Genital Warts

What Is Genital Wart?

Human papillomavirus (HPV) is a virus that causes frequent infections in skin tissue such as the external genital area and in mucosal tissues such as vagina, cervix and mouth. Genital warts, also called condyloma (condyloma acuminatum), are raised, rough warts caused by HPV infection in the anogenital area. They typically form on the vulva, external genitalia, around the anus, groin, or perineum. The most common causative agents are HPV type 6 and type 11.

HPV

HPV is a non-enveloped, double-stranded DNA virus that is a member of the Papillomaviridae family. It has more than 200 different types. More than 40 different types of HPV can involve the genital area (common warts seen on hands and feet are caused by different types than HPV types that cause genital infection).

We classify genital HPV types according to their potential for cancer as  low risk and high risk. HPV 6 and 11, which cause genital warts, are in the low-risk HPV class, as they are potential to cause cervical/vagina/vulva cancer is almost negligible.

HPV is the most common sexually transmitted disease worldwide and in our country. The likelihood that a sexually active woman has been exposed to HPV during her life is about 90%.

How Is HPV Transmitted?

Genital and cervical HPV infections are transmitted primarily through genital-genital or anal-genital contact. The most important predictor of genital HPV has been sexual contact.

Is HPV Only Sexually Transmitted?

HPV is the most common sexually transmitted virus in humans. Non-sexual transmission of HPV has always been the subject of controversy.

Studies on the newly acquired HPV infection showed that HPV enters the body shortly after the first sexual intercourse. In the United States, as a result of a prospective study of women studying at the university and having sexual intercourse for the first time, 40% of these women became HPV positive within the 24 months. HPV 16 was isolated in 10% of HPV (+) cases.

However, we know that HPV can be spread without sexual intercourse as well.

Transmission from external environment

Although it is almost always sexually transmitted, HPV is one of the rare viruses resistant to the environment due to its stable capsid. It can protect its infectious structure on external surfaces. It is even resistant to commonly used disinfectants. The virus is transmitted to external environments through shedding of epithelial cells. In a study that tested the resistance of HPV against dryness in the external environment, HPV was shown to maintain its 50% infectivity at room temperature on the 3rd day. This data reveals the risk of non-sexual transmission of HPV.

A study investigating the exposure of HPV 16 to 11 to commonly used disinfectants has yielded interesting results. HPV has managed to resist the effects of glutaraldehyde, a broad antimicrobial commonly used in hospitals (glutaraldehyde has been shown to be effective against adenovirus, parvovirus, and enteroviruses). Orthophthalaldehyde, which is used as an alternative to glutaraldehyde, has also failed to show full efficacy against HPV 16. HPV also remained resistant to alcohol-based disinfectants such as ethanol and isopropanol. HPV has finally been found susceptible to hypochlorite and peracetic acid. Here is one of the points that should be considered: Hand disinfectant systems do not effectively prevent transmission of HPV.

Nosocomial (hospital-acquired) spread is quite common for many virus infections. In the hospital-acquired transmission of HPV, the potential route is transvaginal ultrasound probes. HPV-containing vaginal probes are candidates for transmission, as they will be in contact with the cervix and vagina during the examination. In the studies that examined HPV DNA on probes, the existence of not only HPV DNA but also free virions has been shown. Although the probes are cleaned between patients, extensive sterilization is not often performed, especially considering the delicate structure of the instrument. A sheath (condom, gloves,…) is placed on the probe for each patient during the examination. However, the perforation chance of these sheaths is up to 9%.

In a study conducted on instruments used in the gynecology outpatient clinic, HPV and its types were investigated in the morning and evening of the same day. These instruments and objects included examination table, colposcope, examination lamp, toilet seat and siphon. HPV was not detected in any of these instruments at 08:30 in the morning, while it was detected in all at 16:30 in the afternoon. HPV 6 and 16 were the most commonly detected types.

Oral cavity is also a site that can be infected with HPV and transmit HPV. Just as microtraumas, including sexual intercourse, are required for HPV to enter the cervical epithelium, many activities take place in the oral cavity that can create microtraumas such as dental care and eating.

Auto-inoculation

Another way of non-sexual transmission of HPV is auto-inoculation. Data on this comes from studies on women and children who have stated that they have not had sexual contact before. In a study that looked at the HPV positivity of women with and without sexual intercourse, HPV was detected in 51% of patients in the first group and 69% of patients in the second group. In other words, half of the women who stated that they did not have sexual intercourse were exposed to HPV. In a study conducted in children, low risk HPV types were found. HPV DNA has been detected especially in the fingers of people infected with HPV. Therefore, it is possible for these people to infect HPV with their hands and to people around them with non-sexual physical contact.

Vertical transmission

Vertical transmission from mother to baby is one of the other possible ways of transmission. This potential transmission can occur either inside the womb or during childbirth or postpartum contact. The transition from the birth canal of the mother with HPV to the baby has been demonstrated. In fact, the higher the HPV DNA load in the mother, the higher the chance of passing HPV to the infant. According to the results of the studies of genome sequences and HPV typing, the mother is directly responsible for infectious transmission. In HPV (+) pregnant women, HPV DNA has been shown in both placenta and amniotic fluid. Although this suggests the possibility of congenital infection, the highest risk of transmission to the baby occurs in birth canal during childbirth. Many times, HPV DNA is found in the oral cavity of the newborn. We know that HPV is associated with oral cancers, but the regression of HPV transmitted to newborns is over 90% in 1-2 months and 100% in 6 months. However, low-risk types such as HPV 6 and -11 can lead to juvenile recurrent respiratory papillomatosis. It usually occurs between the ages of 2-5. The probability of developing condyloma in the children of women with condyloma is 200 times more than the children of women without condyloma.

Treatment of Genital Warts

The purpose of the treatment of genital warts is to provide physical and cosmetic recovery by removing existing lesions. In the treatment, it should be aimed to eliminate the lesions rather than the elimination of HPV.

Patients with HPV may experience psychological problems because of recurrent infections. It is good to know that 80%of people who have HPV infection and whose immune system is normal will clear HPV within 12 months and 92% within 24 months after catching HPV.

Treatment of genital warts varies depending on the patient. The location of the wart, its prevalence, type, duration of the wart and some patient characteristics affect our choice of treatment. As a result, we treat the genital warts according to the patient. Our success rate in wart treatment is over 90% and compatible with advanced clinical literature in Western Europe and North America.

In the treatment, there are only the methods that can be applied by the physician (cryotherapy, surgical excision, acid application (85%-trichloracetic acid)), as well as the cream/ointment/gel options that the patient can apply herself after the training.

How Do I Prevent Genital Warts and HPV?

As we mentioned earlier, HPV will become (+) for a period in almost every adult. Even though this is overcome by the immune system, there is a possibility that HPV, which remains latent at some point in life, can be acquired again due to the chance of activation or new partner.

We have 2×2 steps to prevent HPV:

Get the HPV vaccine (Please see the Frequently Asked Questions section for detailed information).

If you smoke, quit if possible.

Our other two steps are:

Have a regular gynecological examination and have your HPV and/or smear test done.

If you have HPV infection and you are eligible for treatment, you should get it treated before the lesion related to HPV develops.

Do not be afraid of HPV, fear of delay.


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