Anogenital Warts (HPV)

Overview

HPV transmission is from direct skin-to-skin contact with apparent or subclinical lesions and contact with genital secretions. Micro-abrasions in the recipient’s skin allow viral access to the basal epithelial cells.

Most anogenital warts are caused by HPV types 6 and 11 (low oncogenic risk), and infection gives type-specific protection. The long latent period means that the presence of warts in only one partner does not necessarily imply recent infidelity.

Most warts cause little discomfort, though psychological distress is often significant. Urethral lesions can distort the stream or bleed; anal lesions can cause perianal itch or bleeding with stool.

Progression to malignancy is rare and essentially confined to the oncogenic genotypes. Malignancy at the vulva, vagina, cervix, anus, penis or oropharynx is possible with oncogenic HPV genotypes. Oncogenic infection is often picked up incidentally on cervical screening as LSIL rather than as visible warts. Cervical lesions seen on vaginal examination should prompt cervical screening per national guidelines.

Diagnosis

Diagnosis is usually visual. Biopsy atypical lesions — variable pigmentation, raised plaque-like lesions, or new lesions in an older patient — to exclude malignancy, particularly in immunosuppressed or HIV-positive patients.

There is no specific diagnostic test for HPV, and PCR is not used to diagnose warts. Screen for other STIs opportunistically.

Management

Treatment is cosmetic, not curative.

Option	Regimen
Podophyllotoxin (patient-applied)	Twice daily for 3 days, then 4 days off; repeat weekly for 4–6 cycles until resolution. The 0.5% paint suits external keratinised skin; the 0.15% cream suits the perianal/introital area and under the foreskin.
Imiquimod 5% cream (patient-applied)	3 times weekly at bedtime, washed off after 6–10 hours, until resolution (up to 16 weeks).
Cryotherapy (clinician-applied)	Weekly, as an alternative to topical therapy or combined with it for refractory lesions.
Excision	Under local anaesthetic for a localised pedunculated wart.

Site changes the choice:

• Meatal warts: cryotherapy.
• Intra-anal warts: cryotherapy or surgical referral. Cervical warts: cervical cytology plus gynaecology referral.
• Rarely, excision or ablative therapy under general anaesthetic — seek specialist advice.

HIV infection is associated with poorer treatment response, longer treatment courses, and higher recurrence.

Advice and prevention

Contact tracing is not recommended — most partners have probably already acquired subclinical infection.

Offer HPV vaccination to anyone not already up to date (the National HPV Vaccination Program uses 9-valent Gardasil 9, covering more oncogenic and wart-causing types, and vaccination is not therapeutic — it only protects against future acquisition of other HPV types).

Advise avoiding shaving/waxing near warts, which can spread HPV by autoinoculation into microtrauma. Genital warts is not a notifiable condition; follow-up isn’t required if symptoms resolve.

Pregnancy: cryotherapy can respond poorly; lesions often resolve spontaneously postpartum. Vaginal delivery is safe — vertical transmission risk is extremely low.

Pearly penile papules

Small, regular, dome-shaped papules arranged in rows around the corona of the glans — a common, normal anatomical variant, usually first noticed in adolescence and sometimes mistaken for warts. These conditions do not require intervention; reassurance and observation is safe.