8.07 Genital warts (condylomata acuminata)
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agk's Library of Common Simple Emergencies

Presentation
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Patients complain of perineal itching, burning, 
pain and tenderness or they may be asymptom- 
atic, especially with cervical and vaginal 
involvement, but noticed distinctive fleshy 
warts of the external genitalia or anus. 
Lesions are pedunculated or broad based with 
pink to gray soft excrescences, occuring in 
clusters or individually.

What to do:
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- External warts seldom require biopsy for 
    diagnosis. The differential diagnosis of 
    anogenital warts includes molluscum 
    cantagiosum, verruca vulgaris (common 
    non-genital wart), secondary syphilis 
    (condyloma lata), hypertrophic vulvar 
    dystrophies and vulvar intraepithelial and 
    invasive neoplasias. Consider atypical, 
    pigmented, intravaginal cervical and 
    persistant warts for referral for biopsy.
- Prescribe podofilox 0.5% solution (Condylox) 
    3.5mL for self-treatment. Patients may 
    apply podofilox with a cotton swab to warts 
    twice daily for three days, followed by 4 
    days of no treatment. This cycle may be 
    repeated as necessary for a total of 4 
    cycles. Total wart area treated should not 
    exceed ten square centimeters and total 
    volume of podofilox should not exceed 0.5mL 
    per day. If possible, you should apply the 
    initial treatment to demonstrate the proper 
    application technique and identify which 
    warts should be treated.
- Alternatively, apply 25% podophyllin in 
    tincture of benzoin (Podocon-25) 15mL using 
    the above application technique and with 
    the same dosage restrictions. Have the 
    patient thoroughly wash off in 1-4 hours. 
    This may be repeated weekly if necessary 
    but if warts persist after six applications 
    the patient should be referred for altern- 
    ative therapy.
- If the patient is pregnant, has severe 
    involvement or has anal or rectal warts, 
    she should be referred for cryotherapy, 
    application of trichloroacetic acid, 
    ablation with carbon dioxide laser, 
    electrocautery or surgical extirpation.
- If the patient's male partner also has 
    visible lesions, he can be treated using 
    the same regimens.
- Counsel both about the unpredictable natural 
    history of the disease and the possible 
    increased risk of lower genital tract 
    malignancy. Infected women should have an 
    annual Pap smear.

What not to do:
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- Do not use podofilox or podophyllin during 
    pregnancy. There have been a few cases of 
    toxicity reported when large amounts of 
    podophyllin have been used.
- Do not mistake "pearly penile papules" for 
    warts. These dome-shaped or hairlike 
    projections around the corona of the glans 
    penis are normal variants in up to 10% of 
    men.

Discussion
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Genital warts are a result of infection with 
human papillomavirus (HPV). The virus is 
currently considered a leading candidate as a 
causative agent in squamous carcinomas of both 
the female and male genital tracts. The sexual 
transmission of HPV is well documented, with 
the highest prevalence in young, sexually 
active adolescents and acults. HPV types 6 and 
11 are the most prevalent types associated with 
condyloma accuminata and are not considered to 
have malignant potential. HPV frequently 
coexists with other sexually transmitted 
diseases. HPV lesions are difficult to 
eradicate, with a very high recurrence rate, 
and still no definitive therapy.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
 Longwood Information LLC 4822 Quebec St NW Wash DC
 1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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