eMedicine Specialties > Urology > Common Problems of the Urethra

Urethral Warts

Author: Yegappan Lakshmanan, MD, FRCS, Chief of Pediatric Urology, Children's Hospital of Michigan
Coauthor(s): Douglas Dahl, MD, Consulting Staff, Department of Urology, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Oct 21, 2009

Introduction

Condylomatous warts of the genital tract and anus have been described as early as the first century AD. The venereal origin of the disease was described in the 1950s. Intracellular virus particles in the wart tissue were demonstrated in 1968. In the 1970s, further work attributed these cellular changes to human papillomavirus (HPV) infection. Simultaneously, molecular hybridization techniques demonstrated the genetic heterogeneity of HPVs.

In the following decades, nearly 100 HPVs were identified by polymerase chain reaction (PCR)–based assays, and the genomes of about 75 HPVs were cloned and sequenced.1 Of these, more than 30 types infect the genital tract. Recent epidemiologic and molecular studies have conclusively shown the association of HPV types with the development of genital tract and anal cancers.

Problem

Genital and urethral warts are caused by HPV and are easily spread by sexual contact. Subtype HPV 6 is most frequently detected in genital warts. Most of the newly acquired genital HPV infections are subclinical and asymptomatic. Occasionally, the detection of HPV DNA in genital specimens may be the only evidence of current infection. Furthermore, serum antibodies to specific HPV types may be the only indication of past exposure. After a long period of latency, individuals infected with certain HPV subtypes are at risk of developing squamous cell carcinomas.2 Immunosuppression is associated with reactivation of HPV, increasing the risk of malignant transformation.

The epidemiologic extent of this disease was underestimated until recent advances in PCR-based assays and DNA hybridization techniques enabled the identification of people who are asymptomatic and infected. In 1991, a study by Bauer et al utilized PCR techniques and demonstrated that 46% of college women undergoing routine pelvic examination were infected with HPV.3 HPV infection is now considered the principal etiologic agent in cervical dysplasia and cervical cancer. HPV 16 has been associated with more than 50% of cervical malignancies. Condylomata have also been linked with squamous cell carcinoma of the penis.

With increased recognition of the problem and better detection methods, the number of patient visits to physicians' offices for genital warts has steadily increased since the 1950s. In the United States, an 8-fold increase in the age- and sex-adjusted incidence of genital warts was reported from 1950-1954 and 1975-1978. A 4.5-fold increase in the number of first consultations for genital warts occurred from 1966-1984.

Current evidence suggests that more than 50% of sexually active adults have been infected with one or more genital HPV types, most of which are subclinical, unrecognized, and benign. This is presently considered a minor sexually transmitted disease (STD) and not reportable, but the asymptomatic nature of the condition and its potential association with malignancy require a high degree of diligence in its diagnosis and management in patients who are at risk. 

In a recent study screening high-risk individuals such as asymptomatic male partners of females with HPV infection, even though they were clinically free of genital warts, 20.3% tested positive for HPV DNA using the hybrid capture 2 (HC2) microplate assay.4

Frequency

  • United States: Genital warts affect approximately 500,000-1 million patients annually. Approximately 5% of these patients have urethral warts. Recent PCR-based studies detected HPV DNA in 12-16.5% of urethral specimens from healthy young volunteers.
  • International: The incidence is similar to that reported in the United States.

Etiology

Urethral warts are caused by HPV. They are primarily sexually transmitted, and transmission is possibly enhanced by the moisture and abrasion of epithelial surfaces. The risk of genital infection increases with each new sex partner. Condoms are not definitely known to provide an effective barrier. Nonsexual transmission through fomites is significant for skin warts but not known in genital warts. Blood-borne transmission has not been reported. Perinatal transmission accounts for cases of condylomata found during the first week of life. Urethral instrumentation such as in cystoscopy or repeated urethral dilatation in patients with pre-existing genital HPV infection has been shown to cause dissemination of HPV into the proximal urethra.5

HPV is a DNA virus with several characterized subtypes (see Human Papillomavirus).6 Viral types 6,11, 42-44, and 54 are associated with condylomata acuminata and low-grade dysplasia, while types 16, 18, 31, 33, 35, 39, 45, 51, 52, 54, 56, 66, and 68 have a higher association with genital malignancy (especially cervical malignancy). HPV co-infection is also facilitated by immunosuppressed states such as HIV and AIDS. PCR-based methods have shown HPV prevalence rates of 41-74% in women who are HIV seropositive.

