INTRODUCTION

Section 2 of 11  

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Background

Condyloma acuminatum refers to an epidermal manifestation attributed to the epidermotropic human papillomavirus (HPV). More than 100 types of double-stranded HPV papovavirus have been isolated to date. Many of these have been related directly to an increased neoplastic risk in men and women.

Approximately 90% of condyloma acuminata are related to HPV types 6 and 11. These 2 types are the least likely to have a neoplastic potential. Risk for neoplastic conversion has been determined to be moderate (types 33, 35, 39, 40, 43, 45, 51-56, 58) or high (types 16, 18), with many other isolated types. The picture is complicated by proven coexistence of many of these types in the same patient (10-15% of patients), the 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-Löwenstein tumors have been linked to HPV infections though they were previously a part of the differential diagnosis of condyloma acuminata. Bowenoid papulosis consists of rough papular eruptions attributed to HPV and is considered to be a carcinoma in situ. The eruptions can be red, brown, or flesh colored. They may regress or become invasive. Seborrheic keratoses previously were considered a benign skin manifestation. HPV has been linked to rough plaques indicative of this disease. It has both an infectious and an oncogenic potential. Finally, Buschke-Löwenstein tumor (ie, giant condyloma) is a fungating, locally invasive, low-grade cancer attributed to HPV.

Pathophysiology

Cells of the basal layer of the epidermis are invaded by HPV. These penetrate through skin and cause mucosal microabrasions. A latent viral phase begins with no signs or symptoms and can last from a month to several years. Following latency, production of viral DNA, capsids, and particles begins. Host cells become infected and develop the morphologic atypical koilocytosis of condyloma acuminata.

The most commonly affected areas are the penis, vulva, vagina, cervix, perineum, and perianal area. Uncommon mucosal lesions in the oropharynx, larynx, and trachea have been reported. HPV-6 even has been reported in other uncommon areas (eg, extremities).

Multiple simultaneous lesions are common and may involve subclinical states as well-differentiated anatomic sites. Subclinical infections have been established to carry both an infectious and oncogenic potential.

Consider sexual abuse as a possible underlying problem in pediatric patients; however, keep in mind that infection by direct manual contact or indirectly by fomites rarely may occur. Finally, passage through an infected vaginal canal at birth may cause respiratory lesions in infants.

Frequency

United States

Annual incidence of condyloma acuminatum is 1%. It is considered the most common sexually transmitted disease (STD). Prevalence has been reported to exceed 50%. Highest prevalence and risk is among young adults in the third decade and in older teenagers. A 4-fold or more increase in prevalence has been reported in the last 2 decades.

International

International prevalence has been reported variably. Available data from England, Panama, Italy, the Netherlands, and other developed and underdeveloped countries report HPV infections to be at least as common as in the US.

Mortality/Morbidity

• Mortality is secondary to malignant transformation to carcinoma in both males and females. This oncogenic potential has been reported to triple the risk of genitourinary cancer among infected males. Fortunately, this is rare with HPV types 6 and 11, which are the most commonly isolated viruses.
• HPV infection appears to be more common and worse in patients with various types of immunologic deficiencies. Recurrence rates, size, discomfort, and risk of oncologic progression are highest among those patients. Secondary infection is uncommon.
• Latent illness often becomes active during pregnancy. Vulvar condyloma acuminata may interfere with parturition. Trauma then may occur, producing crusting or erythema. Bleeding has been reported in large lesions that can occur during pregnancy.
• In males, bleeding has been reported due to flat warts of the penile urethral meatus, usually associated with HPV-16. Lesions may lead to disfigurement of area(s) involved. Finally, acute urethral obstruction in women also may occur.

Sex

• Both sexes are susceptible to infection.
• Overt disease may be more common in men (reported in 75% of patients); however, infection may be more prevalent in women.

Age

• Prevalence is greatest in persons aged 17-33 years, with incidence peaking in persons aged 20-24 years.

