Condylomata acuminata in male

Condylomata acuminata

Condylomata acuminata is a medical term for anogenital warts, which are growths on the cervical or vulval mucosa in females, or on the glans of penis or prepuce in males. Anogenital warts or genital warts are a sexually transmitted disease (STD) caused by the human papillomavirus (HPV), which has over 100 different strains. Subtypes number 6 and 11 cause 90% of genital warts and are considered low risk because they very rarely will cause genital or anal cancer 1). On the other hand, subtypes 16 and 18, for example, are considered high risk because, although they rarely cause genital warts, they can lead to cervical or anal precancer and cancer. The warts usually appear as a small bump or group of bumps in the genital area. They are flesh-colored and can be flat or look bumpy like cauliflower. Some genital warts are so small you cannot see them. In women, genital warts usually occur in or around the vagina, on the cervix, or around the anus. In men, genital warts are less common. They may have warts on the tip of the penis, around the anus, or on the scrotum, thigh, or groin.

You can get genital warts during oral, vaginal, or anal sex with an infected partner. HPV is also spread by skin-to-skin contact during sexual activity; there does not need to be vaginal or anal intercourse to spread the infection. Correct usage of latex condoms greatly reduces, but does not completely eliminate, the risk of catching or spreading human papillomavirus (HPV). The most reliable way to avoid HPV infection is to not have anal, vaginal, or oral sex. HPV vaccines may help prevent some of the HPV infections that cause genital warts.

Since anogenital warts are not a reportable disease, the incidence of condyloma acuminata is difficult to estimate. However, recent estimates report the incidence of anogenital warts in the United States at 1.1 to 1.2 cases per 1000 person-years 2).

Most people who become infected with HPV will not have symptoms and will clear the infection on their own. Your health care provider usually diagnoses genital warts by seeing them. For people who do develop genital warts, there are many options for treatment, all of which are meant to remove the visible warts. There is no cure for genital warts, the human papillomavirus (HPV) stays in your body even after treatment, so warts can come back.

There are several topical treatment options available, including podophyllotoxin solutions and creams, imiquimod cream, and sinecatechins ointment. Cryotherapy, trichloroacetic acid solution, and several surgical modalities are also available treatments. There is a chance for condyloma acuminata to recur after topical treatments. Surgical excision is the only available treatment with clearance rates close to 100 percent 3). Patients should receive counsel on treatment options, the importance of follow up appointments, and safe sex practices.

Gardasil® is a vaccine that protects against the 4 strains of HPV that cause 70% of cervical cancers and 90% of genital warts. In the US, Gardasil is approved for girls/women and boys/men ages 9–26. In 2011, Health Canada approved the vaccine for women up to the age of 45.

Condylomata acuminata (anogenital warts) key points

  • Anogenital warts are a recognized symptom of genital HPV infections.
  • About 90% of those exposed who contract HPV will not develop genital warts.
  • Only about 10% who are infected may transmit the virus.
  • HPV types 6 and 11 cause genital warts. There are over 100 different known types of HPV viruses.
  • HPV is spread through direct skin-to-skin contact with an infected individual, usually during sex.
  • While some types of HPV cause cervical and anal cancer, these are not the same viral types that cause genital warts.
  • It is possible to be infected with different types of HPV at the same time.
  • There is conflicting evidence about the effect of condoms on prevention.
  • Approximately three out of four unaffected partners of patients with warts develop them within eight months of contact.
  • Although 90% of HPV infections are cleared within two years of infection, it is possible for a latency period to occur, with the first occurrence or a recurrence happening months or even years later.
  • Latent HPV is transmissible, and if an individual has unprotected sex with an infected partner, there is a 70% chance they will become infected.
  • In individuals with a prior HPV infection, the appearance of new warts may be either from a new exposure or a recurrence.
  • Anal or genital warts may be transmitted during birth and may be an indicator of sexual abuse.
  • Genital warts may sometimes result from autoinoculation by warts elsewhere on the body, such as from the hands.

Figure 1. Condylomata acuminata in female

Condylomata acuminata in female

Footnote: Genital warts are a common sexually transmitted infection. They can appear on the genitals, in the pubic area or in the anal canal. In women, genital warts can also grow inside the vagina.

Figure 2. Condylomata acuminata in male

Condylomata acuminata in male
When to see a doctor

See a doctor if you or your partner develops bumps or warts in the genital area.

