Overview 

Often neglected, sexual health plays a fundamental role in the lives of all individuals, society, and the economy of a country. To achieve good sexual health, appropriate education, guidance, and good accessibility to sexual health care are required to ensure the overall well-being of individuals, men or women. Conversely, bad sexual health poses a significant challenge to public health, society and the economy, as it leads to a rise in sexually transmitted infections that could progress into cancers. 

Genital warts are one of the most common manifestations of human papillomavirus (HPV) infections, with an incidence rate of about 360,000 cases per year. It might sound scary, as you may think having genital warts is a sign of HPV-related cancers. That’s not true. It is caused by HPV strains that are incapable of causing cancers. Nevertheless, that doesn’t change the fact that it is a disease that results from poor sexual health. This article will provide an extensive insight into genital warts and its impact and relationship with sexual health. 

Understanding genital warts

Genital warts are the most common form of sexually transmitted infection (STI) that is caused by certain types of human papillomavirus (HPV), specifically type 6 and type 11. These warts are commonly found on the external or internal surfaces of the genital (penis and vagina) or anal region, either separately or in clusters.¹ In some cases, genital warts can also be seen in the oral cavity up to the throat. The standard features of the warts are: 

• Small lumps (sometimes flat) with a diameter of 1 to 5 millimetres
• Cauliflower-like large lumps if several warts form a cluster 
• The soft or firm texture when touched 
• Bleeding may occur spontaneously 
• May appear as skin-coloured, red, white or darker lumps 

Genital warts are a form of HPV infection. However, this infection is different from the type of HPV infection that causes cancer. Most HPV infections are typically harmless. Genital wart HPVs can be classified into two types: low-risk and high-risk. The causative agents of genital warts (HPV type 6 and type 11) fall in the low-risk category, which generally does not give rise to cancer.² Conversely, high-risk HPV infections lead to the development of several types of cancers, with types 16 and 18 accounting for most of them, including cervical cancer, anal cancer and vaginal cancer.¹ 

People often mistake the fact that HPV is transmitted via semen or saliva, but that is not the case. Most cases of genital HPV infections are transmitted via skin-to-skin or skin-to-mucosa contact during sexual intercourse, regardless of which route it is, anal, oral or vaginal sex. Sharing of sex toys can also result in HPV transmission.³

Although uncommon, some individuals can contract HPV infections even if they haven’t had sex before. Studies have reported evidence of HPV infections seen in babies and virgin females. Hence, it is confirmed that HPV can be transmitted through non-sexual pathways which involve direct contact with infected regions via fingers, mouth and fomites (contaminated clothing), or from an infected mother to the fetus during birth.³

When one gets infected, the warts don’t develop instantaneously, they can take months, or even years to be visibly seen.⁴ Genital warts are usually asymptomatic, but on some occasions, you may experience some discomfort, such as:¹ 

• Pain or itchiness 
• Spontaneous bleeding
• Peeing difficulties or blood in pee

Complications associated with genital warts

The HPV strains that cause genital warts typically don’t cause cancers. However, if the warts are left untreated, they could potentially progress into severe malignant consequences, leading to urinary tract infections or, worse.^1,2 

If the wart is located close to the urethral opening, in other words, when the warts develop around the penis and the clitoris, you might experience urinary tract infections. Warts that lie close to the urethral opening might also impede urine flow in the urethra, resulting in urinary blockage occurring mainly in males.¹ 

Genital warts in the anogenital area, could also be a prior manifestation of a rare HPV infection, caused by the same strain causing genital warts (HPV 6 and 11), known as Buschke-Löwenstein tumour (BLT). It is often hardly distinguishable between regular genital warts and BLT due to their similar presentation in the early stages.⁵ It is usually benign, but due to its high proliferation rate and recurrence rate, BLT has a high risk of malignant transformation, which could potentially progress into skin cancer.⁶ Therefore, BLT is also regarded as an invasive complication of genital warts in the anogenital region.⁷

