Sexually Transmitted Infections: Condyloma Acuminata

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Chapter 47 Sexually Transmitted Infections: Condyloma Acuminata

INTRODUCTION

Description: Condyloma acuminata are raised, warty lesions caused by infection by the human papillomavirus (HPV).
Prevalence: Most common sexually transmitted disease: 500,000 cases per year.
Predominant Age: 16 to 25 years.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Caused by infection by HPV (most frequently serotypes 6 and 11; 90%). This DNA virus is found in 2% to 4% of all women, and up to 60% of patients have evidence of the virus when polymerase chain reaction techniques are used. The virus is hardy and may resist even drying, making transmission and autoinoculation common. Some evidence suggests that fomite transmission rarely could occur. The virus is most commonly spread by skin-to-skin (generally sexual) contact and has an incubation period of 3 weeks to 8 months, with an average of 3 months. Roughly 65% of patients acquire the infection after intercourse with an infected partner.
Risk Factors: Multiple sexual partners; the presence of other vaginal infections such as candidiasis, trichomoniasis, or bacterial vaginosis; smoking; and oral contraceptive use.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Asymptomatic (<2% have condyloma)
• Painless, raised, soft, fleshy growths on the vulva, vagina, cervix, urethral meatus, perineum, and anus (mild irritation or discharge may accompany secondary infections). Symmetrical lesions across the midline of the genital area common (condyloma may also be found on the tongue or within the oral cavity, the urethra, bladder, or rectum). (Roughly one third of women with vulvar lesions also have vaginal warts or intraepithelial neoplasia [VAIN], and approximately 40% have cervical involvement. Cervical condyloma are generally flatter and may be identified through colposcopic examination; by Pap test; or through the application of 3% to 5% acetic acid to make apparent the raised, white, shiny plaques.)
• Abnormal cervical cytologic changes common

DIAGNOSTIC APPROACH

Differential Diagnosis

• Condyloma lata (syphilis)
• Papilloma

Associated Conditions: Other sexually transmitted infections (Trichomonas infection or bacterial vaginosis), abnormal cervical cytologic changes, vulvar and vaginal neoplasia.

Workup and Evaluation

Laboratory: No evaluation indicated. (Tests for syphilis when indicated.)
Imaging: No imaging indicated.
Special Tests: Colposcopic examination; Pap test; or the application of 3% to 5% acetic acid to make apparent the raised, white, shiny plaques. Serotyping is not currently indicated. Biopsy is indicated if the warts are pigmented, indurated, fixed, bleeding, or ulcerated.
Diagnostic Procedures: Physical examination, colposcopy, and biopsy.

Pathologic Findings

Sessile (keratotic) lesions.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Local hygiene.
Specific Measures: The treatment of small, uncomplicated venereal warts is generally by cytolytic topical agents, such as podophyllin (Podophyllum resin); bichloracetic or trichloroacetic acid (TCA); or physical ablative methods such as laser, cryotherapy, or electrodesiccation. In rare selected patients, surgical excision or tangential shaving may be used.
Diet: No specific dietary changes indicated.
Activity: Sexual continence until partner(s) are examined and treated.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP009 (How to Prevent Sexually Transmitted Diseases). Patients should be advised to have all sexual partners seen for diagnosis and treatment.

Drug(s) of Choice

Podophyllin (20% to 50% in tincture of benzoin, 25% ointment), podophyllotoxin (0.5% solution, Condylox), bichloracetic or trichloroacetic acid (80% to 100% solution), carefully applied to the warts, protecting the adjacent skin, and allowed to remain for between 30 minutes and 4 hours before being washed off the lesions. With most topical therapy, slough of the treated lesions happens in 2 to 4 days. Treatment may be repeated every 7 to 14 days as needed. Patients may self-apply podofilox (0.5% solution or gel, twice a day for 3 days) or Imiquimod (5% cream, Aldara, every night three times per week for up to 16 weeks).
Contraindications: Podophyllin may not be used during pregnancy because of absorption, potentially resulting in neural or myelotoxicity.
Precautions: To limit toxicity with podophyllin, treatments should be limited to less than 0.5 mL total volume and less than 10 cm2 in area. Imiquimod should be washed from the vulva in the morning (after 6 to 10 hours).

Alternative Drugs

Treatment with 5-fluorouracil 1% or 5% cream is often used as primary therapy or as an adjunct for cervical or vaginal lesions (applied daily until edema, erythema, or vesiculation occurs). Therapy with autologous vaccine, dinitrochlorobenzene, and interferon has been advocated but has yet to gain a significant place in clinical practice.