What is the human papillomavirus?

The human papillomavirus (HPV) is actually a group of double-stranded DNA viruses.

  • There are at least 100 different types of HPV; at least 40 can infect the anogenital area. Many others cause warts on other areas of skin.
  • At least 75% of sexually active adults have been infected with at least one type of anogenital HPV at some time in their life.
  • HPV is incorporated into skin cells and stimulates them to proliferate, causing a visible wart.
  • Visible anogenital warts are often easy to diagnose by their typical appearance. They are usually due to HPV types 6 and 11.
  • Most do not develop visible warts. However, the infection may show up on a cervical smear. This is known as subclinical infection.
  • Some strains of HPV cause anogenital cancer. These strains may not cause visible warts but they remain contagious.

How is human papillomavirus transmitted?

Visible genital warts and subclinical human papillomavirus (HPV) infection nearly always arise from direct skin to skin contact.

  • Sexual contact. This is the most common way amongst adults.
  • Transmission is more likely from visible warts than from subclinical HPV infection.
  • Oral sex. HPV appears to prefer the genital area to the mouth however.
  • Vertical (mother to baby) transmission through the birth canal.
  • Auto (self) inoculation from one site to another.
  • Fomites (ie from objects like bath towels). It remains very controversial whether warts can spread this way.

Often, warts will appear three to six months after infection but they may appear months or even years later.

Who’s at risk of condylomata acuminata?

Genital warts are the most common sexually transmitted disease and affect millions of people throughout the world. It is estimated that 75–80% of sexually active men and women will be infected with HPV at some point in their lives. As anogenital warts are sexually acquired during close skin contact, they are most commonly observed in young adults between the ages of 15 and 30 years. They are highly contagious, and occur in equal numbers in unvaccinated males and females. Approximately 15% of the United States population is infected with HPV. HPV infection occurs in people of all ages and both sexes. However, they are rare in people that have been vaccinated against HPV in childhood before beginning sexual activity. Your risk of acquiring the virus is higher if you have had many sexual partners and if you first had sexual intercourse at a young age. Over 50% of girls will get HPV within 2 years of becoming sexually active.

HPV is spread through skin-to-skin contact and does not require actual intercourse to be passed from one person to another. A person can be infected without any visible signs of infection and, therefore, can pass the infection on without knowing it. Condoms can decrease the risk of spreading the virus, but they do not completely prevent transmission.

Condylomata acuminata causes

Condyloma acuminata results from HPV infection. HPV is the most common sexually transmitted infection worldwide, with 9 to 13 percent of the global population infected 4). Patients who are between 20 and 39 years of age are most commonly affected 5). There are several known risk factors for acquiring HPV. Prevalence of infection increases with an increased number of lifetime sexual partners, a history of chlamydia and gonorrhea infections, smoking, and human immunodeficiency virus (HIV) infection 6).

There have been over 100 types of HPV identified, with 40 strains known to affect the anogenital area. HPV strains 6 and 11 are the most prevalent strains that cause condyloma acuminata. Other strains of HPV are known to cause plantar warts, in which the lesions are on the hands and feet. Infection with several strains of HPV also causes cellular dysplasia leading to certain cancers, namely cervical cancer in females and penile or rectal cancer in males 7). HPV types 16 and 18 are high-risk subtypes for developing a malignancy. Research has solidly established their role in the development of cervical, anogenital, and oral carcinomas. HPV types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73, and 82 may also be present in mucosal cancer. Non-melanoma skin cancers correlate with HPV types 1, 5, 8, 9, 17, 20, 23, and 38. Bowen’s disease has correlations with HPV types 16, 18, 31, 32, and 34. Epidermodysplasia verruciformis has been linked to HPV types 5, 8, 9, 12, 14, 15, 17, 19-25, 36-38, 46, 47, 49, and 50. HPV types 6 and 11 present a low risk for developing malignancy and cause 90 percent of anogenital warts. Cutaneous warts are associated with HPV types 1, 2, 3, 4, 27, and 57 8).

