CONDYLOMA ACUMINATA

DESCRIPTION

Genital warts or condyloma acuminata are warty growths that can be found on the labia, vagina, and cervix as well as in, and around the anal area, the external urethral opening or in the bladder. Men may also have condyloma on the penis and scrotum, in and around the anal opening, and in the urethra. Condyloma are caused by the Human Papilloma Virus (HPV).


There are about 45 strains of this virus, and 5 types are known to cause pre-cancerous or cancerous changes. At present it is not possible to tell from a biopsy specimen which specific type of the virus a given patient has, but the biopsy will at least tell if there are pre-cancerous or cancerous changes present. Condyloma are usually transmitted sexually, that is, passed through direct sexual contact with someone who has the warts. There are certain strains of the virus which are not necessarily sexually transmitted; that is, they may be contracted merely by getting the virus on your hands and then transmitting it to the genital area. All sexual partners need to be examined to rule out the virus. The male partner has a 70% chance of having warts after repeated sexual relations with an infected female partner.


History
* Smoking, oral contraceptives, multiple sexual partners, and early coital age are risk factors for acquiring condyloma acuminata.

* Generally, two thirds of individuals who have sexual contact with a partner with condyloma acuminata develop lesions within 3 months.
* The chief complaint usually is one of painless bumps, pruritus, or discharge.
          o Involvement of more than 1 area is common.
          o History of multiple lesions, rather than 1 isolated wart, is common.
* Oral, laryngeal, or tracheal mucosal lesions (rare) presumably are transferred by oral-genital contact.
* History of anal intercourse in both males and females warrants a thorough search for perianal lesions.
* Rarely, urethral bleeding or urinary obstruction may be the presenting complaint when the wart involves the meatus.
* The patient's history may indicate presence of previous or other current STDs.
* Coital bleeding may occur. Vaginal bleeding during pregnancy may be due to condyloma eruptions.
* Latent illness may become active, particularly with pregnancy and immunosuppression.
* Lesions may regress spontaneously, remain the same, or progress.
* Pruritus may be present.
* Discharge may be a complaint.

Physical
* Single or multiple papular eruptions may be observed.
          o Eruptions may appear pearly, filiform, fungating, cauliflower, or plaquelike.
          o They can be quite smooth (particularly on penile shaft), verrucous, or lobulated.
          o Eruptions may seem harmless or may have a disturbing appearance.
* Carefully search for simultaneously involved multiple sites.
* Eruptions' color may be the same as the skin, or they may exhibit erythema or hyperpigmentation. Check for irregularity in shape, form, or color suggestive of melanoma or malignancy.
* Propensity has been established for penile glans and shaft in men and for vulvovaginal and cervical areas in women.
          o In contrast to early reports, presence of external condyloma acuminata in both men and women warrants a thorough search for cervical or urethral lesions.
          o Such internal lesions have been found in more than one half of females with external lesions.
          o One report indicates that infected males have a 20% chance of having subclinical urethral lesions.
          o More than 50% of female patients with external lesions have been found to have negative Papanicolaou (Pap) tests but tested positive for HPV infection using in situ hybridization.
* Urethral meatus and mucosal lesions can occur.
          o Some are subclinical.
          o Hair or the inner aspect of uncircumcised foreskin hides some lesions.
* Search for evidence of other STDs (eg, ulcerations, adenopathy, vesicles, discharge).
* Look for perianal lesions, particularly in patients with history or risk of immunosuppression or anal intercourse.

Causes

* Several of the epidermotropic human papillomaviruses (HPVs) cause condyloma acuminata.
* HPV types 6 and 11 most commonly are isolated, but many of the more than 60 types of HPV potentially cause condyloma.
* Male sexual partners of women with cervical intraepithelial neoplasia often have infections with the same viral type.



INCUBATION

Warts usually appear within three weeks to six months after contact with an infected person, although there have been reports of warts appearing as long as two or more years after contact. Some persons have naturally good immune systems so not everyone who has been exposed to venereal warts will develop them.