FOLLOW-UP

Patient Monitoring: The patient should be seen weekly until no further lesions are found. Because these patients are at higher risk for cervical neoplasia, close follow-up with Pap tests, colposcopy, or both, at 6- to 12-month intervals is recommended. Follow-up serologic testing for syphilis and human immunodeficiency virus (HIV) infection as indicated. The sexual partners of patients with HPV should also be screened for genital warts.
Prevention/Avoidance: Limitation or elimination of risky behavior (sexual promiscuity). The use of condoms has not been shown to reduce the spread of HPV but should still be encouraged to reduce the spread of other sexually transmitted diseases. Qvadravalent HPV vaccine (types 6, 11, 16, and 18; Guardasil) should provide some measure of protection though its primary indication is to reduce the risk of cervical cancer.
Possible Complications: Those who are immunocompromised, such as patients who have received a transplant, patients with acquired immune deficiency syndrome (AIDS), or pregnant patients, may experience rapid and exuberant growth of condyloma. External factors that suppress the immune system (steroids, cigarette smoking, metabolic deficiencies, and infections with other viruses such as herpes) may have similar effects. Several subtypes (16, 18, 31, 33, 35, and others) are associated with the development of cervical neoplasia. Roughly 90% of patients with cervical squamous cell carcinoma have evidence of HPV DNA present in their cervical tissues. It is currently thought that a cocarcinogen, such as smoking, other viruses, or nutritional factors are required before malignant transformation may take place.
Expected Outcome: The success rate for resolution of overt warts is approximately 75%, with a recurrence rate of 65% to 80%. If lesions persist or continually recur, cryosurgery, electrodesiccation, surgical excision, or laser vaporization may be required. If cryotherapy is chosen, three to six treatments are often required, but cure rates are higher than those for podophyllin and comparable with those for laser ablation (60% to 80%). Even with laser ablation, recurrence rates are reported to vary from 25% to 100%. Scarring is rare. HPV types 16, 18, 31, 33, and 35 are found occasionally in visible genital warts and have been associated with external genital (i.e., vulvar, penile, and anal) squamous intraepithelial neoplasia (i.e., squamous cell carcinoma in situ, bowenoid papulosis, erythroplasia of Queyrat, or Bowen’s disease of the genitalia). For this reason, recurrent lesions or those that do not respond as expected should be further investigated.

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MISCELLANEOUS

Pregnancy Considerations: Pregnant patients may experience rapid and exuberant growth of condyloma, and lesions are more resistant to therapy. Extensive vaginal or vulvar lesions may require cesarean delivery to avoid extensive lacerations and suturing problems.
ICD-9-CM Codes: 078.11.

REFERENCES

Level I

Georgala S, Katoulis AC, Befon A, et al. Oral inosiplex in the treatment of cervical condylomata acuminata: a randomized placebo-controlled trial. BJOG. 2006;113:1088.

Vandepapeliere P, Barrasso R, Meijer CJ, et al. Randomized controlled trial of an adjuvanted human papillomavirus (HPV) type 6 L2E7 vaccine: infection of external anogenital warts with multiple HPV types and failure of therapeutic vaccination. J Infect Dis. 2005;192:2099. Epub 2005 Nov 11

Level II

Bonnez W, Elswick RKJr, Bailey-Farchione A, et al. Efficacy and safety of 0.5% podofilox solution in the treatment and suppression of anogenital warts. Am J Med. 1994;96:420.

Conley LJ, Ellenbrock TV, Bush TJ, et al. HIV-1 infection and risk of vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia: a prospective cohort study. Lancet. 2002;359:108.

Jha PK, Beral V, Peto J, et al. Antibodies to human papillomavirus and to other genital infectious agents and invasive cervical cancer risk. Lancet. 1993;341:1116.

Level III

American College of Obstetricians and Gynecologists. Human papillomavirus. ACOG Practice Bulletin 61. Washington, DC: ACOG, 2005.

American College of Obstetricians and Gynecologists. Human papillomavirus vaccination. ACOG Committee Opinion 344. Washington, DC: ACOG, 2006.

Brotzman GL Evaluating the impact of HPV-related diseases: cervical cancer and genital warts J Fam Pract Suppl HPV Prevention 2005 S3

Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:576.

Hagensee ME, Cameron JE, Leigh JE, Clark RA. Human papillomavirus infection and disease in HIV-infected individuals. Am J Med Sci. 2004;328:57.

Horowitz BJ. Interferon therapy for condylomatous vulvitis. Obstet Gynecol. 1989;73:446.

Kodner CM, Nasraty S. Management of genital warts. Am Fam Physician. 2004;70:2335.

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