Genital warts overview

Sexually Transmitted Infections, or STIs, are a group of infections that can be passed on from one person to another by vaginal, anal or oral sex. This article focuses on genital warts, which are evident due to infection by HPV (Human Papillomavirus), that are passed on. HPV is probably more commonly known in the context of cervical cancer, which is caused primarily by HPV types 16 and 18. HPV ( types 16 and 18) can also cause anal, vulval or vaginal cancer, as well as some oropharyngeal cancers. Genital warts, however, are caused by HPV types 6 and 11.¹ The immense majority of HPV infections are cleared by the body’s immune system, and do not result in any symptoms. Around 1% of HPV infections actually result in genital warts, and usually the warts appear after a few months following initial infection.² 

Genital warts, as the name suggests, appear around the genital areas, the groin area or around the anus. Oral sex can cause them to appear in the mouth or throat.  In people assigned male at birth, they are most commonly found on the shaft of the penis or the scrotum. In those assigned female at birth, they come on the vulva, vagina, or cervix (which will not be visible by eye). Genital warts can be pinkish, dark brown, purple, or grey in colour. In texture, they are usually smaller and appear in clusters, which can have a cauliflower-like appearance. The warts can vary in their texture; they can be rounded at the top, or flat, smooth or rough.  They are generally painless, but sometimes can be itchy.³

People who are between the ages of 16 and 25, those with multiple sexual partners and have unprotected sex, and those who are already infected with another STI are more susceptible to genital warts. Those who are immunocompromised (i.e have another medical condition such as cancer, or AIDS, or who follow lifestyle choices like smoking, which harms the immune system) are also more susceptible. Note that genital warts are not the same as genital herpes. Herpes is another STI which is caused by a different virus, HSV (Herpes simplex virus). Genital herpes presents with red or white ulcerated lesions, which are usually painful.^2,3

HPV vaccination

HPV vaccination is implemented in many countries. The vaccine initiative is primarily for preventing cervical cancer, and so is targeted at assigned females. However, in some countries, including the UK and countries in Europe, HPV vaccines are available for both sexes. One vaccine that is used in many parts of the world (including the UK, Europe, and North America) is Gardasil 9. Gardasil 9 is a nonavalent HPV vaccine, meaning it protects against 9 different types of HPV: 16 and 18 (the most carcinogenic),  31, 33, 45, 52, 58 (which are also carcinogenic but not as potent as 16 and 18), 6 and 11 (which cause genital warts). Data from the UK has shown that the incidence of genital warts (and early signs of cervical cancer) has gone down in both genders, male and female.^4,5

Diagnosis of genital warts is usually by visual inspection; usually, tests are not necessary. 

Treatment

Genital warts do not always require treatment, and warts can go away on their own within 3 months. Note that treatment is to remove the warts, but there is no cure for HPV infections; the body’s immune system usually clears the virus itself. Therefore, treatment has no effect on HPV's transmission: when an individual is infected, they may continue to transmit the virus, but the chance of experiencing any symptoms of infection is low, particularly for those receiving the vaccination.⁶

Treatment is either by using a topical medication (i.e ointment applied to the area) or physically removing the warts. This can be done by surgically cutting them off, laser, cryotherapy using liquid nitrogen or electrocautery (burning using an electric current). Physically removing them is the preferred option for large or hard warts, which may have been there for a long time, though it can leave scarring and pigmentation. Topical treatments are less invasive but rely on patient compliance with the instructions, and are usually enough for smaller, soft lesions. Medications that are used for topical treatments include Imiquimod Cream, podophyllotoxin, Trichloroacetic acid, and Isotretinoin. All of which destroy the warts chemically in different ways. Despite treatment (even if followed correctly), genital warts can recur within 3-4 months.⁷

STI testing

STI testing remains essential in the case of genital warts. Genital warts are a sign of a HPV infection, and those who are not vaccinated, especially in the case of those assigned female at birth, are more likely to present carcinogenic HPV types. Other STIs such as chlamydia or gonorrhoea should also be tested for those not vaccinated against HPV, as it is a significant risk factor for cervical cancer⁸. 

There are two different types of tests which can detect HPV from the cervix: Pap smear and HPV DNA testing. A Pap smear is commonly known as a “smear test” where a sample of cells is taken from the cervix and analysed under a microscope to check for any abnormal cells. If abnormal cells in the cervical smear are found, then a DNA test is carried out to check for the presence of HPV DNA. Depending on the country/region, a Pap smear may be offered, and in other areas, they may just do an HPV- DNA test (as this has been shown to be a more accurate test than a Pap smear). For other STIs, swab tests of the genital/anal/oral region are taken, and these are analysed for genetic information (either DNA or RNA) of STI-causing pathogens. Anyone who has symptoms of an STI, or who has concerns after any sexual intercourse should get themselves tested for STIs.⁹

Stigma

It is acknowledged that stigma around STIs (not just genital warts) and getting tested is very much still present, and it can be difficult for people to be tested. Common fears include judgment from those around them, or from the healthcare professionals, fear of an intimate examination, or a perceived lack of confidentiality. However, STIs have much better treatment outcomes when treated earlier rather than later. Some countries/regions offer self-testing for STIs, so this can circumvent the need for going to a centre and having an examination. Informing partners if a person tests positive for any STI is another challenging part of the process. However, for the sake of the health of the partners and their sexual relationship, it is important to inform partners. Some STI clinics can help with the disclosure process, so you can ask if this is an option.^10,11

FAQs

Can I still have sex if I have genital warts?

It’s best to avoid sexual contact until warts are treated, as HPV is highly transmissible through skin-to-skin contact.

How is STI testing done?

Urine tests: Chlamydia, gonorrhea

Blood tests: HIV, syphilis, hepatitis

Swabs: Herpes (if sores are present), trichomoniasis, HPV (via Pap smear or HPV DNA test)

Do I need symptoms to get tested?

No. Many STIs are asymptomatic. Regular screening is recommended for sexually active individuals, especially those under 25 or with multiple partners

Summary 

Genital warts are a symptom of infection by HPV (Human Papillomavirus) types 6 and 11. They are mostly painless, have a cauliflower-like appearance and can be flesh-coloured, red, brown or purplish-grey in colour. They may not require treatment, especially for small lesions that can resolve on their own, but larger ones can be removed either by a topical medication or surgically. Note that the treatment is for removing the warts, but not as a “cure” for the HPV infection- there is no cure for HPV; the body’s own immune system deals with that. Despite treatment, however, Genital warts often recur even after successful treatment. It can take up to 2 years for the body to completely clear them. For those who are vaccinated against HPV, to the nonavalent HPV virus, the Gardasil 9 vaccine is very effective.  It is important to be tested for STIs if there are symptoms of genital warts, as there may be other STIs, such as chlamydia or gonorrhoea, transmitted at the time of acquiring genital warts.