As the name implies, condyloma acuminata, or genital warts, are warts that occur in the genital area. They are also called venereal warts because they are a type of venereal disease, which is a disease spread by sexual contact. They can also be called anal warts or anogenital warts because they can also be found around the anus.
Genital warts are similar in many ways to regular warts. They are caused by a virus which most people get and fight off eventually on their own. Treatment is also similar, using caustic chemicals, cold or heat to kill off the warts. If you have had warts on your fingers, the main difference between those and genital warts is the area in which they appear and the particular virus that causes them.
Genital warts are caused by a virus called the human papilloma virus or HPV. Papilloma means warts. HPV is a very common infection. It is estimated that most adults who have had sexual contact contract this virus at some time, usually with no apparent symptoms. Some say 80% of adult women have been infected by HPV at least once by the time they are 50 years old, with men similarly affected. Most people with normal immune systems fight this virus off. Many never even have visible warts, but even with warts, most will be rid of the disease in around one to two years.
It is not known why some people have warts and others do not, when infected with HPV. Some may have warts in an area that is not visible (like inside the vagina) or they may have warts that are so small they are not noticed. Having visible warts is not an indicator of any other problem and does not mean the immune system is not normal.
The warts can be found around and in the vagina, the vulva, on the perineum (the area between the vagina and anus), around and in the anus, the penis, and the scrotum. Warts inside the anus (the rectum) usually but not exclusively occur after exposure due to penile penetration. Warts around the anus, usually in a circle, can occur in men or women without anal penetration. The virus just spreads from other genital areas. Genital warts are most commonly found around the vaginal opening, the foreskin of uncircumcised men, and the skin on the penile shaft of circumcised men.
Although it is unusual, genital warts can be found in other places, where there has been sexual contact and the area is moist and warm. This includes the inside of the mouth, the conjunctiva of the eye, the inside of the nose, and the larynx (voice box).
Like common warts that appear on other areas, these warts may be flat or fleshy elevated areas or may look more like skin tags, slightly pink or gray in color. There may be only a few, but there are often many together, such as around the anus, penis or vaginal opening. Most people have less than ten warts.
Warts inside the vagina cannot be seen without a doctors assistance. Warts inside the cervix and warts inside the anus have to be visualized with special instruments. Warts inside the urethra, which is the tube carrying urine and semen out the tip of a man’s penis, cannot be seen. If you have a wart in your urethra, you may notice that your urinary stream is not normal.
Genital warts do not necessarily cause symptoms. Some people experience itching, pain, or bleeding from the warts depending where they are. Many people are very uncomfortable with the appearance of the warts.
It is not known exactly how long a person with warts is contagious, or how long it takes for someone who is exposed to have symptoms. It is believed that the virus can be passed to another person even when there are no visible warts. Since most people are exposed to HPV, it is not recommended to examine or test sexual partners of people with warts, because they have already been exposed. Treatment is only needed if warts appear and the person wants to have them removed.
It is also not known if treatment, by removing tissue with HPV, actually reduces the chance of transmitting the virus.
Genital warts are diagnosed by their appearance. Testing for HPV is not necessary or helpful. Biopsy is only necessary if there is some reason to suspect that the bumps are not venereal warts.
Some doctors use an application of 3% to 5% acetic acid onto the skin to look for genital warts, which turn white. This is not very reliable or necessary, but some doctors believe that they have more success finding all the involved tissue this way.
Human Papilloma Virus and Cancer
There are more than 100 types of HPV. That is one reason why people can get reinfected with HPV. Certain types are most likely to cause genital warts. 90% of genital warts are caused by HPV types 6 and 11. Other types of HPV are associated with certain types of cancer, mainly HPV types 16 and 18.
The most common type of cancer associated with HPV is cervical cancer. Vaccines have been developed to help protect against HPV 16 and 18, and therefore prevent the 70% of cervical cancer that is caused by these two types. One vaccine protects only against these two types, and is called Cervarix. Another vaccine, called Gardasil, includes 6 and 11, which also protects against 90% of genital warts. The other 30% of cervical cancer not caused by HPV types 16 and 18 are caused by so many different types of HPV that a vaccine is not practical.
These vaccines are recommended for adolescent girls before they become sexually active. The first vaccine is recommended at age 11 to 12, but can be given as early as 9 years of age, or later, anywhere between 13 and 26 years of age. The vaccines are not recommended for older women who most likely have already been exposed to the virus. Gardasil is also recommended to protect against genital warts in boys and young men ages 9 to 26 years of age, again, before they become sexually active. There are three doses necessary with each vaccine. The second should be one to two months after the first, and the third should be given six months after the first dose.