DIAGNOSIS

Warts may appear as single entities or form cauliflower-like clusters. In this case, the patient usually recognizes that something is wrong. Warts may also have the appearance of tiny fingerlike projections on the vagina or vulva, or may appear as a flat, roughened area of the vulva, vagina, or cervix. These are so small that even the physician may not see them unless he uses a magnifying instrument called a colposcope. Most persons do not have symptoms with warts, but if they do the most frequent problems are mild itching and a watery vaginal and they are treated with appropriate medication after the discharge has been evaluated. The diagnosis of warts is made by visual examination with a colposcope (a magnifying device) and by a biopsy (a piece of tissue that is removed and sent to a pathologist) of suspicious areas. Pap smears may suggest that there are abnormal cells due to condyloma on the cervix, but biopsy is the only definitive test.



Pathophysiology

Cells of the basal layer of the epidermis are invaded by human papillomavirus (HPV). These  penetrate through skin and cause mucosal microabrasions. A latent viral phase begins with no signs or symptoms and can last from a month to several years. Following latency, production of viral DNA, capsids, and particles begins. Host cells become infected and develop the morphologic atypical koilocytosis of condyloma acuminata.
The most commonly affected areas are the penis, vulva, vagina, cervix, perineum, and perianal area. Uncommon mucosal lesions in the oropharynx, larynx, and trachea have been reported. HPV-6 even has been reported in other uncommon areas (eg, extremities).
Multiple simultaneous lesions are common and may involve subclinical states as well-differentiated anatomic sites. Subclinical infections have been established to carry both an infectious and oncogenic potential.
Consider sexual abuse as a possible underlying problem in pediatric patients;2 however, keep in mind that infection by direct manual contact or indirectly by fomites rarely may occur. Finally, passage through an infected vaginal canal at birth may cause respiratory lesions in infants

Mortality/Morbidity

    * Mortality is secondary to malignant transformation to carcinoma in both males and females. This oncogenic potential has been reported to triple the risk of genitourinary cancer among infected males. Fortunately, this is rare with HPV types 6 and 11, which are the most commonly isolated viruses.
    * HPV infection appears to be more common and worse in patients with various types of immunologic deficiencies. Recurrence rates, size, discomfort, and risk of oncologic progression are highest among those patients. Secondary infection is uncommon.
    * Latent illness often becomes active during pregnancy. Vulvar condyloma acuminata may interfere with parturition. Trauma then may occur, producing crusting or erythema. Bleeding has been reported in large lesions that can occur during pregnancy.
    * In males, bleeding has been reported due to flat warts of the penile urethral meatus, usually associated with HPV-16. Lesions may lead to disfigurement of area(s) involved. Finally, acute urethral obstruction in women also may occur.




CONDYLOMA AND PREGNANCY

Warts during pregnancy usually increase in size due to the increase in hormone levels and the increased vaginal moisture. Treatment depends upon the size and location of the warts. Your physician will keep close watch on them during your pregnancy. There is a rare chance that if warts are in the vagina and on the cervix during labor and delivery, that the baby could inhale the condyloma virus and later develop nodules in the nasopharynx and on the vocal cords. This can be evaluated by doing laryngoscopy and treated if necessary.



TREATMENT OPTIONS

1. Trichloracetic acid (TCA) : This is a strong chemical that causes a very superficial burn, which in turn causes the top layer of skin to peel off. This is usually only used on the vulvar (outside) area and can be repeated every 10-14 days for 3-4 times. Upon application, the acid causes significant discomfort that lasts 3-5 minutes, then subsides. The medication does not have to be washed off. Two to four days after application, the top layer of skin will peel and the underlying area will be mildly sore. Keep the area cool and dry. TCA is more effective for raised warts than for flat ones.

