CHAPTER 155 Treatment of Noncervical Condylomata Acuminata

The increased incidence of human papillomavirus (HPV) infection combined with increased public awareness of the association of HPV with cervical carcinoma has led to a greater number of patients seeking counseling and treatment for condylomata (genital warts). Over 5 million new infections occur every year in the United States, and 74% are in those 15 to 24 years of age. Although there is some evidence that treatment reduces infectivity, there is no evidence supporting the concept that treatment of condylomata (the warty lesions themselves) reduces the incidence of cervical or genital neoplasia. In the majority of cases, genital HPV infection is subclinical and resolves on its own (Fig. 155-1). Treatment of subclinical asymptomatic genital HPV infection, regardless of its mechanism of detection (e.g., colposcopy, biopsy, acetic acid application, laboratory testing), is not recommended. The purpose and goal of treatment are to eliminate visible warts or symptomatic infection, to identify and resolve any associated dysplasia, and to educate the patient and any partners about the disease.

Figure 155-1 Hierarchy of clinically apparent and subclinical human papillomavirus infections: 15 to 49 years of age, United States, 2004. HPV, human papillomavirus.

(From U.S. Census estimates of population as of July 1, 2004. Adapted from Koutsky L.)

HPV is a multicentric infection. Coexisting external and internal lesions, or multiple lesions involving the entire lower genital system of both men and women, may be present. They can present as totally flat or 1- to 2-mm papular lesions, or as large, 1- to 2-cm cauliflower-like growths (see Chapter 118, Androscopy, Figs. 118-1 and 118-5). Some may be detected only with magnification (e.g., a colposcope), whereas others will be detected by a white discoloration after application of acetic acid (white epithelium). Some are flesh colored, whereas others are pigmented (see Chapter 118, Androscopy, Fig. 118-4; for a differential diagnosis, see Box 118-1). Warts may be found in and around the anus and inside the mouth. Because of the risk of neoplastic transformation, a biopsy should be obtained if the clinician is uncertain about the diagnosis, lesions fail to respond or worsen during therapy, the patient is immunocompromised, or the lesion has an atypical, suspect appearance including pigmentation, bleeding, or ulceration.

Biopsy of suspect lesions should be performed before treatment is initiated. If biopsy is performed after treatment, it is important to communicate to the pathologist the type and amount of preceding treatment.

The clinician must decide which treatment modality is best based on clinical skill, extent of disease, cost, patient preferences, and overall chance of success. The 2006 Centers for Disease Control and Prevention Treatment Guidelines point out that there is no definite evidence suggesting any of the available treatments are better than the others or ideal for all patients. Spontaneous resolution is a possibility, and therefore observation alone without specific treatment may be a reasonable alternative for some patients. Because there is no specific “cure” for HPV infection itself, the goal of treating HPV infection is the elimination of obvious visible or troublesome lesions (the disease caused by the virus). Treatment of HPV infection is analogous to the treatment of herpes virus infection. The virus will not be eliminated, but symptoms can be controlled.

Some infections may not be grossly visible, yet still cause anogenital pruritus, burning, vaginal discharge, or bleeding. Conversely, the treatment of asymptomatic intraurethral, intravaginal, or cervical condylomata (without dysplasia) exposes the patient to treatment risk without obvious benefit.

The patient may harbor HPV DNA for life; therefore, patient education is important to prevent unreasonable expectations. Treating male sexual partners with HPV infection has not appeared to change the post-treatment failure rate in women with cervical dysplasia. These findings should not deter the clinician from appropriately counseling, examining, and treating HPV-infected men (see Chapter 118, Androscopy). All methods of treating HPV have significant failure and recurrence rates. Common modalities for treatment are noted in Table 155-1; additional information is presented in Chapter 14, Cryosurgery; Chapter 30, Radiofrequency Surgery (Modern Electrosurgery); Chapter 118, Androscopy; Chapter 137, Colposcopic Examination; and Chapter 142, Human Papillomavirus DNA Typing.

TABLE 155-1 Therapies Currently Available for the Treatment of Genital Warts*

The latest in the “treatment” of HPV infection is prevention. A quadrivalent vaccine (Gardasil) is available and approved by the U.S. Food and Drug Administration (FDA) for women between the ages of 9 and 26 years. It protects against HPV types 6, 11, 16, and 18; 95% to 99% of condylomata are due to an infection with HPV 6 or 11, and 75% of cervical cancers are caused by HPV 16 and 18. Theoretically, a series of three injections effectively prevents nearly all genital warts. The vaccine has no effect on treating an infection once it is present. In October 2009, the FDA approved Gardasil for use in males ages 9 to 26 for prevention of genital warts. At the same time, the FDA also approved another HPV vaccine, Cervarix (types 16 and 18), a GlaxoSmithKline product.

Indications for Treatment of Human Papillomavirus Infection

• Visible, acuminate condylomata

• Symptomatic condylomata

Preprocedure Patient Education

Explain the procedure along with the risks and benefits to the patient. If an investigational drug is to be used, such as 5-fluorouracil ([5-FU] Efudex; Valeant Pharmaceuticals, Aliso Viejo, Calif), review the non–FDA-approved status and why it is still being used. Counseling and education are key components in the comprehensive management of HPV-infected individuals. It is imperative that appropriate time be taken by physicians and staff to counsel patients and answer questions. Educational materials include pamphlets, printouts, videotapes, hotlines, and Internet sites (e.g., www.cdc.gov/std/hpv). Advise patients and sexual partners that although HPV infection itself has been associated with carcinoma, it is very common among sexually active adults and usually remains a benign disease that resolves on its own. Most sexually active adults will be exposed to the virus at some point in their lives. Penile penetration of the vagina is the most common mode of transmissions, but HPV can also be spread through nonpenetrative contact. Most sex partners are infected by the time the patient’s diagnosis has been made, even though they may not have any clinical evidence of infection. HPV DNA testing is currently not indicated for partners of patients with genital warts. In female patients, if not already immunized, HPV recombinant vaccine should be administered to protect against types 6, 11, 16, and 18. Prior infection with HPV is not a reason to withhold the vaccine because it may prevent infection from HPV types other than the one(s) causing the current situation. In the past, condoms were not thought to be of much benefit in providing protection, but a 2006 study by Winer and colleagues suggests a 70% decrease in risk of new infection with consistent use.

Women who develop signs of HPV infection or who are sexually active with a partner who has HPV must be advised to obtain regular Pap smears because they are at higher risk for development of dysplasia.