Genital warts

What are genital warts?

Genital warts are are small, soft lumps in the genital area that are caused by certain types of the human papillomavirus (HPV). They are spread from person to person through intimate skin-to-skin contact, and are among the most common sexually transmitted infections (STIs).

Genital warts (also called condylomata acuminata) can affect both males and females and are most often seen between the ages of 15 to 28 years. Genital warts do clear up on their own over time, but this may take months or sometimes even years. Most people prefer to use available treatments to remove visible genital warts.

Symptoms

Genital warts are small, soft, skin-coloured, white or grey bumps that appear in the genital area. The warts can be different sizes, and there can be just one or several in a clump. When several warts clump or cluster together they sometimes resemble a cauliflower-like shape. They can be found on any part of the female or male genital area, including the vulva, walls of the vagina, cervix, penis, scrotum, and the skin between the genitals and anus. They are referred to as anogenital warts when they affect the genitals and the anus.

Some people may experience itching, discomfort or pain associated with genital warts. This pain may be aggravated by intercourse or contact. In some cases, the warts may bleed after sex.

How do you get genital warts?

Genital warts are caused by an infection with certain types of human papillomavirus (HPV). The virus is passed on through having sex or very intimate skin-to-skin contact with someone who is infected. It’s possible to be infected with several different types of HPV at the same time.

HPV can pass through small tears in the skin (micro-abrasions) of your genitals or through contact with genital secretions. Condoms do not offer 100 per cent protection against HPV, as they don’t necessarily cover all of the infected skin.

Most people infected with human papillomavirus (HPV) have no recognisable symptoms and are unaware that they have the virus. So they can pass on the virus without even realising. And for those who develop visible genital warts, it can be difficult to know when you caught the virus because symptoms do not always appear straight after becoming infected.

What is the risk of catching HPV?

HPV infection is extremely common in Australia, and it’s likely that most sexually active people will be infected with one type of the virus at some time in their lives. Your risk of HPV infection may be increased if you’ve had other STIs or unprotected sex with multiple partners.

It also seems that removing some or all of your pubic hair may increase your risk of getting genital warts. That’s because hair removal through waxing or shaving can cause tiny tears in the skin that may allow the virus to enter the skin more easily. Having a Brazilian wax (where all pubic hair is removed) seems to put you at more risk than a bikini wax because more skin is involved. Other hair removal techniques may increase the risk in a similar way. So to reduce your risk of infection, wait at least a day after waxing or shaving before having intimate contact with someone.

What makes genital warts worse?

If you already have genital warts, shaving and waxing your pubic hair can lead to more widespread infection. That’s because these hair removal techniques can cause tiny cuts and abrasions or irritation of the skin, which can allow the virus to enter and infect a larger area of skin. So if you have genital warts, it’s best to avoid shaving or waxing your pubic hair.

Pregnancy can sometimes trigger genital warts if you have a dormant HPV infection, or it can make an active infection worse, meaning that the warts grow more quickly than usual.

HPV, genital warts and cancer

There are more than 40 different types of HPV that can infect the genital area, and these viruses are very common in the community. The types of HPV that cause genital (or anogenital) warts are usually different to the types that can lead to the development of genital cancers or oropharyngeal (back of the throat) cancer in men and women. The types that are linked with cancers are called high-risk genotypes, while the types that cause genital warts are low-risk genotypes.

About 95 per cent of genital warts are caused by HPV types 6 and 11 - these are low-risk types of HPV, which means that they rarely cause cancer.

Persistent infection with a high-risk type of HPV can lead to the development of cell abnormalities that may eventually turn into cancer. Most cervical cancers are caused by infection with types 16 and 18, but there are 13 other high-risk types than can also cause cervical cancer. Type 16 is the most common cause of cancers involving the vulva, vagina, penis and skin around the anus.

Women found to have high-risk types of HPV may need to have more frequent cervical cancer screening tests. Women with genital warts do not usually need more frequent screening tests unless they have also been infected with a high-risk type of HPV.

Tests and diagnosis

The diagnosis of genital warts can usually be made by examining the affected area. During the examination, your doctor may apply a weak acetic acid (vinegar) solution to the lumps, which should turn white if they are warts.

In some cases, women with genital warts may be referred to a sexual health specialist, dermatologist (skin specialist) or gynaecologist (specialist in conditions affecting the female reproductive organs) for further tests or treatment. If there are warts on your cervix, your doctor may recommend colposcopy. This involves examining the cervix using a colposcope, which magnifies the area and allows close inspection.

A biopsy (small sample of the suspected wart(s) that is examined under a microscope) is generally not needed to diagnose genital warts. However, biopsy may be recommended if:

  • the appearance of the warts is unusual;
  • new warts occur in older people; or
  • genital warts are not responding to treatment.

Treatment

Genital warts usually get better on their own without treatment, and the HPV infection is eventually cleared by the immune system. However, this can take several years, so many people choose to have genital warts treated for cosmetic reasons. Treatment can also reduce symptoms of itching and discomfort. Current treatments can remove the visible warts but as yet there is no treatment to cure HPV infection.

Your doctor may recommend applying medicine to the warts, freezing them, or or having the warts surgically removed. The extent and size of the warts, their location, and your preferences will help determine the best treatment choice.

You may need several treatments to get rid of the warts. Bear in mind that genital warts can come back after treatment while you still have the HPV infection. If this happens (usually it happens in the first 3 months after treatment), you may need to be treated again.

