Genital warts are a very common sexually transmitted infection. They are caused by the Human papillomavirus (HPV). There are many different types of HPV. Some types cause visible genital warts (usually types 6 and 11).
At any one time 1-2% of adults have genital warts that you can see, but many more may be infected without ever having noticeable genital warts. Children can also get genital warts but this is a lot less common than in adults.
Other types of HPV can cause changes on the cervix (the opening of the womb). Most of these cervical HPV infections will get better on their own. However, some types of HPV infection of the cervix are higher risk for causing changes that may progress to cervical cancer (including types 16, 18, 31 and 33).
How do you get genital warts?
Genital warts are considered to be a sexually transmitted infection in adults and teenagers. HPV infection causing genital warts is spread by skin to skin contact during sex. This can happen even when the person you have sexual contact with doesn’t seem to have warts. The person may have had genital warts in the past, or may never have noticed warts, but can still shed virus from normal looking skin. It is possible for genital wart HPV virus to be spread to the mouth through oral sex with someone who has genital warts, but luckily this is rare.
If a child has genital warts, specialist paediatric assessment is usually needed.Genital warts in children can be caused by sexual abuse.
We know that about 1 in 5 women and 1 in 10 men can recall sexual abuse in childhood.
The time between being exposed to the HPV virus and showing signs of genital warts is hard to establish for any particular person as it can vary from weeks to many months. It is also not known how long the virus can be present on the genital skin after all warts have gone away. We simply do not know whether a patient who acquired the virus as a young person can experience warts many years later or whether warts that recur after a long time in otherwise well adults represent infection with another HPV type.
The use of condoms does not completely protect against the transmission of genital warts. HPV can be widely distributed on genital skin (even when there are no obvious warts present) and a condom cannot protect against this.
I have things on my genital skin that my doctor says are warts. Is there anything else they can be?
Not all lesions on the vulva that look like warts are HPV genital warts.
Other possibilities are:
- Seborrhoeic keratoses
These are very common normal lesions found on any part of the skin including the vulva. They may look exactly like viral warts but are likely to be fewer in number. They can easily be differentiated from viral warts with a biopsy. Seborrhoeic keratoses are not a sexually transmitted disease.
- Normal skin folds at the vaginal opening
The opening of the vagina has small folds of tissue around it – these can seem quite lumpy but are quite normal. Sometimes though warts can be found on these skin folds.
- Vulvovaginal papillomatosis
Some people have tiny projections on the inside of the inner lips of the vulva. These are a normal part of many women’s vulval anatomy. These are often mistaken for warts. Again if there is any doubt a biopsy rapidly sorts out what is a wart and what is not.
- Molluscum contagiosum
These are small raised lesions which are usually skin-coloured. They occur on hairbearing genital skin rather than the vulva itself. They often have a slight central dip or dimple. They are a viral infection caused by Pox virus, another sexually transmitted infection of adolescents and young adults. Molluscum can usually be diagnosed by examination alone. Some people find they have molluscum and warts at the same time. Molluscum infection will eventually clear on its own but may take 18 months or more. Many people prefer treatment for cosmetic reasons. Cryotherapy (freezing with liquid nitrogen) is effective but may cause slight scarring. Just popping the lesions or scraping them off is just as effecive.
What exactly do warts look like?
Typical warts are raised, slightly rough bumps or lumps. However, warts can vary greatly in shape and size. The may be tiny and multiple, cauliﬂower-shaped , dome-shaped skin colored or ﬂat-topped lumps. The colour is usually skin-colored to pink to brown and the surface dull rather than shiny. They can be quite flat, or they might have more of a ‘cauliflower’ texture. Warts may be very large and numerous, particularly around the anus.
Warts can occur anywhere on the vulva including around the entrance to the vagina.They can also be found in the vagina and sometimes on the cervix. Warts around the anus are quite common and certainly don’t necessarily mean that a person has had anal sex. You don’t need any specific equipment to see genital warts. They are easy to feel and are visible with the naked eye.
What happens to warts if you don’t treat them?
When left alone genital warts usually go away spontaneously within 1-2 years.
Can genital warts give you cancer of the vulva?
The sort of warts that occur on the vulva are usually not caused by high risk cancer causing HPV types.
However, occasionally skin changes can be caused by high risk HPV subtypes. If you have a localised area of vulval skin that itches, splits, or changes colour your doctor may suggest a biopsy to work out what is going on.
However nearly all patients with vulval warts DO NOT develop cancer of the vulva.
Two vaccines are licensed in Australia to protect against HPV infection in women aged 10-45 years. One of the vaccines protects against HPV types that can cause cervical cancer. The other vaccine targets HPV types that most commonly cause genital warts as well as those that can cause cervical cancer.
