (wavelength 585 nm, 450 s pulse duration; Cynosure, USA) was used with the following settings: spot size 5-7 mm; fluence 9-10 J/cm2.

RESULTS

Complete resolution of treated warts was achieved in 96% of lesions. Side effects were limited, transient and infrequent. Lesion recurrence rate was 5%.

CONCLUSION

The pulsed dye laser has been found to be safe, effective and satisfactory for the treatment of anogenital warts in males. It could be used to selectively destroy warts without damaging the surrounding skin.