CLINICAL

Section 3 of 11  

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History

• Smoking, oral contraceptives, multiple sexual partners, and early coital age are risk factors for acquiring condyloma acuminata.
• Generally, two thirds of individuals who have sexual contact with a partner with condyloma acuminata develop lesions within 3 months.
• The chief complaint usually is one of painless bumps, pruritus, or discharge.
• • Involvement of more than 1 area is common.
  • History of multiple lesions, rather than 1 isolated wart, is common.
• Oral, laryngeal, or tracheal mucosal lesions (rare) presumably are transferred by oral-genital contact.
• History of anal intercourse in both males and females warrants a thorough search for perianal lesions.
• Rarely, urethral bleeding or urinary obstruction may be the presenting complaint when the wart involves the meatus.
• The patient's history may indicate presence of previous or other current STDs.
• Coital bleeding may occur. Vaginal bleeding during pregnancy may be due to condyloma eruptions.
• Latent illness may become active, particularly with pregnancy and immunosuppression.
• Lesions may regress spontaneously, remain the same, or progress.
• Pruritus may be present.
• Discharge may be a complaint.

Physical

• Single or multiple papular eruptions may be observed.
• • Eruptions may appear pearly, filiform, fungating, cauliflower, or plaquelike.
  • They can be quite smooth (particularly on penile shaft), verrucous, or lobulated.
  • Eruptions may seem harmless or may have a disturbing appearance.
• Carefully search for simultaneously involved multiple sites.
• Eruptions' color may be the same as the skin, or they may exhibit erythema or hyperpigmentation. Check for irregularity in shape, form, or color suggestive of melanoma or malignancy.
• Propensity has been established for penile glans and shaft in men and for vulvovaginal and cervical areas in women.
• • In contrast to early reports, presence of external condyloma acuminata in both men and women warrants a thorough search for cervical or urethral lesions.
  • Such internal lesions have been found in more than one half of females with external lesions.
  • One report indicates that infected males have a 20% chance of having subclinical urethral lesions.
  • More than 50% of female patients with external lesions have been found to have negative Papanicolaou (Pap) tests but tested positive for HPV infection using in situ hybridization.
• Urethral meatus and mucosal lesions can occur.
• • Some are subclinical.
  • Hair or the inner aspect of uncircumcised foreskin hides some lesions.
• Search for evidence of other STDs (eg, ulcerations, adenopathy, vesicles, discharge).
• Look for perianal lesions, particularly in patients with history or risk of immunosuppression or anal intercourse.

Causes

• Several of the epidermotropic HPVs cause condyloma acuminata.
• HPV types 6 and 11 most commonly are isolated, but many of the more than 60 types of HPV potentially cause condyloma.
• Male sexual partners of women with cervical intraepithelial neoplasia often have infections with the same viral type.

DIFFERENTIALS

Section 4 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Bowen disease
Condyloma lata
Darier disease
Fibroepitheliomas
Hailey-Hailey disease
Neoplasia
Nevi
Pearly penile papules
Squamous cell carcinoma in situ
Vulvar neurofibromatosis
Vulvar vestibular papillae

WORKUP

Section 5 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• As indicated by history and examination, test for other STDs, such as HIV, gonorrhea, chlamydia, and syphilis.
• Although not ED tests, the following are listed strictly for educational purposes and to assist readers in understanding and managing potential complications:
• • Pap smear: This test is used to look for papillomatosis, acanthosis, koilocytic abnormality, and mild nuclear abnormality.
  • Filter hybridization (Southern blot and slot blot hybridization), in situ hybridization, and polymerase chain reaction (PCR): These tests may be used for diagnosis and HPV typing.
  • Hybrid capture

Other Tests

• Acetowhitening
• • Subclinical lesions can be visualized by wrapping penis with gauze soaked with 5% acetic acid for 5 minutes.
  • Using a 10-X hand lens or colposcope, warts appear as tiny white papules.
  • A shiny white appearance of skin represents foci of epithelial hyperplasia (subclinical infection).

Procedures

• Although not ED procedures, the following are listed strictly for educational purposes and to assist readers in understanding and managing potential presenting complications:
• • Colposcopy (stereoscopic microscopy): This is very useful to identify (mostly) cervical lesions, which are identified better using acetic acid.
  • Biopsy: Biopsy is indicated for lesions that are atypical, recurrent after initial success, or resistant to treatment or in patients with a high risk for neoplasia or immunosuppression.
  • Anoscopy
  • Antroscopy

TREATMENT

Section 6 of 11  

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• Follow-up
• Miscellaneous
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Prehospital Care

Generally, prehospital care is unwarranted and inappropriate; however, reassure the patient and search for the possibility of another underlying reason prehospital care was requested.