Medicines to treat genital warts

A cream called imiquimod (brand names Aldara, Aldiq) can be used to treat external genital warts and anogenital warts. It works by improving the immune system’s response to HPV, and you can apply the cream yourself.

The cream is applied at bedtime and then washed off after 6 to 10 hours. You apply the cream 3 nights per week until the warts are gone (up to 16 weeks). Imiquimod may not be suitable for people with dermatitis or eczema and should not be used during pregnancy or breast feeding. Imiquimod is not suitable for warts inside the vagina or on the cervix in women. You should avoid all sexual contact while the cream is on your skin. Imiquimod can weaken condoms and diaphragms, so you may need to use an alternative form of contraception if you do have sex. Possible side effects of imiquimod include redness, swelling and skin irritation.

Alternatively, a medicine called podophyllotoxin can be applied to external anogenital warts. It comes as a cream (brand name Wartec cream) or solution that can be painted on the warts (Condyline Paint, Wartec topical solution).

These medicines are applied 3 days a week for a maximum of 4 or 5 weeks. The paint is best used on external skin, while the cream may be preferable for warts around the anus, under the foreskin in men and around the opening of the vagina in women. Podophyllotoxin is not suitable for warts inside the vagina or on the cervix in women. It should not be used by women who are pregnant or breast feeding.

You should avoid having sex while using podophyllotoxin. Side effects can include redness, burning, itching and irritation of the skin.

For all wart medicines applied to the skin (known as topical medicines), take care not to get the medicine on normal skin to avoid irritation.

Cryotherapy

Cryotherapy, or cryosurgery, is where liquid nitrogen is applied to the warts to freeze them. Cryotherapy may be recommended for warts that are not responding to topical medicines.

Cryotherapy may be done once a week or once every 2 weeks until the warts disappear. It can be painful, so your doctor may suggest taking a painkiller such as paracetamol before or after the procedure. Following cryotherapy, a blister will usually form - don’t touch or break the blister; it will heal in a few days.

Surgical removal of genital warts

Genital warts can be removed surgically or using laser ablation or electrosurgery (which uses an electrical current to remove warts). These procedures are usually done under general anaesthetic and may be offered to people with anogenital warts over a relatively large area. Some warts may be surgically removed under local anaesthetic.

Treating genital warts during pregnancy and childbirth

Pregnancy can sometimes trigger genital warts if you have a dormant HPV infection, or it can make an active infection worse, meaning that the warts grow more quickly than usual. Warts often clear up on their own after the baby is born, but if treatment is needed during pregnancy, cryotherapy or surgical removal is usually recommended because topical wart medicines are not recommended for pregnant women.

Some women with genital warts are concerned about passing the virus to their baby while giving birth vaginally. However, this is generally rare. Ask your doctor, obstetrician or midwife for advice if you have genital warts while you are pregnant.

HPV vaccination

Australian research has led to the development of vaccines that immunise against the some of the HPV types that can cause genital warts and/or cervical cancer.

Gardasil protects against HPV types 16, 18, 6 and 11, so it can help protect against genital warts as well as cervical cancer. From early 2018 a new 9-valent vaccine (Gardasil 9) will be available that protects against 9 different types of HPV. It is possible to be vaccinated with this newer vaccine even if you have already been immunised - talk to your doctor. Cervarix vaccine protects against 2 high-risk HPV types that are linked with cervical cancer (types 16 and 18), but not the types responsible for genital warts.

HPV vaccination with Gardasil 9 (from 2018) is recommended for all adolescents aged 12-13 years as part of the National Immunisation Program Schedule. The Commonwealth Government currently funds a school-based HPV programme where vaccination is offered for free to girls and boys in year 7 or 8 of high school.

It’s important to remember that none of the current vaccines protect against all types of HPV associated with cervical cancer. So you still need to have cervical cancer screening tests even if you’ve been vaccinated. HPV tests have replaced Pap smears as the primary cervical cancer screening tests in Australia. These tests check for the presence of infection with high-risk types of HPV in the cervix, and cell changes in the cervix if needed.

Protecting yourself and others from genital warts

You can lower your risk of getting genital warts and protect others from infection by practising safe sex using condoms (they offer some protection against genital warts, but not 100 per cent). Remember, vaccination doesn’t protect against all types of HPV that can cause genital warts, and using condoms also helps prevent infection with other STIs.

If you remove your pubic hair by waxing or shaving, wait at least a day before having intimate contact with someone. This gives your skin a chance to repair itself and will help reduce your risk of infection. If your skin is irritated, wait until it returns to normal before having sex.

References

1. Human papillomavirus (published November 2014). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2017 Nov. https://tgldcdp.tg.org.au/ (accessed Dec 2017).
2. Immunise Australia Program. Human papillomavirus (HPV) (updated 17 Jan 2017). http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hpv (accessed Dec 2017).
3. Australian STI management guidelines. Genital warts (last updated 11 Dec 2017). http://www.sti.guidelines.org.au/sexually-transmissible-infections/hpv (accessed Dec 2017).
4. Mayo Clinic. Genital warts (updated 19 Nov 2016). https://www.mayoclinic.org/diseases-conditions/genital-warts/symptoms-causes/syc-20355234 (accessed Dec 2017).
5. Australian Immunisation Handbook, 10th Edition. 4.6 Human papillomavirus (updated July 2016). http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home~handbook10part4~handbook10-4-6 (accessed Dec 2017).
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