Pathophysiology

HPV is a double-stranded DNA virus that primarily infects the nucleus of differentiated squamous epithelial cells. The DNA virus can remain in a latent phase for several months, resulting in an incubation period of one month to two years 9). The genome of HPV contains oncogene, which encodes proteins that stimulate cell proliferation. These proteins enable the virus to replicate via the host cell’s DNA polymerase while the host cells undergo cell division. As the number of virally infected host cells grows, the basal, spinous, and granular layers of the epidermis thicken, leading to acanthosis and the macroscopic appearance of warts. Condyloma acuminata generally take three to four months to form. In otherwise healthy individuals, an adequate immune response can halt viral replication and resolve the infection over time. However, prolonged HPV infection increases the risk of developing malignant transformation 10).

Condylomata acuminata prevention

Transmission of warts to a new sexual partner can be reduced but not completely prevented by using condoms. Condoms do not prevent all genital skin-to-skin contact, but they also protect against other STDs.

Successful treatment of the warts decreases the chance of passing on the infection.

Gardasil® is a vaccine that protects against the 4 strains of HPV that cause 70% of cervical cancers and 90% of genital warts. In the US, Gardasil is approved for girls/women and boys/men ages 9–26. In 2011, Health Canada approved the vaccine for women up to the age of 45.

Human papillomavirus vaccine

HPV vaccination is also recommended for everyone through age 26 years, if not vaccinated already.

Several vaccines are available to prevent HPV infection.

  • Cervarix is effective against HPV types 16 and 18. Available in many countries for prevention of cervical cancer.
  • GARDASIL®9 is effective against HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58, and is for 12 year old girls and boys and up to the age of 26 years. It can be prescribed for older individuals.

Vaccination is not recommended for everyone older than age 26 years. However, some adults age 27 through 45 years who are not already vaccinated may decide to get HPV vaccine after speaking with their doctor about their risk for new HPV infections and the possible benefits of vaccination. HPV vaccination in this age range provides less benefit, as more people have already been exposed to HPV.

HPV vaccination is most effective when offered at a young age, before the onset of sexual activity. However, girls that are already sexually active may not have been infected with the types of HPV covered by the vaccine and may still benefit from vaccination. Women that receive HPV vaccine should continue to participate in cervical screening programmes, as about 30% of cervical cancers will not be prevented by the vaccine.

HPV vaccines are also effective in boys. Vaccination of boys is recommended to reduce transmission of HPV to unvaccinated females. It also reduces the incidence of cancers related to HPV infection.

There has been interest in developing therapeutic HPV vaccines for the treatment of genital warts and cervical cancer in those already infected, and for other strains of HPV that are associated with other forms of viral warts.

Vaccinating boys and girls

Two doses of the HPV vaccine are recommended for all boys and girls at ages 11–12; the vaccine can be given as early as age 9. If you wait until they’re older, they may need three doses instead of two.

Children who start the vaccine series on or after their 15th birthday need three shots given over 6 months. If your teen hasn’t gotten the vaccine yet, talk to his/her doctor about getting it as soon as possible.

Possible side effects

Like any vaccine or medicine, HPV vaccination can cause side effects. The most common side effects are mild and include:

  • Pain, redness, or swelling in the arm where the shot was given
  • Dizziness or fainting (fainting after any vaccine, including HPV vaccine, is more common among adolescents)
  • Nausea
  • Headache

The benefits of HPV vaccination far outweigh any potential risk of side effects.

Condylomata acuminata symptoms

Condylomata acuminata or genital warts appear as flesh-colored, round bumps of varying sizes (few millimeters in diameter). They can be smooth and flat or cauliflower-like with a small stalk. Warts may join together to form plaques up to several centimeters across. They can be seen on the labia, vagina, penis, scrotum, anus, skin around the anus, and urethra. Warts usually do not cause any symptoms, although the warts can bleed and become painful with intercourse if they are located within the vagina.

Condylomata acuminata or anogenital warts may occur in the following sites:

  • Vulva
  • Vagina
  • Cervix
  • Urethra
  • Penis
  • Scrotum
  • Anus.

Warts due to the same types of HPV can also arise on the lips or within the oral mucosa.

Normal anatomical structures may be confused with warts. These include:

  • Pearly papules (these are in a ring around the glans of the penis )
  • Sebaceous glands on the labia (known as “Fordyce spots”)
  • Vestibular papillae (the fronds found in the opening to the vagina).

Condylomata acuminata complications

Condyloma acuminata can have significant psychological effects on patients, including anxiety, guilt, and anger. Patients may also have concerns about the loss of fertility and cancer. Premalignant and malignant lesions can be present within genital warts. Condyloma acuminata can also develop into malignant lesions. Concerning signs for malignant transformation include bleeding, irregular pigmentation, ulceration, and lesions with palpable dermal infiltration 11). Also, as previously mentioned, Buschke-Lowenstein tumors are a known complication of condyloma acuminata 12).

