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Dr Daniela Brawley ST4 Genitourinary medicine 23rd November 2010

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

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


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


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


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



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


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


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

22 And now… other differentials



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


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.

RECURRENCE RATES (%) Cryotherapy 63-88 (75) 63-92 0-39 (20) Imiquimod (Aldara) 50-62 (58) 50-62 13-19 (16) Podophyllotoxin (Warticon) 42-88 (65) 34-77 10-91 (50) Surgical excision 89-93 (91) 36 0-29 (15) Source: United Kingdom National Guideline on the Management of Anogenital Warts, (BASHH) 34


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


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


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


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


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


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


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


53 Single wart at fourchette
Cryotherapy Surgical excision


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


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


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


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

64 Some final points…

65 Chlamydia/Gonorrhoea NAAT test


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

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 Await CT/GC NAAT Recurrence Symptoms of PID Postpartum Gynaecological instrumentation Exam HVS CT/GC NAAT GUM referral if GC positive or unresolved CT/GC NAAT BV- bacterial vaginosis VVC- vulvovaginal candida CT/GC NAAT- Chlamydia/Gonorrhoea molecular test GUM- genitourinary medicine clinic

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