Emergency Department Care

• Type of workup, treatment regimens, and necessary follow-up care for condyloma acuminata generally are far beyond the scope of ED practice. However, the following procedures may be implemented if indicated:
• • Use pressure to stop any bleeding.
  • Relieve urethral obstruction in rare cases.
  • Reassure the patient.
  • Search for evidence of other coexistent STDs and treat if found.
  • Do not begin treatment of condyloma in the ED.
• Although not ED treatments, the following are listed strictly for educational purposes and to assist readers in understanding and managing potential presenting complications:
• • Cryotherapy
    • Cryotherapy may be performed using an open spray or cotton-tipped applicator for 10-15 seconds and repeated as needed. Lift away mobile skin from underlying normal tissue before freezing.
    • Cryotherapy is an excellent first-line treatment, particularly for perianal lesions.
    • Response rates are high with few adverse sequelae.
    • Adverse reactions include pain at time of treatment, erosion, ulceration, and postinflammatory hypopigmentation of skin.
    • Cryotherapy is safe during pregnancy.
  • Electrodesiccation: Smoke plume potentially may be infective.
  • Curettage
  • Surgical excision
    • Excision has highest success rate and lowest recurrence rate.
    • Initial cure rates are 63-91%.
  • Carbon dioxide laser treatment
    • Use carbon dioxide laser treatment for extensive or recurrent condyloma acuminata.
    • Potentially infectious HPV-6 DNA has been detected in the carbon dioxide laser plume.
    • Local, regional, or general anesthesia is required. Eutectic mixture of local anesthetics (EMLA) cream may be used as an alternative anesthetic.

Consultations

• No emergent ED consultation generally is indicated.
• Outpatient OB/GYN or urologic follow-up care is appropriate.

MEDICATION

Section 7 of 11  

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Although not ED medications, the following are listed strictly for educational purposes and to assist readers in understanding and managing potential presenting complications.

Drug Category: Cytotoxic agents

Inhibit proliferation of cells at various stages of the cell cycle.

Drug Name	Podofilox (Condylox)
Description	Purified podophyllotoxin that is antimitotic, cytotoxic, and available for patient's home use. While exact mechanism of action on condyloma is unknown, podofilox results in necrosis of genital condyloma acuminata. Condylox is 1 agent containing podofilox. Slightly higher cure rates can be expected with podofilox than with podophyllin. Additionally, useful for prophylaxis.
Adult Dose	Apply 0.5% solution bid for 3 consecutive d and discontinue for 4 d, not to exceed 4 wk Use <0.5 mL of solution or 0.5 g of gel/d; treat <10 cm2 of tissue per d; wash hands thoroughly after each application
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Avoid contact with eyes; if eye contact, immediately flush eye with copious quantities of water and seek medical advice; not for use on mucous membranes of genital area including urethra, rectum and vagina; do not exceed frequency of application or duration of usage

Drug Name	Trichloroacetic or bichloracetic acids
Description	At various concentrations (up to 80%), these agents rapidly penetrate and cauterize skin, keratin, and other tissues. Bichloracetic acid is one such agent. Although caustic, this treatment causes less local irritation and systemic toxicity. Additionally, has low cost. Response is often incomplete, and recurrence is frequent.
Adult Dose	Paint treatment onto lesions, avoiding uninvolved skin; can be used in anal area; repeat treatment q1-2wk; treatment area does not need to be cleansed after several hours
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; not for use on premalignant or malignant lesions
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	External use only; restrict use to treatment areas only

Drug Name	5-Fluorouracil (Adrucil, Efudex, Fluoroplex)
Description	No longer recommended for routine use. Has antimetabolic and/or antineoplastic and immunostimulative activity. Useful in prevention of recurrence after condyloma ablation if started within 4 wk, especially in immunocompromised patients.
Adult Dose	Administer 5% cream qd or periodically for 10 wk; apply 1% cream bid for 2-6 wk; mild local discomfort can be treated with cortisol cream; topical 5-FU is best option for preventing recurrence in immunocompromised patients; in general, no systemic adverse effects exist; however, prolonged use results in erosive dermatitis and mucositis; additionally, risk of vaginal adenosis and clear cell adenocarcinoma exists
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; potentially serious infections; not for use in women who are or who may become pregnant
Interactions	None reported
Pregnancy	D - Unsafe in pregnancy
Precautions	Delayed hypersensitivity reaction may occur; do not use an occlusive dressing since incidence of inflammatory reaction in adjacent skin may increase; avoid prolonged exposure to sunlight or UV radiation; increased absorption may occur through ulcerated or inflamed skin; use care near eyes, nose, and mouth; wash hands immediately after application; pain, pruritus, burning, irritation, inflammation, allergic contact dermatitis, and telangiectasia may be observed

