Genital Warts And Human Papillomavirus (Hpv)

Overview

HPV infection and genital wart manifestation is one of the most common sexually transmitted conditions. Diagnosis of either of the two is usually accompanied by stress, confusion, and many open questions for individuals. This article provides valuable information about the link between these two conditions and discusses prevention and available therapeutic options.  

Introduction

Definition of Genital Warts 

Genital warts are small growths, usually located in the genital area. They might occur after a human papillomavirus infection (HPV).

Overview of Human Papillomavirus (HPV) 

Human papillomavirus (HPV) refers to a group of viruses most commonly sexually transmitted. More than 200 subtypes belong to this group, some of which are responsible for genital warts development.¹

Importance of the Topic

HPV has gained a lot of attention in recent years since some strains have been associated with an increased risk for several cancer types. However, some other strains might lead to genital warts, which, although benign, might require several doctor visits, irritating procedures, and psychological stress. 

Understanding HPV

What is HPV? 

Papillomaviruses are viral particles about 60 nm in diameter. They consist of protein structures surrounding the genetic material, responsible for the replication of the particles. In the case of HPV, the genetic material is double-stranded DNA.¹

Virus types and classification 

A viral structural protein called L1 is responsible for the HPV subtype and variant classification.² Officially 221 types have been described; however, this number is expected to grow in the future.¹  

High-risk and low-risk strains 

Some HPV types are considered high-risk since they are associated with an increased probability of developing several cancer types. HPV-16 and HPV-18 are high-risk infections. Other HPV types are classified as low-risk and are linked to genital warts development, such as HPV-6 and HPV-11. About 90% of the patients are infected with those two HPV types.³ This means that the low-risk HPV strains leading to genital warts are different from the high-risk strains that might cause cancer. 

Transmission

How HPV is spread 

HPV is spread through skin-to-skin contact, commonly through sexual intercourse, although indirect transmission through hand contact has also been reported. Auto-inoculation describes self-infection, and it is considered rare. The infection probability increases with age and multiple sexual partners; however, a person might be infected even after sexual contact with one person.⁴

Common risk factors

HPV is to a great extent sexually transmitted; therefore, high-risk sexual behaviour increases the infection probability. High-risk sexual behaviour refers to a high number of oral and vaginal sexual partners, or sexual intercourse onset at a younger age.⁵ 

Genital Warts

What Are Genital Warts? 

Genital warts are small lumps that appear on the skin or the mucosa. It is one of the most common sexually transmitted diseases, and they might appear after an infection with a low-risk HPV type. Not all HPV-infected people will develop genital warts, but rather a small percentage of 1% of the sexually active population.³ 

Description, appearance, and location 

Genital warts vary in size but are usually small skin growths. They can either be few or more in number, usually white, red, lighter, or darker than the surrounding skin. Common locations on the body include the area around the vagina, penis, or anus. 

Symptoms and Complications 

Physical symptoms 

They are usually asymptomatic, although they can sometimes be itchy, painful, or bleed after being injured. On rare occasions, they might disturb peeing, depending on their exact location and size.   

Potential complications if untreated 

Although they are usually asymptomatic and on several occasions disappear after some months, it is important to check and remove them as they can increase in number and size, causing irritation. Treating the warts will also decrease the infection probability of another partner, although some infected individuals might transmit the virus, even without having genital warts. Moreover, it is important to check and remove them, as on rare occasions they might be transmitted to the baby during pregnancy.

Diagnosis 

Medical examination 

Medical examination and evaluation can be performed by a dermatologist or at a sexual health clinic. Usually clinical examination with possibly a magnifying lens is sufficient for the diagnosis of genital warts. 

Tests for HPV

To diagnose the specific HPV type causing the warts, an additional test for the genetic sequence of the virus might be performed. This might be useful to understand if the person is also infected by a high-risk HPV strain.

Relationship Between HPV and Genital Warts

HPV Strains Causing Genital Warts 

Low-risk HPV strains might cause genital warts. HPV-6 and HPV-11 account for more than 90% of the cases. HPV-44 and CP8305 are responsible for a few cases of genital warts.⁶ However, about 1% of infected individuals will have symptomatic warts, which in some cases regress on their own.³ 

Differences Between HPV-Related Warts and Other HPV-Related Conditions 

Infection with a low-risk HPV strain does not increase the probability of cancer. High-risk HPV strains have been linked to cervix dysplasia and cancer development. Other types are responsible for oral cancers.  