Condylomata acuminata and cancer

The HPV types that cause external visible warts (HPV Types 6 and 11) rarely cause cancer. Other HPV types (most often Types 16, 18, 31, 33 and 35) are less common in visible warts but are strongly associated with anogenital cancer, including:

Squamous intraepithelial lesion of penile, vulval and anal skin
Invasive squamous cell carcinoma (SCC) of cervix, penis, vulva and anus

HPV also causes some cases of oral and nasopharyngeal cancer.

Only a small percentage of infected people develop genital cancer. This is because HPV infection is only one factor in the process; cigarette smoking and how well the immune system is working are also important.

Cervical smears, as recommended in the National Cervical Screening guidelines, detect squamous intraepithelial lesions of the cervix, which can be treated. If these abnormalities were ignored over a long period, they could progress to cervical cancer.

Condylomata acuminata diagnosis

Genital warts are usually diagnosed clinically.

Biopsy is sometimes necessary to confirm the diagnosis or viral wart or to diagnose an associated cancer.

Additional testing can be done to aid in the diagnosis. A colposcope can be used to magnify the lesion for improved visualization. Confirmatory testing and gene typing are possible via DNA detection assays such as polymerase chain reaction (PCR). Additionally, the acetic acid test can be used to evaluate the lesion further. In this test, five percent acetic acid gets applied to the lesion. Following the application, white areas of the lesion raise concern for dysplasia. The acetic acid test is not valid for screening as it has high false-positive rates. If the clinician is concerned about dysplasia, a biopsy of the lesion is the appropriate followup 13).

Cystoscopy should be considered in patients where the glans is involved, the patient has lower urinary tract symptoms, or there are significant urethral symptoms. In patients who have no symptoms, some experts have suggested waiting until any glans lesions have healed to avoid possible transfer of HPV virus into the urethra 14).

In some circumstances, researchers and clinicians may wish to confirm the presence or absence of HPV. One commercially available qualitative test for HPV is the COBAS 4800 Human Papillomavirus (HrHPV) Test, which evaluates 14 high-risk (HR oncogenic) HPV types. A negative test excludes high-risk infection.

Physicians should have a concern regarding sexual abuse in children with condyloma acuminata. Although condyloma acuminata are considered to be sexually transmitted, there are other forms of transmission. The suspicion of sexual abuse should increase as the age of children increases. Physicians in the United States are required to report suspected sexual abuse. Clinicians should use their professional judgment when considering reporting sexual abuse 15). In children with anogenital warts, reports of sexual abuse have varied from 0% to 80% 16), 17). Of sexually abused children, HPV DNA and/or abnormal PAP cytology has been reported in 3.4–33% and anogenital warts only in 0.3–2% 18). Evaluation is complex as most children who have been sexually abused will neither show carriage of the virus nor have evidence of physical trauma 19).

Whether HPV infection was a consequence of perinatal transmission or by family or environmental contact would need to be determined. At this time, the data on the epidemiology of the acquisition of clinically apparent HPV disease in children are inconclusive 20).

Condylomata acuminata differential diagnosis

  • Condyloma lata
  • Molluscum contagiosum
  • Lichen planus
  • Psoriasis
  • Malignancy
  • Pearly penile papules
  • Acrochordon
  • Sebaceous cysts
  • Buschke-Lowenstein tumor 21).

Condylomata acuminata treatment

There is no cure for HPV 22). Removing visible warts does not reduce transmission of the underlying HPV infection. About 80% of individuals with HPV will clear the infection spontaneously within 18 to 24 months.

There are multiple treatment options for patients diagnosed with condyloma acuminata. Treatment varies depending on the number, size, and location of warts. Treatment can cause permanent depigmentation, itching, pain, and scarring. Treatment can be delayed in children, adolescents, and young, healthy adults, as lesions often resolve spontaneously over months to years 23).

Treatment should be pursued with lesions that persist for more than two years if the lesions are symptomatic, or for cosmetic purposes 24). Topical therapies, cryotherapy, and surgical excision are available treatment options for patients.

The primary goal of treatment is to eliminate warts that cause physical or psychological symptoms such as:

  • Pain
  • Bleeding
  • Itch
  • Embarrassment.

