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Warts and All Dr Daniela Brawley ST4 Genitourinary medicine 23 rd November 2010.

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Presentation on theme: "Warts and All Dr Daniela Brawley ST4 Genitourinary medicine 23 rd November 2010."— Presentation transcript:

1 Warts and All Dr Daniela Brawley ST4 Genitourinary medicine 23 rd November 2010

2 Cases of genital warts/year in UK

3 Human Papilloma Virus > 100 sub-types of HPV HPV 6 and 11 cause 90% of genital warts Most clear the infection in 9 months HPV 16 and 18 risk for malignant change – Persistent infection with oncogenic sub-types increases risk of malignant change

4 Prevalence 1% of population have visible warts 10% have active HPV infection 60% have cleared HPV – However can have long latent or lifelong phase ? Missed opportunity with quadrivalent HPV vaccine (6/11/16/18)

5 Transmission Sexual in majority of cases – Female to male 71% at 3 months – Male to female 54% at 3 months Condoms can reduce risk but don’t eliminate Increased risk if immunocompromised and/or smoker

6 Diagnosis Diagnosis is by examination under good light Consider referral/biopsy if atypical or unsure STI screening Partner notification not necessary

7 STI screening 10-20% have co-existing STIs Extensive warts – HIV indicator disease – BHIVA 2008 HIV testing guidelines Chlamydia/ Gonorrhoea – Urine in males – Vulvovaginal/cervical swab in females HIV/Syphilis

8 But first… ….what’s a normal lump?

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10 Pearly penile papules Normal anatomy No treatment Common presentation in young men Reassure strongly that are normal

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12 Vulval papillomatosis Smooth and symmetrical Easily confused with HPV Don’t progress – review at 1 month No treatment

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14 Parafrenular glands Symmetrical, small and smooth surface No treatment required

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17 Fordyce spots or sebaceous follicles Glands in clusters Prepuce, shaft of penis and vestibular area of vulva More obvious when skin is stretched Reassurance

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19 Sebaceous cysts No treatment necessary unless become too large or get infected Reassurance In men scrotal sebaceous cysts may occur

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21 Lymphocoele Hard swelling behind coronal surface No treatment required Usually resolves over time Reassurance

22 And now… other differentials

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25 Molluscum contagiosum Pox virus Skin to skin contact, most likely sexual Cryotherapy STI screening including HIV especially if extensive

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27 Condyloma Lata of Secondary Syphilis Refer GUM Syphilis PCR and serology Dark ground microscopy STI screening Penicillin and GUM follow-up

28 Now for warts…. Site, distribution and number Morphology- keratinised or non keratinised Patient features Experience and equipment – Availability of cryotherapy

29 Treatments Podophyllotoxin (warticon) Cryotherapy Imiquimod (aldara) Smoking cessation Excision

30 Warticon Purified extract of podophyllin Solution (0.5%) or cream (0.15%) Non-keratinised warts, not perianal 3 days BD then 4 days rest for 4 weeks Soreness and ulceration NOT used in pregnancy

31 Cryotherapy Necrosis of dermal-epidermal junction Keratinised warts and intrameatal warts Weekly application with “Halo” and “Freeze and thaw” techniques Safe in pregnancy

32 Aldara Immune response modulator Non formulary and expensive (£50/month) Used for resistant/extensive warts 3 times a week for maximum 16 weeks NOT used in pregnancy

33 Source: Sandyford Protocols- External Anogenital Warts.

34 Clearance rates TREATMENTEND OF TREATMENT >3 MONTHSRECURRENCE RATES (%) Cryotherapy63-88 (75)63-920-39 (20) Imiquimod (Aldara) 50-62 (58)50-6213-19 (16) Podophyllotoxin (Warticon) 42-88 (65)34-7710-91 (50) Surgical excision89-93 (91)360-29 (15) Source: United Kingdom National Guideline on the Management of Anogenital Warts, 2007. (BASHH)

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36 Keratinised Warts Cryotherapy first line Imiquimod if not improving Warticon less likely to be effective but can try for 4 weeks

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38 Non-keratinised warts Warticon Cryotherapy or imiquimod if not improving

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40 Perianal warts Cryotherapy first line Imiquimod if not improving Warticon can be used but not licensed Proctoscopy not indicated unless immune suppressed, or symptoms in anal canal

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42 Extensive Sub-preputial warts GUM referral Imiquimod and cryotherapy Surgical referral

43 20 week pregnant female

44 Warts in pregnancy Cryotherapy Warticon and Imiquimod contraindicated Improve/resolve 6-8 weeks after delivery Not an indication for Caesarean Section Small risk of transmission both genital and laryngeal papilloma – 1 in 400 – No reduction with c-section

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46 Warts and Bowen’s Disease Referral for biopsy of suspicious areas Cryotherapy/ electrocautery Circumcision

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48 Warts and VIN Referral for biopsy of suspicious areas Localised surgical excision Referral to Gynaecology

49 Features indicating biopsy Atypical Pigmentation Flat warts Older age groups Immunosuppression including HIV Heavy smokers

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51 Extensive warts Trial of imiquimod +/- cyrotherapy Referral to Gynaecologist for surgical removal STI screening

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53 Single wart at fourchette Cryotherapy Surgical excision

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55 Extensive anal warts HIV positive gay man GUM referral Syphilis PCR and serology Cryotherapy and/or Imiquimod Proctoscopy Surgical referral – Risk of AIN

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57 Meatal Warts Cryotherapy – If can see extent of warts Concern about causing urethral stenosis Warn about symptoms of urethral obstruction

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59 Vaginal warts Usually resolve with treatment of external warts Cryotherapy if not improving

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61 Cervical warts Usually resolve with treatment of external warts Ensure has had recent smear – No need for additional smears If no external warts or no improvement with treatment of external warts refer to colposcopy

62 Summary points Treat the patient in front of you Offer STI testing Smoking cessation Refer if unsure, not improving or suspicious features

63 Sandyford contacts www.sandyford.org 0141 211 8130 dbrawley@nhs.net

64 Some final points…

65 Chlamydia/Gonorrhoea NAAT test

66 PREFERRED SAMPLE VULVOVAGINAL SWAB

67 Tests for ulcers Syphilis Herpes type 1 and 2 Combined PCR test Confirm with syphilis serology

68 History Low risk STI Typical BV or VVC history No symptoms of PID Examination and pH pH < 4.5 Treat for VVC pH > 4.5 Treat for BV High risk STI Pregnant Requests testing Examination, pH and CT/GC NAAT pH > 4.5 Treat for BV Await CT/GC NAAT pH < 4.5 Treat for VVC Await CT/GC NAAT Recurrence Symptoms of PID Postpartum Gynaecological instrumentation Exam HVS CT/GC NAAT GUM referral if GC positive or unresolved PRIMARY CARE VAGINAL DISCHARGE PROTOCOL CT/GC NAAT BV- bacterial vaginosis VVC- vulvovaginal candida CT/GC NAAT- Chlamydia/Gonorrhoea molecular test GUM- genitourinary medicine clinic


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