Ten year follow-up study of women presenting to a genitourinary medicine clinic with anogenital warts

Number of external anogenital warts is associated with the occurrence of abnormal cervical cytology

BACKGROUND

Anogenital warts (AGWs) are common results of sexually transmitted infection (STI). Human papillomavirus (HPV) types 6 and 11, which are non-oncogenic types, account for 90% of the clinical manifestations. Although the quadrivalent HPV vaccine has been launched, AGW remains prevalent in some countries and shows association with abnormal cervical cytology.

OBJECTIVES

To study the prevalence of abnormal cervical cytology (low grade squamous intraepithelial lesions or worse; LSIL+) in immunocompetent Thai women newly presenting with external AGWs.

MATERIALS AND METHODS

Medical charts of all women attending Siriraj STI clinic during 2007-2011 were reviewed. Only women presenting with external AGWs who were not immunocompromised (pregnant, human immunodeficiency virus positive or being on immunosuppressant drugs) and had not been diagnosed with cervical cancer were included into the study. Multivariate analysis was used to determine the association between the characteristics of the patients and those of AGWs and LSIL+.

RESULTS

A total of 191 women were eligible, with a mean age of 27.0±8.9 years; and a mean body mass index of 20.6±8.9 kg/m2. Half of them finished university. The most common type of AGWs was exophytic (80.1%). The posterior fourchette appeared to be the most common affected site of the warts (31.9%), followed by labia minora (26.6%) and mons pubis (19.9%). The median number of lesions was 3 (range 1-20). Around 40% of them had recurrent warts within 6 months after completing the treatment. The prevalence of LSIL+ at the first visit was 16.3% (LSIL 12.6%, ASC-H 1.1%, HSIL 2.6%). After adjusting for age, parity and miscarriage, number of warts ≥ 5 was the only factor associated with LSIL+ (aOR 2.65, 95%CI 1.11-6.29, p 0.027).

CONCLUSIONS

LSIL+ is prevalent among immunocompetent Thai women presenting with external AGWs, especially those with multiple lesions.

Female genital warts: global trends and treatments

The increasing incidence of human papillomavirus (HPV) infection and HPV-associated conditions such as genital warts in women is a global concern. Genital warts are a clinical manifestation of HPV types 6 and 11, and are estimated to affect 1% of sexually active adults aged between 15 and 49. HPV infection is also strongly associated with cervical cancer, and is prevalent in as many as 99% of cases. The psychological stress of having genital warts is often greater than the morbidity of the disease, and therefore successful treatment is crucial. Current treatments are patient-applied and provider-administered therapies. Imiquimod 5% cream, a patient-applied therapy, is an efficacious treatment with tolerable side-effects and a low recurrence rate, and has the potential to be an effective strategy for the management of genital warts.

Spontaneous evolution of intraepithelial lesions according to the grade and type of the implicated human papillomavirus (HPV)

Because of the fact that any meaningful classification should bear a close relationship to the biological behavior of the lesions, the usefulness of all new classifications of cervical precancer lesions can only be established by well controlled prospective follow-up studies. However, several methodological and conceptual problems are encountered in the natural history studies conducted during the past several decades. While reviewing the available prospective follow-up studies on cervical intraepithelial neoplasia (CIN), Ostör (1993) found 3529 cases of CIN 1, of which 57% showed regression, persistence was found in 32%, progression to CIN III in 11%, and progression to invasive cancer in 1% of cases. The corresponding figures for CIN II were 43%, 35%, 22%, and 5%, respectively. The recognition of the association between human papillomavirus (HPV) and CIN has further complicated the assessment of the natural history of cervical precancer lesions. Results from the early prospective follow-up studies are remarkably consistent, however. Progression from HPV-NCIN (i.e., koilocytosis without CIN) to CIN I or greater was reported for 18 (8%) of 232 women followed by Syrjänen et al. for an average of 25 months, for 26 (8%) of 314 women followed by de Brux et al. (1981) for 15 to 18 months, and for 113 (13%) of 846 women followed for up to six years by Mitchell et al. During a 42-month follow-up period, 10% progression rate was found in 1269 women with HPV-CIN I, and in 17% of 762 women with HPV-CIN II by de Brux et al. (1983). The spontaneous regression rates were 53% and 39% in these cohorts, respectively. This is fully consonant with our experience from an almost 14-year follow-up of 530 women in Kuopio, where the spontaneous regression rate seems to increase in parallel with the extent of the follow-up time, currently being 66.7% for HPV-NCIN and 55.7% for HPV-CIN I. The figures for progression are 6.3% and 14.2%, respectively. It is obvious that the probability of a cervical precancer lesion to progress into an invasive disease increases with the severity of the atypia. Another distinct prognostic factor is HPV type, HPV 16 lesions possessing a significantly higher risk for progression than infections by other HPV types. The follow-up data also indicate, however, that even the high grade lesions may spontaneously regress, which should have important implications in therapy. The continuous problem still remains; these natural history observations only apply to a large series of women but are of little help in predicting the disease outcome in individual women.

Anogenital warts in prepubertal children; sexual abuse or not?

Forty-two prepubertal children presenting with anogenital (AG) warts (15 boys and 27 girls) were prospectively followed up (mean 15.9 months, SD 12.24). Most (73.8%) of these children had perianal condylomatous-type warts and 11 (26.2%) had concurrent non-genital (NG) warts. None had any other AG infections or sexually transmitted disease (STD). Twelve (28.6%) children acquired their AG warts by vertical transmission from an infected maternal birth canal, 3 (7.1%) by autoinoculation from common hand warts and 2 children (4.8%) through sexual abuse. In the remaining 25 children (59.5%) mode of acquisition of AG warts was uncertain but not thought to be sexual. Human papilloma virus (HPV) DNA (types 6/11, 16/18 or 31,33,35-31+) was detected in 10/32 (31.3%) of AG warts biopsied from these children, types 6/11 in the majority of positive biopsies (9/10). Detection of HPV DNA (types 6/11, 16/18 or 31+) in a child's AG warts was significantly associated with either vertical or sexual transmission (P < 0.02). Thirty-one children had their warts treated with a combination of scissor excision and electrocautery under general anaesthesia. Warts recurred in 10 (31.4%) of these children all within 4 months following treatment. Spontaneous resolution of AG warts was seen in 9 (21.4%) children. Of 42 children with AG warts 10 (23.8%) had at least one adult family member with AG warts, 13 (36.9%) on adult family member with another AG infection or STD, and 23 (62.2%) had a mother with cervical intraepithelial neoplasia (CIN). Twenty (47.6%) of these children had a family member with NG warts.(ABSTRACT TRUNCATED AT 250 WORDS)