Options include:

  • No treatment
  • Self-applied treatments at home
  • Treatment at a doctor’s surgery or medical clinic.

The underlying viral infection may persist after the visible warts have cleared. Warts sometimes re-emerge years later because the immune system has weakened.

Self-applied treatments

To be successful the patient must identify and reach the warts, and follow the application instructions carefully. Available treatments include:

  • Podophyllotoxin solution or cream. Podophyllotoxin 0.5% solution and 0.15% cream can be used to treat the fleshy papules. Podoxophyllin toxin is applied twice daily for three days, followed by a four-day break. Lesions can resolve after four weeks.
  • Imiquimod cream. Imiquimod cream 5% is another topical treatment, with lower rates of recurrence than with podophyllotoxin. Imiquimod is applied three times per week, every other day with resolution seen in sixteen weeks.
  • Sinecatechins ointment. Sinecatechins 15% ointment is used three times daily for up to sixteen weeks. Sinecatechins is an ointment of catechins extracted from green tea that appears to have a higher clearance rate than podophyllotoxin and imiquimod while causing less local irritation, but clearance takes longer than with imiquimod. They work by reducing HPV gene products E6 and E7 25).

Note: Skin erosion and pain are commonly reported with imiquimod and sinecatechins.

Treatment at the clinic

Patients can also receive treatments in the clinic for condyloma acuminata.

In-clinic treatments include:

  • Cryotherapy. Cryotherapy is inexpensive, minimally painful, and considered safe for use during pregnancy. Liquid nitrogen is applied to the margin of the lesion three to five times for twenty seconds each application. These applications take place weekly for six to ten weeks. Liquid nitrogen cryosurgery ablation does not usually cause much scarring, but requires cryosurgical equipment and training.
  • Podophyllin resin
  • Trichloroacetic acid applications. Trichloracetic acid 80 to 90% is an available treatment for smaller lesions. After application, a small ulcer will form that heals without scarring. Trichloracetic acid is applied once per week for eight to ten weeks. Trichloroacetic acid is not as effective as cryosurgery and should be avoided on the vagina, cervix, or urinary meatus 26).
  • Electrosurgery. Electrocauterization is considered effective but causes scarring and requires some level of anesthesia 27).
  • Curettage and scissor or scalpel excision. Simple surgical excision under local anesthesia is simple and direct but will leave a scar and requires a small surgical procedure. Surgical removal under general anesthesia may be necessary for more extensive lesions, intra-anal warts, or in children.
  • Laser ablation. Laser vaporization has minimal bleeding but may be somewhat less effective than other ablative techniques. It is relatively expensive and may cause a plume of virus containing smoke 28).
  • 5% fluorouracil cream.

Only surgical therapies have clearance rates near one hundred percent 29).

Experimental therapies for genital warts include:

  • Interferon
  • 5-fluorouracil/epinephrine-gel implant. A 5% 5-fluorouracil (5-FU) cream is no longer considered acceptable due to the side effects.
  • Cidofovir
  • Application of 5-aminolevulinic acid (ALA) with photodynamic therapy is an emerging treatment for condyloma acuminata. This treatment modality was found to be more effective, simpler, and have lower recurrence rates than CO2 laser treatment. Photodynamic therapy with 5-aminolevulinic acid may be a useful adjuvant to other traditional treatment modalities 30).

Condylomata acuminata prognosis

While condyloma acuminata can be challenging to treat, the condition is curable. However, lesions may require multiple treatments or a combination of treatments over time. Surgical excision is the only treatment option with clearance rates near 100 percent, although condyloma acuminata can recur after all treatment types. In fact, recurrence of lesions after clearance is seen 20 to 30 percent of the time. The recurrence rates for genital warts treated with topical podophyllotoxin treatments have a clearance rate of 45 to 83 percent and a recurrence rate of 6 to 100 percent. Imiquimod treatments have a lower rate of recurrence at 6 to 26 percent and a clearance rate of 35 to 68 percent. Sinecatechins ointment clears 47 to 59 percent of condyloma acuminata, and only 7 to 11 percent of patients have a recurrence of lesions after clearance. Cryotherapy with liquid nitrogen clears 44 to 75 percent of genital warts with a 21 to 42 percent recurrence rate. Treatment with trichloroacetic acid solution clears 56 to 81 percent of lesions and 36 percent of lesions recur after clearance 31).

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