eMedicine Specialties > Dermatology > Viral Infections

Warts, Genital: Follow-up

Author: Tsu-Yi Chuang, MD, MPH, Clinical Professor, Department of Dermatology, University of Southern California; Staff Dermatologist, Desert Specialty Group, Inc
Coauthor(s): Ryan Brashear, MD, Staff Physician, Department of Dermatology, Indiana University School of Medicine
Contributor Information and Disclosures

Updated: Oct 27, 2009

Follow-up

Further Outpatient Care

• Patients typically are monitored on a periodic basis to assess for efficacy of treatment, unwanted side effects, and the development of complications. Outpatient follow-up care also provides an opportunity to evaluate for other sexually transmitted diseases (STDs) and provides patient education on an ongoing basis.

Deterrence/Prevention

• A vaccine for human papillomavirus (HPV) infection has been approved by the US Food and Drug Administration.

Complications

• Disease complications can include progression to malignancy and transmission to other sexual contacts. In the setting of genital warts active during a pregnancy delivery, there is a small risk of laryngeal papillomatosis.
• Each therapeutic modality carries its own unique set of risks. Risks of individual medical options are enumerated above.
• Expected effects of cryosurgery include pain, edema, vesicles, bullae, weeping, and some necrosis. There is a small risk of infection, bleeding, abnormal scarring, pigment alteration, paresthesias, and alopecia with cryosurgery.
• Similarly, laser surgery of genital warts may result in pigment alteration, abnormal scarring, and infection. Special care must be taken to prevent respiratory infection from the laser plume generated by vaporization of virally infected tissue.

Prognosis

• Prognosis is good, and most cases of genital warts are amenable to treatment.
• Patients who are immunosuppressed with genital warts may represent a special challenge.

Patient Education

• STD counseling and evaluation of partners
  • Patients with genital warts deserve a focused history and physical with appropriate testing to assess for other STDs.
    • In a population study, 7% of men and 31% of women who had genital warts had concurrent STDs. In fact, 28% of these men and 71% of women had other STDs before or after their genital warts.
    • Several consort studies documented that 30% of female consorts and 80% of male consorts had HPV infection. Usually, the same type of HPV involved both parties, and often they were HPV 6, 11, 16, and 18.
  • The benefit of evaluating sex partners of patients with genital warts has been apparent.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center. Also, see eMedicine's patient education article Genital Warts.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnosis genital warts correctly can result in considerable morbidity. Confusing condyloma lata for genital warts will miss the diagnosis of syphilis and will lead to inappropriate therapy. Confusing pearly penile papules or Fordyce spots with genital warts will result in unnecessary treatment and likely unwarranted psychosocial concern. Missing a diagnosis of verrucous carcinoma or squamous cell carcinoma is likely to delay appropriate therapy and may lead to unneeded morbidity, even mortality.
• Treatment of genital warts can be difficult and lengthy. Patient expectations should be set appropriately. Patients should be counseled on their risk of infectivity to others. They also should be advised of their increased risk of having acquired other STDs.
• Each therapy of genital warts has a unique set of potential adverse effects. Patients should be appropriately aware of potential adverse consequences of therapy.

Special Concerns

• Increased risk of anogenital malignancy
  • Patients with genital warts have an increased risk of anogenital malignancy.
  • Infection with HPV is the primary cause of cervical malignancy, although most patients with HPV-infected cervices have a benign outcome. This mandates that female patients with genital warts should have an annual screening examination and Papanicolaou test. Up to 90% of cervical cancers are caused by HPV infection of the cervix.
  • Strong epidemiologic evidence suggests that 10% of patients who had a high-grade squamous intraepithelial lesion (HGSIL, which includes so-called moderate-to-severe dysplasia, carcinoma in situ, and cervical intraepithelial neoplasia II and III) would have persistence of lesions that eventually would progress to invasive cancer without treatment. Patients with perianal warts, patients who are HIV positive, and those with a history of receptive anal intercourse are at increased risk for anal HGSIL. No direct evidence suggests that this would progress to invasive anal cancer, as lesions of the cervix are capable of doing. Nonetheless, penile, vulvar, vaginal, ovarian, and anal carcinomas have been linked to HPV infection.
• Anogenital warts in children
  • Anogenital warts are rare in the general pediatric population.
  • More than one half of children with anogenital warts have a manifestation either of viral inoculation at birth or of incidental spread of cutaneous warts. Such cases often are caused by nongenital HPV types.
  • Diagnosis of genital warts in a child requires that the clinician report suspected abuse to begin an evaluation process that may or may not confirm sexual abuse.^13,14
• Laryngeal papillomatosis of neonates and infants
  • Although childhood laryngeal papillomas frequently are acquired from condyloma of the mother (HPV types 6 and 11 are frequently cited), most infants of mothers with condyloma do not contract laryngeal papillomas.
  • Accordingly, cesarean delivery should not be performed solely to prevent transmission of HPV infection to the newborn.
  • Route of transmission in pregnancy is not known, and infants born by cesarean delivery have developed laryngeal papillomatosis. However, it is advisable to remove visible lesions during pregnancy.
• Patients who are immunosuppressed: Patients who are immunosuppressed such as those with AIDS and those on immunosuppressive therapy (eg, patients with renal transplants) are more likely to develop persistent HPV infection and subsequent dysplasia and malignancy.
• Verrucous carcinoma of genitalia (giant condyloma of Buschke-Löwenstein): It is a low-grade, locally invasive, squamous cell carcinoma that is associated with HPV types 6 and 11 and should be considered in the differential of lesions measuring greater than 1 cm in diameter. Only radical surgical extirpation is considered appropriate treatment.

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