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Genital Warts in Emergency Medicine Treatment & Management

  • Author: Delaram Ghadishah, MD; Chief Editor: William D James, MD  more...
 
Updated: Apr 26, 2016
 

Emergency Department Care

Although an in-depth discussion of the treatment of genital warts (ie, type of workup, treatment regimens, necessary follow-up) is beyond the scope of ED practice, symptomatic treatment may be warranted. Use pressure to stop bleeding, if present. Relieve urethral obstruction (rare). Search for evidence of coexistent STDs; treat them if found and indicated.

The following measures are beyond the scope of the ED and are presented for educational purposes only. Further treatment, screening, and vaccination guidelines from the American College of Obstetricians and Gynecologists and Centers for Disease Control and Prevention are available.[1, 2, 3]

Untreated

If visible genital warts are left untreated, they can undergo spontaneous resolution, increase in size, increase in number, or remain unchanged. Complete resolution of lesions after 2 years occurs in 75% of individuals without intervention.

Ablative therapy

Cryotherapy[2] can be used. Use an open spray or cotton-tipped applicator for 10-15 seconds and repeat as needed. Lift away mobile skin from the underlying normal tissue before freezing. Response rates are high, clearance occurs about 75% of the time with few adverse sequelae. Adverse reactions include pain during treatment, erosion, ulceration, and postinflammatory hypopigmentation of skin. Cryotherapy is safe for use during pregnancy.

Electrodesiccation (smoke plume may be infective) and curettage have been used.

Surgical excision[2] has the highest success rate and lowest recurrence rate. Initial cure rates are 63-91%.

Carbon dioxide laser treatment is used for extensive or recurrent genital warts. The procedure requires local, regional, or general anesthesia. (A eutectic mixture of local anesthetics [EMLA] cream may be used as an alternative anesthetic.) Clearance rates are more than 90%, but reoccurrence can be up to 40%. HPV-6 DNA has been detected in the carbon dioxide laser plume; therefore, the laser operator is at risk of developing mucosal warts.

With infrared coagulation, a beam of infrared light is delivered to the affected lesions, causing tissue coagulation and necrosis. Treatment is successful in about 80% of cases.

Immune-based therapy

Physician administered treatments include acid applications (bichloroacetic acid or trichloroacetic acid) and interferon injections with antiviral mechanisms.

Medications for home use include imiquimod 5% cream, podofilox gel or solution, and antiproliferative compounds (5-fluorouracil).

Vaccination [4, 5]

Two HPV vaccines have proven to be highly effective in clinical trials: Gardasil and Cervarix. Gardasil, Merck's HPV vaccine, was licensed by the Food and Drug Administration (FDA) in June 2006 for the prevention of cervical cancers and other diseases caused by HPV in females.[6] It is composed of a viruslike particle consisting of recombinant L1 proteins from HPV types 6, 11, 16, and 18. It has been recommended by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices to be routinely given to girls and boys at age 11-12 years.[7] It can be administered starting at age 9 years, with catch-up vaccinations recommended for females aged 13-26 years and boys through age 21 years.

Cervarix is GlaxoSmithKline's HPV vaccine candidate and focuses on cancer prevention with L1 proteins from HPV types 16 and 18 only.[8] The vaccines do not eliminate the need for other prevention strategies and screening.

Special concerns

Pregnancy

Latent infections may become activated with numerous large lesions. Lesions often present or increase during pregnancy. Lesions may make vaginal delivery difficult if they are in the cervix, vagina, or vulva. Lesions tend to bleed easily. Lesions often regress spontaneously after delivery.

Pediatrics

Neonates may become infected during passage through an infected birth canal. The incidence of perinatal transmission to the infant pharynx may be as high as 50%; transmission occurs most frequently with HPV-6 and HPV-11. Incidence of genital infection in neonates is 4%, although the American College of Obstetrics and Gynecology currently does not recommend cesarean delivery due solely to positive HPV status.

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Consultations

No emergent consultation is indicated. Outpatient follow-up with a dermatologist, an OB/GYN, or a urologist is indicated.

