Genital Warts in Emergency Medicine Treatment & Management

  • Author: Elizabeth Rubano, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Aug 16, 2010
 

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 and screening guidelines from the American College of Obstetricians and Gynecologists and Centers for Disease Control and Prevention are available.[1, 2]
    • 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] : 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)
      • Curettage
      • Surgical excision[2] : Excision has the highest success rate and lowest recurrence rate. Initial cure rates are 63-91%.
      • Carbon dioxide laser treatment: This 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.
      • 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).
      • Two HPV vaccine candidates 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. 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 at age 11-12 years.[3] It can be administered starting at age 9 years, with catch-up vaccinations recommended for females aged 13-26 years. The vaccine is not established as CDC policy until it is accepted by the director of the CDC.
      • Cervarix is GlaxoSmithKline's HPV vaccine candidate and focuses on cancer prevention with L1 proteins from HPV types 16 and 18 only.[4] The vaccines do not eliminate the need for other prevention strategies and screening.
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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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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

Specialty Editor Board

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, A Antoine Kazzi, MD, and Rasha A Hindiyeh, MD, to the development and writing of this article.

References

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

  2. [Guideline] Centers for Disease Control and Prevention, Workowski KA, Berman SM. HPV infection and genital warts. Sexually transmitted diseases treatment guidelines 2006. MMWR Morb Mortal Wkly Rep. Aug 4 2006;55(RR-11):62-7. [Full Text].

  3. [Guideline] Centers for Disease Control and Prevention. ACIP Provisional Recommendations for the Use of Quadrivalent HPV Vaccine. 2006. Accessed August 18, 2006. [Full Text].

  4. 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.

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

  6. [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. May 28 2010;59(20):626-9. [Medline]. [Full Text].

  7. [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. May 28 2010;59(20):630-2. [Medline]. [Full Text].

  8. American Academy of Dermatology. Genital Warts. 2006. Accessed June 6, 2006. 2006. [Full Text].

  9. [Guideline] Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines. 2002. Accessed June 6, 2006. [Full Text].

  10. Chan PD, Winkle PJ, Winkle CR. Condyloma acuminata. Current Clinical Strategies - Family Medicine. 2nd ed. 1995: 209-10.

  11. Congilosi SM, Madoff RD. Current therapy for recurrent and extensive anal warts. Dis Colon Rectum. Oct 1995;38(10):1101-7. [Medline].

  12. Garrido JL. Human papilloma virus--H.P.V. condyloma. Current studies in diagnosis, treatment and prognosis. Clin Exp Obstet Gynecol. 1996;23(2):99-102. [Medline].

  13. Kresge KJ. Cervical cancer vaccines. Introduction of vaccines that prevent cervical cancer and genital warts may fore-shadow implementation and acceptability issues for a future AIDS vaccines. IAVI Rep. Nov-Dec 2005;9(5):1-5. [Medline].

  14. Mayeaux EJ, Harper MB, Barksdale W, Pope JB. Noncervical human papillomavirus genital infections. Am Fam Physician. Sep 15 1995;52(4):1137-46, 1149-50. [Medline].

  15. Prasad CJ. Pathobiology of human papillomavirus. Clin Lab Med. Sep 1995;15(3):685-704. [Medline].

  16. Rosen T. Sexually transmitted diseases 2006: a dermatologist's view. Cleve Clin J Med. Jun 2006;73(6):537-8, 542, 544-5 passim. [Medline].

  17. Sykes NL Jr. Condyloma acuminatum. Int J Dermatol. May 1995;34(5):297-302. [Medline].

  18. Vandepapeliere P, Barrasso R, Meijer CJ, et al. Randomized controlled trial of an adjuvanted human papillomavirus (HPV) type 6 L2E7 vaccine: infection of external anogenital warts with multiple HPV types and failure of therapeutic vaccination. J Infect Dis. Dec 15 2005;192(12):2099-107. [Medline].

 
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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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