Since there is cervical cancer associated with other HPV types, screening by Pap test is still necessary.
Type 16 and 18 HPV, as well as some less common types, are also associated with rectal/anal cancer, as well as cancer inside the mouth. For this reason, Gardasil may also be a good vaccine for adolescent boys and young men, especially men who have sex with men.
Condoms cannot completely protect men or women against HPV because the virus can live on skin not covered by the condom. The only way to prevent HPV absolutely is abstinence.
Treatment of Genital Warts
This section on treatment assumes that you are in general good health. If you have an abnormal immune system because of HIV, cancer chemotherapy or other medication, you need to see the doctor and may need different treatment.
Genital warts themselves are not precancerous and are not dangerous. Treatment is to stop symptoms, and for cosmetic reasons. Since they are not dangerous, the treatment should not be in any way risky. While it is very reasonable to want to get rid of them, no one should undergo treatment in which the cure is worse than the disease.
Most treatments of genital warts are applied directly to the warts. The exception to this is homeopathic remedies which are ingested. All other treatment, in a doctor’s office, at home, by prescription, surgical methods or via alternative medicine involves a way to remove or kill off the affected tissue. The key is to get rid of the areas with HPV and not cause any damage to normal skin. This is not necessarily easy.
Many of the treatments, whether in the doctor’s office or used at home, whether conventional or alternative, have not been subjected to rigorous scientific testing. For the most part they have not been tested against each other in large-scale, placebo-controlled, randomly-assigned trial. No methods are guaranteed to remove all warts. Even if they appear to be gone, they can reoccur. Most methods remove warts about 50% of the time.
If your warts do not go away after an adequate trial of any of these methods, you can switch to a different method. No one method has been proven to be better than any other method.
Your own immune system should eventually get rid of the warts in time. If your warts are not causing symptoms, are not very large or bothersome, and the diagnosis of genital warts is certain, you can opt to wait. When your body eliminates warts there are no side effects.
The most common side effects of all the treatments include:
- Local pain
- Local burning
- Local swelling
- Reoccurrence of warts
The worst complications of all prescription treatments, including those used in a doctor’s office as well as those used at home include
- A change in pigmentation can occur after the warts heal. This depends on the site of the warts, and can be increased or decreased pigmentation.
- Scars, which are rare, but are more likely if there is not enough time for healing in between treatments.
- Severe pain can occur and become chronic either in any treated area
- Pain can occur in the vaginal area which increases with sexual intercourse.
- Pain can occur around the anus which increases when passing stool.
There are almost never any side effects in other parts of the body when treating genital warts with any of these local treatments. Rare reports of problems that may have been caused by podophyllin resin and/or imiquod have been reported. In these cases, large amounts of the chemicals were used.
Treatments in the doctor’s office
There are a number of factors determining the type of treatment given by a doctor. These include the doctor’s preference and what he or she has the most experience with, the patient’s preference, and the availability of the medicines needed to treat the warts.
Treatment with compounds applied to the warts
There are a few chemicals that doctors can apply to genital warts to remove them. These chemicals all damage the tissue, which then dies and falls off. The key is to apply the chemical only to the warts. If there are a lot of warts or if they are very flat and close to normal skin, this is harder than if there are large, visible, discrete warts. Warts in moist, warm areas are best treated by creams or chemicals.
Multiple treatments are usually necessary; 3 months is the length of time it takes for most warts to disappear.
Sometimes petroleum jelly will be applied to the normal skin around the warts to prevent damage if the chemical gets on the skin. The doctor will apply the treatment, and then let you know how long you should leave the chemical on. The length of time will vary depending on the size and amount of warts, the delicacy of the surrounding tissue, and whether or not they have been treated in the past.
The two most commonly used treatments in the office have been podophyllin resin, 10% to 25% strength, applied weekly for up to four weeks, and trichloroacetic acid or bichloroacetic acid, 80% to 90% applied weekly.
Podophyllin is put into a resin to keep it on the skin and prevent it from being absorbed. It should not be used over a very large area. This will usually stay on a number of hours, 6 to 8, and then should be washed off. The warts should shrink. They may form a crust or a scab, and should eventually fall off. Small warts might just disappear.
Unfortunately, there are very few manufacturers of podophyllin resin at this time. Many doctors cannot acquire it. This was a very good treatment which is currently unavailable to many people, leaving the two types of acetic acid as in-office doctor-applied treatments.
