Excerpt from Warts, Genital

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Approximately 90% of all genital warts are related to HPV types 6 and 11 (HPV-6, HPV-11). These are the least likely to have neoplastic potential.

Thirteen HPV types (ie, 33, 35, 39, 40, 43, 45, 51-56, 58) have a moderate risk for neoplastic conversion; HPV-16 and HPV-18 are considered high risk. This picture is complicated by the proven coexistence of many types in the same patient (10-15%), lack of adequate information on the oncogenic potential of many other types, and ongoing identification of additional HPV-related clinical pathology. For example, bowenoid papulosis, seborrheic keratoses, and Buschke-Lowenstein tumors—previously parts of the differential diagnosis of genital warts—all have been linked to HPV infections.

• Bowenoid papulosis consists of rough papular eruptions and is considered a carcinoma in situ. Eruptions can be red, brown, or flesh colored and may regress or become invasive.

• Seborrheic keratoses previously were considered a benign skin manifestation. These consist of rough plaques and have an infectious and an oncogenic potential.

• Buschke-Lowenstein tumor (giant condyloma) is a fungating, locally invasive, low-grade cancer attributed to HPV.

Pathophysiology: HPV invades cells of the basal layer of the epidermis, penetrating skin and mucosal microabrasions in the genital area.

A latency period of months to years may ensue. Following that period, viral DNA, capsids, and particles are produced. Host cells become infected and develop the morphologic atypical koilocytosis of genital warts.

Most frequently affected are the penis, vulva, vagina, cervix, perineum, and perianal area. These mucosal lesions occasionally can be found in the oropharynx, larynx, and trachea. HPV-6 even has been reported in other uncommon areas (eg, extremities).

Multiple simultaneous lesions are common and may involve subclinical states as well as different anatomic sites. Subclinical infections have an infectious and oncogenic potential.

Consider the possibility of sexual abuse in pediatric cases; however, remember that infection by direct manual contact or, rarely, by indirect transmission from fomites may occur. Additionally, passage through an infected vaginal canal at birth may cause respiratory lesions in infants.

Frequency:

• In the US: Annual incidence is 1%, and genital warts are considered the most common sexually transmitted disease (STD). A 4-fold or more increase in prevalence has been reported in the last 2 decades; prevalence reportedly exceeds 50%.

• Internationally: Reports vary on international prevalence, but available data from England, Panama, Italy, the Netherlands, and other developed and underdeveloped countries show HPV infections to be at least as common internationally as in the United States.

Mortality/Morbidity: Mortality is secondary to malignant transformation to a carcinoma. This oncogenic potential, which is rare with HPV-6 and HPV-11 (the most commonly isolated viruses), reportedly triples the risk of genitourinary cancer among infected males.

• HPV infection appears to be more common and worse in patients with various types of immunologic deficiencies. Recurrence rate, size, discomfort, and risk of oncologic progression are highest among these patients. Secondary infection is uncommon. Latent illness often becomes active during pregnancy.

• Vulvar warts may interfere with parturition. Trauma then may occur, producing crusting or erythema. Acute urethral obstruction .....

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