Drug Name	Bleomycin (Blenoxane)
Description	Composed of cytotoxic glycopeptide antibiotics, which appear to inhibit DNA synthesis with some evidence of RNA and protein synthesis inhibition to a lesser degree; used in management of several neoplasms as a palliative measure; may cause a variety of adverse effects; observe patients frequently and carefully during and after treatment.
Adult Dose	Reconstitute Blenoxane 15-U vial with 1-5 mL of sterile water or NS for injection; administer intralesionally
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; significant renal function impairment; compromised pulmonary function
Interactions	May decrease plasma levels of digoxin and phenytoin; cisplatin may increase toxicity of bleomycin
Pregnancy	D - Unsafe in pregnancy
Precautions	Bleomycin may be mutagenic; clearance may be reduced with renal impairment; may be secreted in breast milk; adverse effects include pulmonary toxicity (10%), idiosyncratic reaction similar to anaphylaxis (1%), erythema, rash, striae, vesiculation, hyperpigmentation, tenderness of skin (50%), hyperkeratosis, nail changes, alopecia, pruritus, and stomatitis

Drug Name	Imiquimod (Aldara)
Description	Induces interferon production and is a cell-mediated immune response modifier. Has minimal systemic absorption but causes erythema, irritation, ulceration, and pain. Burning, erosion, flaking, edema, induration, and pigmentary changes may occur at application site. Imiquimod 5% cream comes in single-use packets.
Adult Dose	Apply at bedtime for 3 d, then rest 4 d; alternatively, may apply qod for 3 applications; may repeat weekly cycles up to 16 wk (Patients should apply thin layer to external, visible warts, then rub in cream until vanishes. Area is washed with soap and water 6-10 h after treatment.)
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Genital use: Not recommended for treatment of rectal, cervical, intravaginal, urethral, and intra-anal human papilloma infection; following surgery or drug treatment, do not use topical imiquimod until genital/perianal tissue is healed Actinic keratosis: Avoid exposure to sunlight or artificial tanning; regular use of sunscreen is encouraged; avoid contact with lips, eyes, or nostrils; common adverse effects include erythema, edema, vesicles, erosion or ulceration, weeping, exudate, flaking, scaling, dryness, and scabbing or crusting Basal cell carcinoma: Medical follow-up is essential to ensure cancer has responded adequately to treatment; may cause redness, swelling, and sore development at application site; may cause itching or burning

Drug Category: Interferons

No longer recommended for routine use.

Naturally produced proteins with antiviral, antitumor, and immunomodulatory actions. Alpha, beta, and gamma interferons exist and may be administered topically, systemically, and intralesionally. Topical, systemic, and intralesional interferons are not efficacious.

Drug Category: Miscellaneous topical ointment

Another topical product that has gained FDA approval for genital warts includes kunecatechins.

Drug Category: Vaccines

A human papillomavirus vaccine is now available for prevention of HPV-associated dysplasias and neoplasia including cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions. The immunization series should be completed in girls and young women aged 9-26 years.

FOLLOW-UP

Section 8 of 11  

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Further Inpatient Care

• Generally, no further inpatient care is necessary unless the patient has malignant transformation of lesions to carcinoma.

Further Outpatient Care

• Patient should have a follow-up visit with OB/GYN (female) or with urology (male) within 1 week.
• • Treat patient using medications and, if ineffective, with cryotherapy, curettage, electrodesiccation, surgical excision, carbon dioxide laser treatment, or combination therapy.
  • Evaluate and treat sexual partner(s).
  • Perform workup for HPV and other STDs.
• Search for immunosuppression in patients with treatment failures and recurrences.
• Look for biopsy recurrences and treatment failures.