Trichloroacetic (TCA) and bichloroacetic acid (BCA) 80% to 90% applied weekly kill wart-containing tissue. Either has to be applied very carefully because it spread onto healthy skin.
The risks and side effects of these treatments are damage to local tissue, and not causing the disappearance of all the warts. Multiple treatments are usually necessary. If chemicals are left on the warts for too long, you can feel burning. You have to wash off the chemicals as instructed. Remaining warts can be treated at another visit. Any damage to adjacent tissue will usually heal well. It is not known if any of these medicines is safe during pregnancy.
Treatment by surgery or energy application
Genital warts can be removed surgically, or destroyed in many ways, by application of heat, cold, and other kinds of energy. Large warts should be physically removed by one of these methods.
Warts can be shaved off with a blade or other types of surgical instruments (called curettage). Warts with thin bases can be cut off with sterile scissors. This type of removal is best for warts that are hanging off of thin bases or otherwise easy to separate from normal tissue. If bleeding results, it can be stopped with chemical cautery, similar to what is in a styptic pencil. A related way to remove warts is with electrocautery. This is delivered by a machine that has a pointed end which heats up. This can destroy the warts at the same time that the heat closes blood vessels so there is no bleeding. Most of these procedures require local anesthetic.
Some doctors have other instruments to destroy warts. Laser therapy (with a carbon dioxide laser) may have a higher success rate and better cosmetic appearance than some of the other methods. In at least one small trial, women treated twice by laser therapy had 100% cure rate with no reoccurrence. The men’s cure rate was slightly lower, at 88%. Most primary care doctors do not have lasers. Dermatologists and plastic surgeons do. If you have large, unsightly warts and you would prefer surgery or laser therapy, you will need to see a specialist.
A method available in almost every primary care doctors’ office is cryotherapy, or freezing. This is usually done with liquid nitrogen. A cold probe or cotton swab is held to each wart until it is sufficiently frozen. This will cause the wart to fall off in 7 to 10 days. Cryotherapy may be the method of choice for many doctors and patients. No anesthesia is needed. There is no bleeding. Although multiple applications are usually necessary, there is no need to put on medication repeatedly or worry about washing it off in time. You need to go back to the doctor after the first treatment to see if there are any small warts that were missed, or any large warts which got smaller but are still there.
All of these methods depend on the skill level and comfort level of the doctor using them. Choice also depends on patient preference. This is something to discuss with the doctor.
The risks and side effects of all these methods are similar. There can be pain, usually very temporary. Normal tissue can be damaged. All of the wart may not be removed, so that warts remain and grow back. Too much cautery, or too deep of a cut that gets into normal tissue will cause more bleeding and potentially cause a scar. Scarring is unlikely in many of the areas where these warts occur. However, very large warts requiring surgery may leave a scar.
Cryotherapy probably has the least risk, and is the most widely available. Multiple treatments are often necessary. If warts are missed, they can be treated at the next visit. Freezing is not the fastest method to get rid of visible warts. Surgical procedures can remove them immediately, but are more painful, cause more bleeding, and have the highest risk of scarring. If done by a doctor skilled in these procedures, surgical removal or laser therapy may be the best choice. Surgery in which anesthesia is used and laser therapy will usually cost considerably more than the other treatments.
Prescription medication to be used at home
Prescription medications to treat genital warts are creams to be applied to the warts that will cause a similar reaction to the medications above. They include podofilox 0.5% solution or gel, imiquimod 5% cream, and sinecatechins 15% ointment. The safety of all of these in pregnancy is unknown. As noted above, the side effects of all creams and gels applied to warts are similar.
Podofilox is generally considered safe. It is made of the active ingredient in podophyllin. It is easy to use and inexpensive to obtain. The solution is applied to the warts twice a day for three days. There are then 4 days when no treatment is done. This cycle can be repeated a total of four times. The prescribing doctor can apply to first treatment to demonstrate, but this is not absolutely necessary. Pain and irritation are side effects. If warts are still there after four cycles of treatment, it is best to switch to another method of treatment.
Imiquimod is an ìimmune enhancerî which causes the body to make chemicals that kill the warts. The cream is applied at bedtime, once a day, three times a week. The cream must be washed off 6 to 10 hours after it is applied, so the following morning. This cream can be used for a maximum of 16 weeks. If warts are still there, a different method should be used. Side effects from imiquimod are somewhat more severe than those with podofilox, and can include irritation, redness, swelling, ulceration of the tissue, and blisters. After healing, there can be a loss of pigmentation. There have been very rare reports of systemic reactions to this chemical which is an immune system activator. It can also weaken the materials that make condoms and diaphragms.