Untreated warts can increase the risk of malignant progression of the HPV infection, leading to anogenital cancers (vulvar cancer, penile cancer, vaginal cancer, anal cancer and cervical cancer), primarily cervical cancers in females. Studies reported that people affected with genital warts are more prone to develop HPV-related anogenital cancers. However, this might be attributed to the co-infection of both, low-risk and high-risk (oncogenic), HPV strains instead of the malignant progression of the low-risk HPV infection.⁸ 

The connection between genital warts and sexual health 

Besides the physical drawbacks resulting from the condition, people affected by genital warts are reported to experience psychological distress, such as decreased sex drive, low self-esteem, depression and sexual anxiety, leading to an overall drop in their quality of life and mental well-being.⁹ 

Couples, specifically when someone has genital warts, often find it embarrassing to talk about it with their partners, or are worried that this condition might put an end to the relationship. Not to mention the sense of fear, as STIs are commonly associated with cervical cancers and other anogenital cancers. These psychological effects have a significant impact on their social and sexual health status, thus reflecting the detrimental influences that genital warts imply, not only to one’s physical health but also the psychological side. Notably, based on studies, it is reflected that women are often more concerned about their sexual health and well-being as compared to men, which might be due to several social and cultural norms that believe “STI only affects promiscuous individuals”.^9,10

This highlights the importance of proper communication and education between affected individuals, their family/partner and their GPs. Counselling and awareness campaigns are crucial, mainly to reduce their anxiety levels by educating them about HPV, as misconceptions often arise from the false information that is made accessible from the internet that HPV infections will undoubtedly lead to cancers. Through proper counselling by GPs, they will be well informed about the condition, and to have an appropriate treatment and good management of the disease. By that, affected partners may be less distressed and are more willing to inform their partners about it.¹⁰ 

Diagnosis and treatment 

Diagnosis

Genital warts can be diagnosed visually as they usually grow externally upon the skin surface. However, a biopsy might be required to justify the diagnosis, especially when the lesions are pigmented, or ulcerated, or when the affected person has a weakened immune system. If the warts do not respond well to the routine therapy given, or worsen during treatment, a biopsy will also be helpful for a differential diagnosis.¹

Pap smear will be performed on women with the condition (age >30), for the examination of abnormal changes in the vagina and cervix caused by the warts, which could be an early sign of cervical cancer. The cell samples taken from the Pap test will also be tested for the presence of high-risk oncogenic HPV strains, so that, early treatment and management can be given to control the infection.²

Treatments

Genital warts can recover over time, sometimes even without treatment. Treatments are targeted at relieving discomfort and often leave scars. Topical treatment is the standard treatment prescribed during the initial stages and for small warts. Some examples of topical treatments given are Imiquimod and Podophyllotoxin. For more severe scenarios, surgical procedures (heat or laser removal) might be required for wart removal. Do note that the successful removal of warts does not cure HPV infection. Therefore, HPV transmission can still occur even after the removal of warts.¹ Besides, you might experience recurrent development of warts, especially in immunocompromised individuals, until the infection is cleared.¹⁰ There is no cure for HPV infection, but roughly 80% of HPV carriers reported spontaneous eradication of the infection within 18 to 24 months.¹

Given the devastating consequences of HPV, preventive measures are essential to reduce the incidence of HPV infections in the general population. Awareness campaigns, and education, can improve the public’s understanding of STIs, and HPV, by implying the importance of practising safe sex tips, such as the use of condoms and having monogamous relationships to control the prevalence of the infection.⁷ Vaccination programmes (Gardasil vaccine) should be widely implemented to increase herd immunity against HPV infections.¹

Summary 

Genital warts are a common occurrence and usually resolve within a few months. However, the underlying HPV infection is incurable. As a result, long-term treatment, and management, are necessary to prevent the infection from developing into more severe conditions, such as cancer. The impact of HPV infection on physical, sexual, and psychological health presents a significant challenge for healthcare professionals. Therefore, it is crucial to implement preventive strategies, such as vaccination programmes, public awareness campaigns, and educational efforts to ensure that individuals seek immediate medical attention when they experience similar symptoms. These initiatives can effectively manage and control the transmission and progression of the infection.