Pathophysiology

Cells infected with HPV divide rapidly with duplication of viral particles. These epitheliotropic viruses depend on differentiating squamous epithelium for their replication. Viral capsid proteins and infectious viruses are found in the superficial differentiated cell layers. The disease is transmitted when the viral particles released from the lesions come into contact with another person. Approximately two thirds of the sexual contacts of patients with genital warts develop the same disease. Incubation periods are usually 1-2 months but may extend to several months.

Presentation

A significant proportion of affected men and women are asymptomatic, and their subclinical lesions are not identifiable by simple inspection. When present, the warty lesions are located in moist mucocutaneous surfaces of the perineal and genital areas. A few patients complain of associated symptoms of itching, burning, pain, or bleeding; women may notice a vaginal discharge. Warts occur either singly on a stalk or in broad-based clusters and are soft and friable.

In males, the glans penis, shaft, and prepuce are common sites of infection. Urethral warts are mostly found in the meatus and fossa navicularis but may extend as far as the prostatic urethra. In females, the vulva, vagina, and cervix are common sites of infection. Lesions are also observed at the anal verge and occasionally in the mouth. Bladder involvement is rare.

Generally, condylomata appear in areas subject to physical trauma occurring during sexual intercourse. They may spread to adjacent areas by autoinoculation. Morphologic types include (1) larger cauliflowerlike condylomata, (2) flesh-colored, dome-shaped papular warts that are 1-4 mm in diameter, (3) keratotic warts with a thick crustlike layer resembling skin warts; and (4) flat-topped macular warts. Regional lymph nodes are not enlarged.

Suspect urethral warts when patients with genital warts present with pyuria or urethral discharge. Intraurethral warts may be a cause of recurrent meatal warts. Urethral and bladder involvement with condylomata is often associated with immunosuppression. Gay men who are HIV positive and who practice receptive anal intercourse may present with anal and intra-anal warts. Other groups of immunosuppressed persons (eg, people receiving transplants, people with Hodgkin disease, people with AIDS, people with diabetes) may develop perianal lesions but not intra-anal warts, which are due to transfer of the virus inside the anus.

Carefully assess the external genitalia of patients presenting with a typical sexual history and symptoms suggestive of urethral involvement. Include investigations to exclude other concomitant STDs. Offer current sexual partners of the patients an examination and treatment for macroscopically visible warts and other STDs. If screening of male partners is to be offered, specimens obtained from penile and urethral brushing for HPV DNA detection appear to be the most accurate.7 Semen may be alternative to urethral brushing.

Contraindications

Medical treatments aimed at treating urethral warts should generally be used with caution, and they should be used only when the warts are easily accessible, as in the fossa navicularis.

Podophyllin is contraindicated during pregnancy.

More on Urethral Warts

Overview: Urethral Warts
Workup: Urethral Warts
Treatment: Urethral Warts
Follow-up: Urethral Warts
References
Further Reading

References

  1. Koutsky LA, Kiviat NB. Genital human papillomavirus. In: Sexually Transmitted Diseases. 3rd ed. 1999:347-359.

  2. Burmer GC, True LD, Krieger JN. Squamous cell carcinoma of the scrotum associated with human papillomaviruses. J Urol. Feb 1993;149(2):374-7. [Medline].

  3. Bauer HM, Ting Y, Greer CE, Chambers JC, Tashiro CJ, Chimera J, et al. Genital human papillomavirus infection in female university students as determined by a PCR-based method. JAMA. Jan 23-30 1991;265(4):472-7. [Medline].

  4. Hadjivassiliou M, Stefanaki C, Nicolaidou E, Bethimoutis G, Anyfantakis V, Caroni C, et al. Human papillomavirus assay in genital warts--correlation with symptoms. Int J STD AIDS. May 2007;18(5):329-34. [Medline].

