A 16-year-old boy presents with growths in the genital area for about 1 month (Figure 118-1). He has never had a sexually transmitted disease (STD) or vaccination against human papillomavirus (HPV) infection. He has had multiple sexual partners. The patient is told that he has genital warts which are an STD caused by HPV. The treatment options are discussed and he chooses to have cryotherapy with liquid nitrogen. A urine test for gonorrhea and Chlamydia is performed and the patient is tested for syphilis and HIV. Fortunately, all the additional tests are negative. Further patient education is performed and follow-up is arranged.
More than 100 types of HPV exist, with more than 40 that can infect the human genital area. Most HPV infections are asymptomatic, unrecognized, or subclinical. Low-risk HPV types (e.g., HPV types 6 and 11) cause genital warts, although coinfection with HPV types associated with squamous intraepithelial neoplasia can occur. Asymptomatic genital HPV infection is common in sexually active persons and usually self-limited.1
Genital warts are caused by HPV infection in males (Figure 118-1) and females (Figure 118-2). HPV encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from 3 weeks to 8 months.
HPV can be transmitted both sexually and non-sexually.3 Cutaneous HPV types can persist over a long time in healthy skin.4 HPV DNA detection in amniotic fluid, fetal membranes, cord blood and placental trophoblastic cells all suggest some HPV infection may occur in utero (prenatal transmission).3
The first systematic review on vertical transmission of HPV included 2,113 newborns found the pooled mother-to-child HPV transmission was 6.5 percent. Transmission was higher after vaginal delivery than after caesarean section (18.3% vs 8%) (RR = 1.8; 95% CI 1.3–2.4).5
Most of the mucosal HPV infections in infants are incidental, persistent infections in oral and genital mucosa being found in less than 10 and 2 percent respectively.3 Condyloma acuminata in children younger than two to three years of age are more likely the result of maternal-child transmission, but may be due to sexual or nonsexual transmission (Figure 118-3).
In one study, 73 children with anogenital warts were examined for sexual abuse during a 2-year period. Approximately 25 percent of these children were younger than age 1 year, and another 50 percent were between the ages of 1 and 3 years. No evidence of sexual abuse was detected in 66 children. The authors concluded that nonsexual transmission is common, particularly in children under 3 years of age.6
HPV testing of mothers does not exclude sexual abuse and is not generally performed.
Evaluation for potential sexual abuse should be considered, especially in older children, and evaluation by appropriately experienced professionals considered.
FIGURE 118-3
Perianal condyloma in a 2-year-old girl for 2 months. The child was brought in by her mother who did have warts on her hands. The mother claims that the child is always with her immediate family, never in day care, and no one in the family had genital warts. The clinician did not suspect child abuse, did not file a report and treated the condyloma topically. (Image used with permission from Robert Brodell, MD.)
Diagnosis of genital warts is usually clinical based on visual inspection.1
Genital warts are usually asymptomatic, and typically present as flesh-colored, exophytic lesions on the genitalia, including the penis, vulva, vagina, scrotum, perineum, and perianal skin.
External warts can appear as small bumps, or they may be flat, verrucous, or pedunculated (Figures 118-4 to 188-6).
Less commonly, warts can appear as reddish or brown, smooth, raised papules, or as dome-shaped lesions on keratinized skin.
FIGURE 118-5
Condyloma can take on a cauliflower appearance even on the well-keratinized skin of a circumcised male. (Used with permission from Richard P. Usatine, MD.)
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