Prevention of HPV and Genital Warts

Vaccination 

Available vaccines 

There are available vaccines to prevent an infection with several HPV strains. Gardasil-9 protects against an infection from the low-risk strains HPV-6 and HPV-11. It additionally protects from some high-risk strains. 

Age groups and vaccination schedules 

Vaccination is usually performed between 9 and 26 years old, with a recommended age of 11–12 years. Older adults might still benefit from the vaccine until the age of 46. After this age, due to the higher number of sexual partners, people might have been infected with the virus, and therefore the vaccine is not effective. People younger than 15 years old need two doses; however, older people or people with weakened immune systems should have three doses. 

Effectiveness and safety 

Vaccines are effective against the infection by the targeted HPV strains. They are mostly beneficial before exposure to the virus, therefore before the first sexual activity. 

Safe Sexual Practices

Condom use is beneficial for the covert areas against exposure to the HPV virus. It is important to know that areas of the skin that are not protected might still be infected, leading to genital warts. Limiting the number of sexual partners is a way of decreasing the infection probability and the appearance of genital warts.

Treatment of Genital Warts

Medical Treatment Options 

There are several therapeutic options for managing genital wart removal. Although they might re-emerge several times and require several rounds of therapy, treatments are effective and eventually regress.^3,7 These treatments include:

Topical treatments 

Treatments might include the application of an immunomodulatory reagent to the areas where genetic warts appear, activating the host's immunity topically. Imiquimod boosts the immune response against warts. Polyphenon E is another option that might be suitable, according to the appearance of the warts. These agents are usually used as first-line treatments. 

Removal of genital warts

If the warts are bigger, removal of the warts might be more suitable through one of the following methods:⁷

• Cryotherapy (freezing) 
• Surgical removal 
• Laser therapy 

Vaccination

A few reports are claiming that vaccination even after HPV infection might be beneficial for some patients with recurrent lesions, although this view is controversial and needs further validation.⁸

Managing Recurrence 

It is important to note that even after treatment application, the probability of genital warts recurrence is high. Usually, genetic warts will eventually regress after some time. Communication and history description to the clinician are essential to deciding on the most appropriate therapeutic scheme or its adaptation. 

Living with HPV and Genital Warts

Psychological Impact 

A genital wart or HPV diagnosis can affect the mental health of individuals. Recurrence of genital warts might cause anxiety and even trigger depression in some cases. Furthermore, confusion is often experienced by individuals since some HPV strains are linked to more serious conditions. Communication with clinical experts and support groups when necessary is central to minimising emotional stress.

Communication with Partners 

Following a genital wart or HPV diagnosis, an open discussion with the partner is essential, as they might also need an examination. Misinformation and stigma on sexually transmitted conditions might make disclosure difficult and often cause additional stress. 

FAQs 

How can I distinguish genital warts from another condition?

As genital warts can vary in colour, shape, or size, it is important to visit a clinician or clinic focusing on sexual health for a certain diagnosis. 

Does an HPV infection causing genital warts also increase the probability of cervical cancer?

The HPV strains responsible for genital warts (e.g., HPV-6 and HPV-11) are low-risk and are not the high-risk (e.g., HPV-16 and HPV-18) associated with cancer. However, it can not be excluded that the person with genital warts is also infected with a high-risk HPV type. Following the official recommended guidelines for regular screenings, such as a Papanicolaou (Pap) test, is therefore necessary.

Summary

Genital warts are small skin growths located at the genital or rectum area. They are a common sexually transmitted disease and might occur following an infection with a low-risk HPV variant. Although there are several available therapeutic options, recurrence rates are high, often causing anxiety to individuals. Prevention with an available vaccine targeting some strains of HPV is recommended for people before engaging in sexual activity, and it might be beneficial also for sexually active individuals in certain age groups. Individuals must consult a specialised clinician to diagnose and treat genital warts, as well as to be informed about HPV infections and their repercussions.