2. Efudex Cream: Efudex or 5FU, is a strong anticancer cream that is prescribed for women with vaginal condyloma. The cream is placed into the vagina for five consecutive nights and causes a sloughing of the top layer of skin in the vagina. The cream is very irritating to the outside of the vulva so care must be taken to keep the labia coated with Vaseline or A&D ointment. If this treatment is used, a separate hand out will be given to you that explains proper usage.

3. Cryosurgery: This technique uses a cold probe that freezes the wart. As the wart freezes, fluid is lost which causes cell destruction. As the warts drop off there may be a watery discharge that lasts a few weeks. Cryo is especially useful in large, cauliflower-like warts. Each wart is treated for 30-60 seconds depending on size and requires no anesthesia.

4. Laser: Laser is a strong beam of concentrated light that evaporates tissue. Laser treatment is used for warts that have not responded to office therapies or when there is extensive involvement of the cervix, vagina and vulva. When warts are small they can be treated in the office using local anesthesia. When warts are extensive, laser is done as out patient surgery in the hospital with either general or regional anesthesia. Laser has the advantage of causing virtually no scar tissue. Laser therapy is also a very accurate treatment because the beam of light is directed through the colposcope, thus the physician is able to treat every wart that is visible. If you have laser therapy, you will be given a separate handout that describes the procedure, the risks and benefits, and postoperative care.

5. Watch: If the pap smear is normal and biopsies show only condyloma, some patients will choose not to be treated. As some of the strains of the wart virus cause pre-cancerous and cancerous changes, strict adherence to follow-up is mandatory: pap smears and colposcopy must be done every three months.

If office therapy is used, the urethra and bladder base must be evaluated by urethroscopy and the anal canal by anoscopy to determine if warts are in these locations. Mild discomfort may occur after any of these treatments, but will generally not last longer than a day or two (except extensive vulvar laser). It is important to keep all follow-up visits as warts that you can not see with the eye may remain or reappear. After the condyloma have been treated, they may recur without re-exposure, so you need to be checked monthly for six months. Other treatments are used for condyloma (podophyllin, excision, cautery and liquid nitrogen), but we have the best results with the treatments described above.

SELF CARE

By following the instructions below and keeping a positive attitude, you will give yourself the best possible care during your recovery from venereal warts.
1. Keep the areas clean and dry: The virus grows rapidly in warm, moist areas, so wear cotton underwear, loose clothing, and use a hairdryer on a low setting to dry the vulva after a bath or shower.
2. Sitz Baths: Soaking in a warm tub of water, especially after a treatment, will soothe the area, decrease the pain, and promote healing. After the bath, dry the area well with a hairdryer on a low setting.
3. Vaginal Infections: Vaginal infections may help the wart virus grow and spread. If you have a discharge that has a bad odor, or if you have itching or burning of the vulvar/vaginal area, make an appointment for evaluation.
4. Stay Healthy : Overall wellness can be achieved by eating nutritious meals, getting plenty of rest, and by reducing stress as much as possible. For those whose diets consist primarily of “junk” and “fast foods”, you may choose to supplement your diet with some vitamins: a general multiple vitamin, a B complex, 1,000 mg of vitamin C and 400 iu of vitamin E per day. Decreasing or stopping smoking will also enhance your overall wellness. 5. Intercourse: While the warts are present, you may wish to abstain from intercourse. The virus is very contagious. Small undetectable warts may be shedding viral particles, and sexual contact may spread the virus into the vagina or onto the cervix. Remember, there are other ways to make love besides intercourse.

6. Condoms: If you do have intercourse while the warts are present in either partner, use a condom. However, the condom may not offer complete protection for the transmission of  condyloma. As it only covers the penis, the male could still get warts on the scrotum, and if he has them on the scrotum, the female could get the warts on her vulva. It is advisable to continue the use of condoms for at least three months after both partners are clear of warts. Condoms also have the advantage of protection against gonorrhea, chlamydia, AIDS and herpes. Their use is encouraged when you are starting new relationships.