In/Out Patient Meds

• Podofilox (purified podophyllotoxin) is available for home use by the patient.

Deterrence/Prevention

• No medications are 100% effective. A vaccine for HPV has been recently approved by the FDA.
• Sexual abstinence and monogamy are protective.
• Condoms may discourage transmission.

Complications

• Local disfigurement
• Transformation to genitourinary malignancies in both males and females
• Transmission to neonate or partners
• Recurrence of condyloma acuminata

Prognosis

• Many patients either fail to respond to treatment or condyloma acuminata recurs after adequate response.
• Recurrence rate of cervical dysplasia in women is not altered by treatment of sexual partners.
• Recurrence rates exceed 50% after 1 year and have been attributed to the following:
• • Repeat infection from sexual contact
  • Long incubation period of HPV
  • Location of virus in superficial skin layers away from lymphatics
  • Persistence of virus in surrounding skin, hair follicles, or sites not adequately reached by intervention used
  • Missed or deep lesions
  • Subclinical lesions
  • An underlying immunosuppression

Patient Education

• Identify and educate individuals at risk for condyloma acuminata.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center. Also, see eMedicine's patient education article Genital Warts.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to inform patient of potential risk of malignant transformation of lesions
• Failure to indicate necessity for follow-up care, even after treatment eradicates lesions
• Failure to indicate possibility of subclinical combined with intravaginal or cervical lesions and need to search for them
• Failure to indicate treatment availability and follow-up care
• Failure to inform patient of risk of HPV transmission to sexual partners and neonates
• Failure to inform patient of necessity of treating partners
• Failure to search for immunosuppression in patients with treatment failures and recurrences

Special Concerns

• Pregnant patients
• • Latent infection may become activated with numerous large lesions.
  • Lesions often present or increase during pregnancy.
  • Lesions may make vaginal delivery difficult if in cervix, vagina, or vulva.
  • Lesions tend to bleed easily.
  • Lesions often spontaneously regress after delivery.
  • The American College of Obstetrics and Gynecology currently does not recommend cesarean sections simply due to positive HPV status.
• Pediatric patients
• • Neonates may become infected during passage through an infected birth canal.
  • Incidence of perinatal transmission to the infant pharynx is as high as 50% and occurs most frequently with HPV types 6 and 11. Incidence of genital infection in the neonate is 4%.

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Genital wart in pubic area
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Media file 2:  Genital wart in pubic area (close-up view)
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Media file 3:  Genital wart in pubic area (very close-up view)
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Media file 4:  Genital wart in pubic area (look at bottom middle of picture)
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REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
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• Follow-up
• Miscellaneous
• Multimedia
• References

• Chan PD, Winkle PJ, Winkle CR. Condyloma acuminata. In: Current Clinical Strategies - Family Medicine. 2nd ed. Current Clinical Strategies Publishing, Inc; 1995:209-210. [Medline].
• Congilosi SM, Madoff RD. Current therapy for recurrent and extensive anal warts. Dis Colon Rectum. Oct 1995;38(10):1101-7. [Medline].
• Garrido JL. Human papilloma virus--H.P.V. condyloma. Current studies in diagnosis, treatment and prognosis. Clin Exp Obstet Gynecol. 1996;23(2):99-102. [Medline].
• Kodner CM, Nasraty S. Management of genital warts. Am Fam Physician. Dec 15 2004;70(12):2335-42. [Medline].
• Leung AK, Kellner JD, Davies HD. Genital infection with human papillomavirus in adolescents. Adv Ther. May-Jun 2005;22(3):187-97. [Medline].
• Mayeaux EJ, Harper MB, Barksdale W, Pope JB. Noncervical human papillomavirus genital infections. Am Fam Physician. Sep 15 1995;52(4):1137-46, 1149-50. [Medline].
• Prasad CJ. Pathobiology of human papillomavirus. Clin Lab Med. Sep 1995;15(3):685-704. [Medline].
• Sinal SH, Woods CR. Human papillomavirus infections of the genital and respiratory tracts in young children. Semin Pediatr Infect Dis. Oct 2005;16(4):306-16. [Medline].
• Sykes NL. Condyloma acuminatum. Int J Dermatol. May 1995;34(5):297-302. [Medline].

Article Last Updated: Jan 18, 2007