Guidelines 2016 – Condylomata Acuminata (Genital Warts)
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Condylomata acuminata is a sexually transmitted condition (but it may also be a fomite) caused by one or more members of the HPV group numbering more than 150 types and characterized by the formation of warty excrescences on the external genitalia and on the cervix, vagina, anal area, nipples, umbilicus, and pharynx. The virus does not always cause a lesion; subclinical infection occurs on cervix and externally.
II. ETIOLOGY
A. The cause of the condition is a DNA virus of the papilloma group (HPV); more than 30 types of HPV can affect the genital tract; 17 are considered high-risk types. Ninety percent of genital warts (condylomata) are caused by HPV types 6 and 11. Types 16, 18, 31, 33, and 35 usually are found as coinfections with types 6 and 11.
B. Incubation period: 1 to 6 months; may be much longer (up to 30 years); up to 70% may regress spontaneously
C. Period of communicability is unknown
III. HISTORY
A. What the patient may present with
1. “Feeling a lump” in vulvar area
2. Increased vaginal discharge
3. Vulvar itch, burning, pain, bleeding
B. Additional information to be considered
1. Previous vaginitis/vaginosis; diagnosis, treatment
2. Sexual activity, last intercourse, sexual contact
3. LMP: any chance of pregnancy
4. Method of birth control
5. Previous history of genital warts, herpes simplex
6. Known contact; consider any contact with person with warts on any body part
7. History of STI(s) or PID
8. Description of discharge (odor, consistency, amount, color)
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9. Any drug allergies
10. History of abnormal Pap smear, colposcopy, treatment
11. Reactivation of subclinical infection with sexual activity
12. Self-infection from condyloma on any body part
13. Lifestyle: smoking, sexual practices such as anal intercourse, sex toys, exposure to ultraviolet light, nutrition
IV. PHYSICAL EXAMINATION
A. External examination
1. Small, pink or flesh colored, soft papillomatous, or raised “warty” lesion visualized in
a. Periclitoral area
b. Vestibule
c. Posterior perineal and perianal areas
d. Extragenital areas
2. Confluence of many individual warts may give impression of a single, fleshy, proliferative lesion
3. Secondary infection of lesions (from scratching)
4. On hair-bearing skin, keratotic appearance
B. Vaginal examination (speculum): observe for same lesions as described previously
1. Vaginal walls
2. Cervix (more often subclinical and no visible lesions on inspection)
V. LABORATORY EXAMINATION
A. Visual examination (classic appearance, as described previously); often visible after application of 5% acetic acid (white vinegar)—not a specific test for HPV
B. GC culture
C. Chlamydia smear
D. Serology test for syphilis
E. Other laboratory work as indicated by history and examination
F. Colposcopy
G. Pap smear
H. DNA testing, such as the Hybrid Capture 2 DNA Test
I. Biopsy of cervix or unresponsive or unusual lesion on vulva for histologic examination
J. HIV testing
VI. DIFFERENTIAL DIAGNOSIS
Condylomata lata (associated with syphilis), molluscum contagiosum, lipomas, fibroma, adenomas, squamous cell carcinoma, nevi, seborrheic keratoses, psoriatic plaques, carcinoma in situ, micropapillometosis labialis, giant condyloma (Buschke–Löwenstein tumor), Bowenoid papulosis, malig- nant melanoma, skin tags, lichen nitidus, lichen planus, sebaceous Tyson’s glands, herpes simplex, angiokeratoma
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VII. PREVENTION
A. Gardasil, which prevents infection with HPV types 6, 11, 16, and 18, and a 9-valent vaccine that prevents infection with HPV types 6, 11, 16, and 18, 31, 33, 45, 52, and 58.
B. The bivalent and quadrivalent vaccines offer protection against five additional types accounting for 15% of cervical cancers. The quadri- valent HPV vaccine also protects against types 6 and 11, which cause 90% of genital warts.
C. All HPV vaccines are administered as a three-dose series of intramus- cular (IM) injections over a 6-month period, with the second and third doses given 1 to 2 and 6 months after the first dose, respectively. The same vaccine product should be used for the entire three-dose series.
D. For girls, either vaccine is recommended routinely at ages 11 to 12 years and can be administered beginning at 9 years of age; girls and women aged 13 to 26 years who have not started or completed the vaccine series should receive the vaccine.
E. The quadrivalent or 9-valent HPV vaccine is recommended routinely for boys aged 11 to 12 years; boys can be vaccinated beginning at
9 years of age (http://www.cdc.gov/vaccines/hcp/acip-recs/index. html). Boys and men aged 13 to 21 years who have not started or com- pleted the vaccine series should receive the vaccine (http://www.cdc
.gov/vaccines/hcp/acip-recs/index.html).