Vaccination has demonstrated high level protection against cervical cancer. The vaccine that protects against HPV types 6 and 11 as well provides high levels of protection against genital warts. However, vaccines may not be 100% effective so a check-up is still important if you find genital lumps, just as regular Pap tests will continue to be important for all women.
I feel so bad about getting genital warts
If you have been diagnosed with genital warts the emotional impact can be huge.
Many people say they feel “dirty” and feel very distressed when they are diagnosed with genital warts. If you are in a monogamous partnership and you discover that you have genital warts it puts a major stress on your relationship. Because of the unknown period between being exposed to HPV for the first time and getting warts, it is very difficult to know why you have warts now. Often the question arises as to whether a partner has been unfaithful, in the process of acquiring genital warts and passing the infection on to you. Equally, a partner may feel you have been unfaithful. It helps to discuss the situation honestly. There may well never be a satisfactory answer as to where the warts came from. Sometimes it helps to talk to a counsellor (for example at a sexual health centre). Sometimes couples seek counselling together to clear up distress about a diagnosis of warts.
If you have been diagnosed with warts, remember the importance of you and your partner getting a full check-up for sexually transmitted infections if you have not had one already. It is often very reassuring to know that everything else is OK.
What treatment is available for genital warts?
There is no one ideal treatment for genital warts. It is possible to just wait for them to clear of their own accord, but most people are troubled by the look and feel of them and prefer treatment. Even with treatment, warts can be slow to clear and new warts can appear during treatment. This is frustrating but normal. When the warts have cleared up, they may still recur, often months later. Going back for treatment each time they recur can help regain a sense of control.
There is no evidence that any of the available treatments change the natural course of warts or reduce infectivity, so treatment choice depends largely on individual preference and convenience. If left untreated, visible warts may remain unchanged, or increase in size or number before eventually resolving.
Many patients require a course of therapy rather than a single treatment. In general, warts on moist surfaces respond well to topical paints and creams. Warts on drier skin surfaces often respond best to freezing with liquid nitrogen.
Things you do yourself:
THERE ARE TWO OPTIONS FOR TREATMENT THAT YOU CAN DO YOURSELF AT HOME. BOTH NEED A PRESCRIPTION FROM YOUR DOCTOR. PAINTS AND SOLUTIONS THAT ARE AVAILABLE OVER THE COUNTER AT PHARMACIES ARE NOT SUITABLE FOR USE ON GENITAL SKIN AND CAN CAUSE A LOT OF BURNING AND DISCOMFORT.
Podophyllotoxin solution or cream (Condyline® or Wartec®)
Patients may apply podophyllotoxin solution with a cotton swab or small applicator, or cream with a ﬁnger, to visible genital warts twice a day for three days, followed by four days of no therapy. This cycle may be repeated for a total of four cycles. Treatment is safe and easy to use. Occasionally the surrounding skin reacts badly – if this happens, see your doctor.This treatment should not be used if you are pregnant.
Imiquimod 5% cream (Aldara®)
Imiquimod cream is applied with a ﬁnger at bedtime, three times a week for as long as 16 weeks. The treatment area should be washed with mild soap and water 6–10 hours after the application. Many patients may be clear of warts by 8–10 weeks or sooner. The safety of imiquimod during pregnancy has not been established.
Things your doctor can do:
1. Freezing with liquid nitrogen
This is a simple procedure where each wart is frozen. Pain is short-lived but may be reduced with the use of topical anaesthetic cream for 5-10 minutes beforehand. Some warts may disappear over the following days but it is common for larger warts to require several treatments, which work best at regular intervals (one to two weekly).
Surgical removal of warts is particularly appropriate in cases where the lesions are very numerous and are interfering with function, particularly in the perianal area. However, a general anaesthetic is usually required.
3. Laser surgery
Again, laser surgery can be good if warts are interfering with function. Laser surgery can cause quite signficant post procedure pain. Treatment can be expensive.
Follow up after treatment
After visible genital warts have cleared, watch for recurrences. These occur most frequently during the ﬁrst three months. Try and organise more treatment as they recur.
Unfortunately, treatment of genital warts does not eliminate the HPV infections.
Even though the warts have gone, you might remain infectious as HPV virus is “shed” from apparently normal skin.
Imiquimod and podophyllin should not be used during pregnancy as their safety is not yet fully established. However, cyrotherapy (freezing) is quite safe. Genital warts can get much worse during pregnancy, and most women prefer to try treatment. However, warts do usually improve after the baby is born, and leaving them alone may be the best thing to do. Women are often highly embarrassed to have genital warts in pregnacy, but midwives and doctors are very used to seeing this common infection. It is worth discussing any worries about warts early in your pregnancy care. The preventive value of caesarian delivery is unknown and caesarian delivery is not offered solely to prevent transmission of HPV infection to the newborn.