Condylomata acuminatum, more commonly known as genital warts, are caused by human papillomavirus (HPV) types 6 and 11. HPV is a widely spread sexual virus. The body’s immune system deals with the vast majority of HPV infections without any symptoms or damage caused– around 90% of HPV infections are cleared within 2 years. The proportion of HPV infections that result in any symptoms is very small. Symptoms usually do not manifest until months or even years after infection, so if you do get genital warts, it may be after a period following the sexual encounter.¹ 

There are many different types of HPV. The most well-known are 16 and 18, which are the most common causative agents of cervical cancer and can cause some oropharyngeal cancers or anal cancers affecting both sexes (there are other HPV types which cause cancer, but these are not as potent as types 16 and 18). However, HPV types 16 and 18 are not causative of genital warts. 

In people assigned male at birth (AMAB), genital warts can appear on the penis or scrotum. In those assigned female at birth (AFAB), they can appear on the vulva, vagina, or in the cervix. Genital warts can also appear around the anus or in the groin area in both sexes. If HPV is passed on during oral sex, warts can appear in the mouth or throat area too – although this is not as common as in the genital area. The warts can vary in appearance: they can be pink, flesh-coloured, purplish or greyish. They can appear alone or in clusters, which can have a cauliflower-like appearance. They may be flat or rounded, smooth or rough in texture. They are generally painless but can bleed spontaneously. They can also cause itching or discomfort. 

Diagnosis of genital warts is by visual inspection, there is no investigation or test for them. However, other sexually transmitted infections (STIs) will be tested for genital warts, which is by a swab sample. For testing for HPV DNA specifically, either a Pap smear or an HPV DNA test is carried out with a swab of cells taken from the cervix. This is generally done in people AFAB to test for carcinogenic HPV types.

Transmission of HPV

Between two (or more) people, sexual contact of any kind (penis-in-vagina sex, anal sex or oral sex) can lead to HPV transmission. Other contact with the genital areas like masturbation can also lead to HPV transmission. HPV types 6 and 11 can spread by skin-to-skin contact too.

HPV can also spread from mother to foetus. This can be around the time of conception, during pregnancy (any of the three trimesters), or birth, though the incidence of HPV infections in babies or young children is relatively uncommon. 

Recurrence

Recurrence of genital warts is very common. The virus can live in the human tissues for a very long time without causing symptoms. This is known as a latency period. HPV can persist in the body for months or even years. Additionally, because HPV is a commonly transmitted virus, viral load (the amount of virus that is passed on) can be increased with different sexual encounters. 

In a study of high-risk adults in Montreal, Canada, almost 50% of adults experienced recurrence of genital warts. This is despite over 90% of patients having reported that the first episode was resolved. Initial clearance would last for a median time of 4 months. Around 95% of patients did have some kind of intervention as treatment, mostly cryotherapy (freezing off of warts). There were about 3% of patients who had 4 or more episodes of recurrence.²

Another study, which looked at data from Brazil, Mexico and the USA also found a high rate of recurrence. Around 44% of people had a recurrence within 6 months, and 6.5% had four or more episodes of recurrence. 

A study from sub-Saharan Africa has shown that HPV type 6 and 11 infections are relatively common amongst both sexes, especially amongst those who are HIV positive. Those who are immunocompromised for other reasons – such as having inflammatory bowel disease, lupus, or rheumatoid arthritis, or taking medications like chemotherapy – are also more prone to recurrence.³

Some countries have been vaccinating both people AMAB and AFAB to reduce the incidence of oral cancers caused by HPV and genital warts. The UK is one such country, and data has found a significant reduction in the incidence of genital warts (around 74% in people AFAB) and high effectiveness against early-stage cervical cancer. Vaccination against HPV usually starts before the onset of sexual activity, around early adolescence. Nationalised vaccination and cervical screening programmes have been in place in many developed countries (like those in Europe, North America and Australia). However, developing countries (which also have the highest incidence of cervical cancer worldwide) may not have the same access to healthcare.

Treatment

Genital warts in most cases spontaneously resolve within 18 months. For larger lesions, or for ones that may be causing particular discomfort, itchiness, etc, they can be removed. This can happen in a number of ways including cryotherapy (freezing off), and using a topical medication on the warts to destroy them. Surgical removal is another option under anaesthetic for ones that may be larger.⁴ 

It is worth noting that the methods of removal eliminate only the warts. They do not deal with the HPV infection, the virus is cleared by the immune system. Genital warts often recur after the initial warts have gone, even if the warts have been removed by medical intervention. However, the body can still deal with the warts and infection itself. If not, the removal may need to be repeated.¹

Protection against genital warts 

Condoms do not cover the entire genital, groin or anal area, so do not offer 100% protection against genital warts. They are however very effective as protection against other STIs and for contraception, so their use is still recommended.

The most effective way to prevent infection is to be vaccinated against HPV. Gardasil 9, is a nonavalent vaccine, meaning it protects against 9 types of HPV(carcinogenic types 16, 18, 31, 33, 45, 52, and 58, and genital wart-causing 6 and 11). Gardasil 9 is given in many countries around the world for their HPV immunisation. Another World Health Organisation-licensed vaccine is quadrivalent (brand name Gardasil) protecting against 4 types- 16, 18, 6 and 11.⁵ Of note, vaccination does not reduce the transmission or prevalence of HPV itself but does prevent the virus from causing any infection or symptoms. HPV DNA can still be detected in those who have been vaccinated. 

Testing

Anyone with symptoms of an STI should be tested (either at a clinic or with a self-testing kit). It is not uncommon for STIs to co-occur, so STIs such as chlamydia or gonorrhoea may also be there if you have genital warts. You should also be tested if you have any concerns following a sexual contact, or with a new sexual partner. It is acknowledged that testing and informing partners often carry stigma along with it, but it is important for the sake of the health of yourself, your sexual partners, and their sexual partners. Talking of sexual health can be very difficult, but in particular, for people AFAB who have not been vaccinated, it is even more important to be tested for HPV ascervical cancer often does not show any symptoms until the later stages. 

Summary 

Genital warts are caused by types 6 and 11 of human papillomavirus (HPV). Recurrence of genital warts is very common, even if treatment is followed correctly. The best way to prevent the occurrence of genital warts is to be vaccinated, either by the quadrivalent or nonavalent HPV vaccine. Vaccines are effective for people both assigned male and female at birth. Data has shown that the incidence of genital warts has gone down almost to the point of disappearing altogether with mass vaccination against HPV. 

If you have symptoms of genital warts, you should be tested for other STIs (such as chlamydia or gonorrhoea) as they can co-occur.