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Complications

Possible complications are as follows:

  • Local disfigurement
  • Transformation to genitourinary malignancies in both males and females
  • Transmission to neonate or partners
  • Recurrence: According to Diamantis et al, recurrence rates for anogenital warts ranged from 19% at 3 months to 23% at 6 months. [9]
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Prevention

No treatment is 100% effective. Two HPV vaccines are FDA approved.[7, 8] Sexual abstinence and monogamy are protective. Condoms may discourage transmission.

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Long-Term Monitoring

Ensure follow-up with a dermatologist, OB/GYN (females), or urologist (males) within 1 week. Perform a workup for human papillomavirus (HPV) and other sexually transmitted diseases (STDs) as indicated. Treat the patient using medications; if medications are ineffective, treat with cryotherapy, curettage, electrodesiccation, surgical excision, carbon dioxide laser treatment, or combination therapy.

Evaluate and treat sexual partner(s).

Search for immunosuppression in patients with treatment failures and recurrences. Perform a tissue biopsy if recurrences or treatment failures occur.

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Contributor Information and Disclosures
Author

Delaram Ghadishah, MD Physician, Emergency Department, Kaiser Permanente West Los Angeles Medical Center

Delaram Ghadishah, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Acknowledgements

Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center

Disclosure: Nothing to disclose.

Rasha A Hindiyeh, MD, MBA Physician, Department of Internal Medicine, University of California Irvine School of Medicine

Disclosure: Nothing to disclose.

A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Elizabeth Rubano, MD Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center

Elizabeth Rubano, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Binita R Shah, MD, FAAP Professor of Clinical Pediatrics and Emergency Medicine, SUNY Health Sciences Center at Brooklyn; Director of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, Kings County Hospital Center

Binita R Shah, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

References
  1. [Guideline] American College of Obstetricians and Gynecologists (ACOG). Human papillomavirus. Washington (DC): American College of Obstetricians and Gynecologists (ACOG). 2005 Apr. ACOG practice bulletin; no. 61. [Full Text].

  2. [Guideline] Centers for Disease Control and Prevention, Workowski KA, Berman SM. Genital Warts. Sexually Transmitted Diseases Treatment Guidelines 2010. Available at http://www.cdc.gov/std/treatment/2010/genital-warts.htm. Accessed: November 4, 2014.

  3. [Guideline] American College of Obstetricians and Gynecologists. Human Papillomavirus Vaccination. Available at http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Human-Papillomavirus-Vaccination. Accessed: November 4, 2014.

  4. [Guideline] FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010 May 28. 59(20):626-9. [Medline]. [Full Text].

  5. [Guideline] FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010 May 28. 59(20):630-2. [Medline]. [Full Text].

  6. Mandic A. Primary prevention of cervical cancer: prophylactic human papillomavirus vaccines. J BUON. 2012 Jul-Sep. 17(3):422-7. [Medline].

  7. [Guideline] Centers for Disease Control and Prevention. HPV Vaccines. Available at http://www.cdc.gov/hpv/vaccine.html. Accessed: November 4, 2014.

  8. Food and Drug Administration. FDA Approves New Vaccine for Prevention of Cervical Cancer. Oct 16, 2009. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm187048.htm. Accessed: January 5, 2010.

  9. Diamantis ML, Bartlett BL, Tyring SK. Safety, efficacy & recurrence rates of imiquimod cream 5% for treatment of anogenital warts. Skin Therapy Lett. 2009 Jun. 14(5):1-3, 5. [Medline].

  10. American Academy of Dermatology. Genital Warts. Available at https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/e---h/genital-warts. Accessed: April 26, 2016.

 
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Genital wart in pubic area.
Genital wart in pubic area.
Genital wart in pubic area.
Genital wart in pubic area (close-up). Note the pearly appearance.
Genital warts. Condyloma acuminatum. Courtesy of Tsu-Yi Chuang, MD, MPH.
Genital warts. Small papilloma of the vulva. Courtesy of Tsu-Yi Chuang, MD, MPH.
Genital warts. "Cauliflower" condyloma of the penis. Courtesy of Tsu-Yi Chuang, MD, MPH.
Genital warts. Small papilloma on the shaft of penis. Courtesy of Tsu-Yi Chuang, MD, MPH.
Genital warts. Small papilloma of the anus. Courtesy of Tsu-Yi Chuang, MD, MPH.
 
 
 
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