  5. Sumino Y, Mimata H, Nomura Y. Urethral condyloma acuminata following urethral instrumentation in an elderly man. Int J Urol. Oct 2004;11(10):928-30. [Medline].

  6. Smotkin D. Virology of human papillomavirus. Clin Obstet Gynecol. Mar 1989;32(1):117-26. [Medline].

  7. Giovannelli L, Migliore MC, Capra G, Caleca MP, Bellavia C, Perino A, et al. Penile, urethral, and seminal sampling for diagnosis of human papillomavirus infection in men. J Clin Microbiol. Jan 2007;45(1):248-51. [Medline].

  8. Schneider V. Microscopic diagnosis of HPV infection. Clin Obstet Gynecol. Mar 1989;32(1):148-56. [Medline].

  9. Beutner KR, Ferenczy A. Therapeutic approaches to genital warts. Am J Med. May 5 1997;102(5A):28-37. [Medline].

  10. Beutner KR, Wiley DJ, Douglas JM, Tyring SK, Fife K, Trofatter K, et al. Genital warts and their treatment. Clin Infect Dis. Jan 1999;28 Suppl 1:S37-56. [Medline].

  11. Carpiniello VL, Schoenberg M. Laser treatment of condyloma and other external genital lesions. Semin Urol. Aug 1991;9(3):175-9. [Medline].

  12. Dretler SP, Klein LA. The eradication of intraurethral condyloma acuminata with 5 per cent 5-fluorouracil cream. J Urol. Feb 1975;113(2):195-8. [Medline].

  13. Wen YC, Wu HH, Chen KK. Pan-urethral wart treated with 5-fluorouracil intraurethral instillation. J Chin Med Assoc. Aug 2006;69(8):391-2. [Medline].

  14. Zaak D, Hofstetter A, Frimberger D, Schneede P. Recurrence of condylomata acuminata of the urethra after conventional and fluorescence-controlled Nd:YAG laser treatment. Urology. May 2003;61(5):1011-5. [Medline].

  15. Langley PC, Tyring SK, Smith MH. The cost effectiveness of patient-applied versus provider-administered intervention strategies for the treatment of external genital warts. Am J Manag Care. Jan 1999;5(1):69-77. [Medline].

  16. Wang XL, Wang HW, Wang HS, Xu SZ, Liao KH, Hillemanns P. Topical 5-aminolaevulinic acid-photodynamic therapy for the treatment of urethral condylomata acuminata. Br J Dermatol. Oct 2004;151(4):880-5. [Medline].

  17. Chen K, Chang BZ, Ju M, Zhang XH, Gu H. Comparative study of photodynamic therapy vs CO2 laser vaporization in treatment of condylomata acuminata: a randomized clinical trial. Br J Dermatol. Mar 2007;156(3):516-20. [Medline].

  18. Shaw MB, Payne SR. A simple technique for accurate diathermy destruction of urethral meatal warts. Urology. May 2007;69(5):975-6. [Medline].

  19. Harper DM, Franco EL, Wheeler C, Ferris DG, Jenkins D, Schuind A, et al. Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet. Nov 13-19 2004;364(9447):1757-65. [Medline].

Further Reading

For more information, visit Medscape’s HPV and Cervical Cancer Resource Center.

Keywords

urethral warts, genital warts, condylomatous warts, venereal warts, genital condyloma, condyloma acuminatum, sexually transmitted diseases, STDs, human papillomavirus, HPV, squamous cell carcinomas, SCCs, cervical dysplasia, cervical cancer, sexually transmitted infections, STIs

Contributor Information and Disclosures

Author

Yegappan Lakshmanan, MD, FRCS, Chief of Pediatric Urology, Children's Hospital of Michigan
Yegappan Lakshmanan, MD, FRCS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Urological Association, Endourological Society, Massachusetts Medical Society, Royal College of Surgeons of Edinburgh, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

Coauthor(s)

Douglas Dahl, MD, Consulting Staff, Department of Urology, Massachusetts General Hospital
Douglas Dahl, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Massachusetts Medical Society, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.