F. For previously unvaccinated immunocompromised persons, HPV testing with or replacing Pap smear (see Chapter 1 on well-woman exam).
VIII. TREATMENT
A. Medical treatment
1. Patient applied
a. Podofilox (Condylox) 0.5% solution or gel twice a day for 3 days; no therapy for 4 days; repeat as needed up to four cycles or
b. Imiquinod (Zyclara, Aldara; an immune response modifier inducing cytokines) 5% cream three times a week at bedtime for up to 16 weeks (may weaken rubber in diaphragms, condoms); needs to be washed off after 6 to 10 hours or
c. Sinecatechin (Veregen) 15% ointment: green tea extract with active ingredient catechins applied three times a day (0.5-cm strand of ointment to each wart, covering the wart with a thin layer of ointment), continuing this treatment until all warts are covered and should not be washed off. Use no longer than 16 weeks.
2. Provider applied for visible genital warts
a. Cryotherapy with liquid nitrogen or cryoprobe with repeat application every 1 to 2 weeks or
b. Apply podophyllin resin (podophyllin), 10% to 25% in compound tincture of benzoin and isopropyl alcohol (10%) or trichloracetic acid (TCA) or bichloracetic acid (BCA; 80%–90%): allow to air dry (apply vaseline collar with podophyllin); no need to wash TCA off; wash podophyllin off in 1 to 4 hours; may burn on
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application; if excess amount of TCA or BCA is applied, powder treatment area with talc, sodium bicarbonate, or liquid soap to remove unreacted acid; only use once a week for 8 to 12 weeks
c. Inject intralesional interferon
3. Cervical warts—colposcopy/consultation; vaginal warts— cryotherapy, TCA, or BCA repeated weekly; urethral meatus— cryotherapy or podophyllin; oral and anal—cryotherapy, BCA, or TCA or surgical removal
4. Pregnancy: Podofilox, imiquimod, and podophyllin should not be used in pregnancy.
B. Surgical treatment
1. Cryotherapy with liquid nitrogen or cryoprobe; dimethylether (Histofreezer), repeat every 1 to 2 weeks
2. Carbon dioxide (CO2) laser vaporization
3. Surgical excision
4. Loop electrosurgical excision procedure
C. General measures
1. Sexual partner(s) should be checked if lesions are present; CDC guidelines of 2015 note that the role of reinfection in recurrences is probably minimal.
2. Stress the importance of personal hygiene
D. Use of condoms to help prevent further infection with partners likely to be uninfected (Note: precaution with imiquimod)
E. Education that even after treatment and elimination of visible warts, the potential for transmission exists
IX. COMPLICATIONS
A. Lesions can become numerous and large, requiring more extensive treatment.
B. Visible genital warts and benign low-grade cervical changes are usually caused by HPV types 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, and 81. Other HPV types in the anogenital region (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82) have been strongly associated with low-grade and high-grade cervical changes, cervical neoplasia, and anogenital and other cancers.
C. Laryngeal papillomatosis in infant
D. Men with HPV are at increased risk for dysplastic changes and cancers in the penile and anorectal areas.
X. CONSULTATION/REFERRAL
A. Refer to or consult with physician
1. After 8 to 12 treatments for evaluation
2. If warts are present on vaginal walls or cervix or rectal mucosa (see Treatment, VII.C)
3. Extensive or deep anorectal warts for proctologic examination; urethroscopy as indicated
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4. If any wart is more than 2 cm in size or for large cluster of warts
5. Abnormal Pap smear (per American Society for Colposcopy and Cervical Pathology [ASCCP] guidelines, see Cervical Aberrations, Chapter 10)
6. For possible biopsy in older age groups; atypical appearance of lesions, poor response to treatment in younger patients
7. Pregnant women
XI. FOLLOW-UP
A. Weekly for 8 to 12 weeks
B. Patient advised to check self periodically and return if warts recur
C. Consider use of HPV vaccine Gardasil (quadrivalent vaccine against HPV types 6, 11, 16, and 18 and also protects against most genital warts) or Cervarix (protects against HPV 16 and 18) in preadolescent girls, adolescent girls, and young women ages 9 to 26. Gardasil and Ceravix are both licensed for boys and men ages 9 to 26 per U.S. Food and Drug Administration (FDA) approval.
See Appendix I on condylomata acuminata and for information you may want to photocopy or adapt for your patients.
See Bibliographies.
Website: www.cdc.gov/std/tg2015/tg-2015-Print.pdf