VeregenÆ Ointment 15% is a formulation of sinecatechins from green tea. While it is a prescription medication, it can also be considered alternative treatment because it comes from a natural source. Veregen should be applied three times a day to warts visible on the outside only. It is not to be used for warts inside the vagina or rectum, for example, because you cannot see them yourself to make sure you do not get the cream on normal tissue. You apply it with your
fingers, leaving a thin layer on all warts. It is only approved for 16 weeks of use, which should be enough time to treat warts.
Common side effects are reactions on the skin, including redness, itching, burning, pain, ulceration, swelling, thickening and blister formation.
In trials reported by the manufacturer, Veregen completely clears up warts in approximately 50% of patients. This takes an average 10 to 16 weeks. There is at least one other brand-name, sinecatechin-containing prescription medication.
Previously used medications including 5-fluorouracil and interferon are no longer recommended due to cost and possibly increased side effects with no greater treatment success.
One completely safe alternative remedy is to wait for your body’s immune system to get rid of the warts. You would want to make sure you are eating a good diet with enough nutrients and that you are in generally good health. If you believe you need supplements to maintain good health, continue to take them. For some people, this is the best treatment. It is free of cost as well as free of side effects.
Homeopathic remedies for genital warts are available. One commonly-used remedy is Thuja alternating with Nitric acid. Ascending potencies of Thuja are given over three to four weeks, after which ascending potencies of Nitric acid are given. This is the treatment suggested by Samuel Hahnemann, the founder of homeopathy, some 200 years ago.
Modern homeopaths suggest that treatment for genital warts actually needs to address more underlying problems, and they have a more complex remedy. Each person’s needs are different, depending on their underlying state of health. The following remedies can be used:
Antimonium crudum – recommended for swelling and eruptions on mucous membranes
Argentum nitricum – recommended for pain and sores on genitals
Aurum muriaticum – recommended for cancerous warts
Aureum muriaticum natronatum – recommended for warts associated with erosions, ulcers, and cancers
Causticum – recommended for some warts along with vaginal discharge
Cinnabaris – recommended for warts including genital and eye. Better than Thuja for some penile warts
Medorrhinum – recommended for general warts with other conditions
Mercurius dulcis – recommended for genital warts, also Mercurius nitrosus or Mercurius precipitatus ruber
Natrum sulphuricum – recommended for warts on hands as well as vaginal pain and discharge
Nitric acid – for all warts plus discharge and pain
Sabina – similar to Thuja and good for large warts
Sarsaparilla – recommended for warts especially with other sexually transmitted diseases
Staphysagria – recommended for genital wars
Thuja – recommended for most kinds of warts (Thuja occidentalis = Arbor Vitae)
In order to get the best homeopathic mix to take for genital warts, seeing a homeopath would be recommended. These kinds of ingredients will be put together so that they can be ingested in very small amounts. Because homeopathy uses such tiny doses of ingredients, it tends to be very safe. Homeopathic treatments are to be taken into the body, not rubbed into the skin.
Tea tree oil has many antibiotic properties. It has been suggested as useful for warts. Baptisia tinctoria has antiviral properties and could also be helpful.
The actual methods of homeopathic diagnoses and treatments are beyond the scope of this article.
The product called Wartrol has most of these homeopathic ingredients.
Green tea was considered a home remedy until active compounds were found that can destroy warts. There are a variety of slightly irritating or caustic ingredients people have used on genital warts, from lemon juice to garlic. As long as whatever is being placed on the warts does not cause pain or damage normal skin, there is really not much harm in trying. As long as the cure is not worse than the problem, it is probably safe to try.
New and Upcoming Developments
Lasers are being used to treat more and more diseases. Dermatologists, plastic surgeons, and some other kinds of doctors are learning how best to use the lasers. There is more than one type of laser. In addition to the carbon dioxide laser, other lasers may prove useful.
When to See Your Doctor
You should see a doctor when you first discover that you have genital warts, or believe that you do. This is to make sure that your self-diagnosis is correct, and that there is nothing else more serious going on. It is also a time at which the doctor can make sure you don’t have warts in hard to treat places.
You can ask the doctor what he or she recommends, and you can think about what you would like to try based on what your doctor offers, how much the treatments cost, and whether or not you want to try home treatment with a prescription medication, homeopathy, a home remedy, or tincture of time.
If your warts are getting worse or the treatment is causing you pain, you should check back with your doctor. Eventually your warts should go away.
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