Genital Warts

Question 1

Genital warts are caused by ____________

Answer 1

Human papillomavirus (HPV)

Question 2

90% of genital warts are caused by (HPV subtypes)

Answer 2

HPV 6 or 11

Question 3

How many types of HPV are there?

Answer 3

> 100

Question 4

How many types of HPV can infect the anogenital and oropharyngeal mucosa

Answer 4

> 40

Question 5

HPV can be divided into ______ and ______ types, based on their association with the development of malignancy

Answer 5

Low-risk and high-risk

Question 6

Are HPV 6 and 11 low risk or high risk

Answer 6

These are low-risk types of HPV, which are generally not associated with malignancy

Question 7

How common is HPV in sexually active populations

Answer 7

Almost universal
Can be regarded as an inevitable consequence of being a sexually active adult

Question 8

How is HPV transmitted?

Answer 8

Skin-to-skin contact

Question 9

What types of sex can transmit HPV?

Answer 9

Can occur through penetrative and non-penetrative sex, as well as sexual activity through fingers or sex toys from genital areas infected with HPV

Question 10

Are most anogenital HPV infections symptomatic or asymptomatic?

Answer 10

Asymptomatic

Question 11

Is HPV infection permanent or transient?

Answer 11

Most HPV infection is transient and often becomes undetectable within 12 months

Question 12

What should you advise patients if genital warts develop during a long term relationship?

Answer 12

HPV infection may become latent, and reactivate after several years –> doesn’t necessarily imply the presence of other sexual contacts

Question 13

Can immunity develop from natural infection?

Answer 13

Immunity from natural infection is poor. Previous infection does not necessarily create long-term immune memory, so may not prevent future infection with the same HPV type

Question 14

How effective is vaccination at preventing HPV infection

Answer 14

Vaccination provides effective long-term protection against HPV acquisition

Question 15

What is the vaccination available for HPV in NZ

Answer 15

Gardasil 9

Question 16

What age group is Gardasil 9 funded for?

Answer 16

9-26 year olds

Question 17

What does Gardasil 9 protect against?

Answer 17

Protects against the types of HPV that cause most genital warts, as well as 7 types of oncogenic HPV

Question 18

Is vaccination recommended if you are already sexually active?

Answer 18

Yes

Question 19

Clinical presentation anogenital warts

Answer 19

Warty growths in and around anogenital skin. Little discomfort (sometimes itchy)

Question 20

Clinical presentation for warts on penile urethra

Answer 20

Distorted urinary stream or bleeding with urethral lesions

Question 21

Clinical presentation for warts on cervix

Answer 21

Cervical lesions noted on vaginal examination

May cause mild transient cervical smear abnormalities

Question 22

Clinical presentation for anal warts

Answer 22

Rectal bleeding may occur after passage of stools with anal lesions

Question 23

Diagnosis of genital warts is made by…

Answer 23

Genital warts are clinically diagnosed, based on characteristic appearance. Consider biopsy if lesions are atypical

Question 24

The goal of treatment of genital warts is to…

Answer 24

Eliminate warts that cause physical or psychological symptoms

Question 25

Does the elimination of visible external warts decrease infectivity?

Answer 25

May not decrease infectivity since the warts may not represent the entire viral burden. For this reason recurrence is common, esp in first 3 months

Question 26

Treatment options for genital warts

Answer 26

No treatment Cryotherapy Podophyllotoxin 0.5% solution Imiquimod 5% cream

Question 27

No treatment as an option

Answer 27

An option for asymptomatic warts. 30% of patients will experience spontaneous clearance of warts over a 6-month period.

Question 28

What is the only treatment suitable in pregnancy?

Answer 28

Cryotherapy

Question 29

How often does cryotherapy need to be repeated?

Answer 29

Weekly until clearance

Question 30

Instructions for treatment with podophyllotoxin 0.5% solution

Answer 30

Apply carefully to warts twice daily for 3 consecutive days, followed by 4 days rest each week, until warts have resolved, or for a maximum of 5 consecutive weeks

Question 31

Can you use podophyllotoxin 0.5% solution in pregnancy (or if partner is pregnant) or breastfeeding

Answer 31

No Teratogenic

Question 32

Why does podophyllotoxin have very limited utility for vulvovaginal warts

Answer 32

Patients must be able to visualise, identify and reach their warts, as the solution must not come in contact with normal skin

Question 33

Instructions for treatment with Imiquimod 5% cream

Answer 33

Apply to affected area at bedtime 3 times per week (alternate days), wash off in the morning

Question 34

Duration of treatment with imiquimod

Answer 34

Can be used for up to 16 weeks, although the majority who clear their warts will do so by 8 weeks

Question 35

How often should you review someone on treatment with imiquimod?

Answer 35

Monthly review recommended

Question 36

S/E imiquimod

Answer 36

Local skin reactions are common, but rarely result in discontinuation of treatment

Question 37

What patients should you use imiquimod cautiously in

Answer 37

Patients with autoimmune conditions or those on systemic immunosuppressant drugs (discussion with specialist recommended)

Question 38

Can you use imiquimod in pregnancy?

Answer 38

No

Question 39

Do you need to treat genital warts in pregnancy?

Answer 39

Smaller genital warts may not require treatment as spontaneous resolution often occurs after delivery. Genital warts are not a contraindication to vaginal delivery.

Question 40

When would c section be indicated due to genital warts

Answer 40

When genital warts are likely to cause obstruction of the pelvic outlet or excessive bleeding

Question 41

Special management considerations for immunocompromised patients with genital warts

Answer 41

May respond less well to therapy and may have more frequent recurrences after treatment. Manage in consultation with a sexual health specialist

Question 42

If a patient has urethral warts what should you do?

Answer 42

Refer for specialist management (risk of stenosis with over-zealous treatment)

Question 43

Management of cervical or vaginal warts

Answer 43

High rate of spontaneous resolution – consider no treatment Follow up at 6 months, refer if still present Cryotherapy possible

Question 44

Do you need to do a cervical smear for cervical or vaginal warts?

Answer 44

Not indicated unless due

Question 45

What should you for a patient with Intra-anal warts

Answer 45

Refer to specialist for management

Question 46

If no response to treatment in 4-6 weeks consider...

Answer 46

Change in treatment modality or onward referral

Question 47

What additional advice should you give to patients undergoing treatment? (Other supportive measures)

Answer 47

Saltwater baths can sooth and heal the genital skin during treatment Avoid shaving or waxing as this may spread the warts

Question 48

Advice to a patient with genital warts re sexual activity

Answer 48

No need to alter sexual activity with a regular partner (sharing of HPV would have occurred long before the clinical appearance of the lesions) Consistent condom use recommended if new sexual contact

Question 49

Consistent condom use has been shown to reduce the risk of HPV acquisition and genital warts by ____%

Answer 49

30-60%

Question 50

Is follow up with patients recommended?

Answer 50

Not required if symptoms resolve Review if patient anxious, warts are difficult to visualise, or poor response to treatment

Question 51

Indications for specialist referral

Answer 51

Lack of response to therapy Diagnosis unclear Immunocompromised patients with genital warts Urethral warts Cervical warts which are still present after 6 months Intra-anal warts