Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis
- Noah Scheinfeld, MD
Noah Scheinfeld, MD
- Assistant Clinical Professor of Dermatology
- Weill Cornell Medical College
Human papillomavirus (HPV) is a common cause of cutaneous and mucosal infection. Condylomata acuminata (CA, singular: condyloma acuminatum), also known as anogenital warts, are manifestations of HPV infection that occur in a subset of individuals with anogenital infection. External CA typically manifest as soft papules or plaques on the external genitalia, perianal skin, perineum, or groin (picture 1A-H). HPV types 6 and/or 11 are detected in most cases of CA.
The etiology, epidemiology, clinical features, and diagnosis of external CA will be reviewed here. Greater detail on HPV infection and discussions of pediatric CA, treatment of CA, and the relationship between HPV infection and cancer are provided separately. (See "Human papillomavirus infections: Epidemiology and disease associations" and "Condylomata acuminata (anogenital warts) in children" and "Treatment of vulvar and vaginal warts" and "Condylomata acuminata (anogenital warts): Management of external condylomata acuminata in men" and "Virology of human papillomavirus infections and the link to cancer".)
Human papillomavirus (HPV) is a group of nonenveloped, double-stranded DNA viruses belonging to the family Papillomaviridae. Investigators have identified over 200 types of HPV, more than 40 of which can be transmitted through sexual contact and infect the anogenital region [1,2]. The virology of HPV is reviewed in detail separately. (See "Human papillomavirus infections: Epidemiology and disease associations", section on 'Microbiology'.)
HPV types are divided into low-risk and high-risk types based upon associated risk for cancer. The low-risk types HPV 6 and/or HPV 11 are detected in around 90 percent of anogenital warts, although coinfection with other low-risk or high-risk types of HPV is common. For example, in an analysis of 8800 women in the placebo arms of two randomized trials assessing the efficacy of a quadrivalent vaccine, 298 (3 percent) developed anogenital warts, and HPV 6 and/or HPV 11 were detected in 447 of 520 examined warts (86 percent) . High-risk HPV types, such as HPV 16, 18, 52, and 56, were detected in 191 warts (31 percent). (See "Virology of human papillomavirus infections and the link to cancer", section on 'HPV Genotypes and risk of cancer'.)
Human papillomavirus (HPV) is transmitted through contact with infected skin or mucosa. The virus invades the cells of the epidermal basal layer through microabrasions. Anogenital HPV infection is almost always acquired through sexual contact. Warts are not required for transmission but are highly infectious because of their high viral load.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- de Villiers EM, Fauquet C, Broker TR, et al. Classification of papillomaviruses. Virology 2004; 324:17.
- Division of STD Prevention (1999). Prevention of genital HPV infection and sequelae: report of an external consultants' meeting. Atlanta, GA: Centers for Disease Control and Prevention www.cdc.gov/std/hpv/hpvsupplement99.pdf (Accessed on February 08, 2016).
- Garland SM, Steben M, Sings HL, et al. Natural history of genital warts: analysis of the placebo arm of 2 randomized phase III trials of a quadrivalent human papillomavirus (types 6, 11, 16, and 18) vaccine. J Infect Dis 2009; 199:805.
- Winer RL, Kiviat NB, Hughes JP, et al. Development and duration of human papillomavirus lesions, after initial infection. J Infect Dis 2005; 191:731.
- Arima Y, Winer RL, Feng Q, et al. Development of genital warts after incident detection of human papillomavirus infection in young men. J Infect Dis 2010; 202:1181.
- de Camargo CC, Tasca KI, Mendes MB, et al. Prevalence of Anogenital Warts in Men with HIV/AIDS and Associated Factors. Open AIDS J 2014; 8:25.
- Patel H, Wagner M, Singhal P, Kothari S. Systematic review of the incidence and prevalence of genital warts. BMC Infect Dis 2013; 13:39.
- Fleischer AB Jr, Parrish CA, Glenn R, Feldman SR. Condylomata acuminata (genital warts): patient demographics and treating physicians. Sex Transm Dis 2001; 28:643.
- Brown DR, Schroeder JM, Bryan JT, et al. Detection of multiple human papillomavirus types in Condylomata acuminata lesions from otherwise healthy and immunosuppressed patients. J Clin Microbiol 1999; 37:3316.
- www.hpv.org.nz/pdf/DocGuide.pdf (Accessed on February 01, 2016).
- Lombard I, Vincent-Salomon A, Validire P, et al. Human papillomavirus genotype as a major determinant of the course of cervical cancer. J Clin Oncol 1998; 16:2613.
- Kodner CM, Nasraty S. Management of genital warts. Am Fam Physician 2004; 70:2335.
- Coleman N, Birley HD, Renton AM, et al. Immunological events in regressing genital warts. Am J Clin Pathol 1994; 102:768.
- Scheinfeld N, Lehman DS. An evidence-based review of medical and surgical treatments of genital warts. Dermatol Online J 2006; 12:5.
- Tchernev G. Sexually transmitted papillomavirus infections: epidemiology pathogenesis, clinic, morphology, important differential diagnostic aspects, current diagnostic and treatment options. An Bras Dermatol 2009; 84:377.
- Scheinfeld N. Update on the treatment of genital warts. Dermatol Online J 2013; 19:18559.
- King EM, Gilson R, Beddows S, et al. Human papillomavirus DNA in men who have sex with men: type-specific prevalence, risk factors and implications for vaccination strategies. Br J Cancer 2015; 112:1585.
- Marty R, Roze S, Bresse X, et al. Estimating the clinical benefits of vaccinating boys and girls against HPV-related diseases in Europe. BMC Cancer 2013; 13:10.
- Hoy T, Singhal PK, Willey VJ, Insinga RP. Assessing incidence and economic burden of genital warts with data from a US commercially insured population. Curr Med Res Opin 2009; 25:2343.
- Gormley RH, Kovarik CL. Human papillomavirus-related genital disease in the immunocompromised host: Part I. J Am Acad Dermatol 2012; 66:867.e1.
- Yong M, Parkinson K, Goenka N, O'Mahony C. Diabetes and genital warts: an unhappy coalition. Int J STD AIDS 2010; 21:457.
- Radja N, Lau R. Extensive genital warts associated with HTLV-I infection. Int J STD AIDS 2004; 15:202.
- Weiss DA, Yang G, Myers JB, Breyer BN. Condyloma overgrowth caused by immune reconstitution inflammatory syndrome. Urology 2009; 74:1013.
- Kaderli R, Schnüriger B, Brügger LE. The impact of smoking on HPV infection and the development of anogenital warts. Int J Colorectal Dis 2014; 29:899.
- Wiley DJ, Elashoff D, Masongsong EV, et al. Smoking enhances risk for new external genital warts in men. Int J Environ Res Public Health 2009; 6:1215.
- Banura C, Mirembe FM, Orem J, et al. Prevalence, incidence and risk factors for anogenital warts in Sub Saharan Africa: a systematic review and meta analysis. Infect Agent Cancer 2013; 8:27.
- Lynde C, Vender R, Bourcier M, Bhatia N. Clinical features of external genital warts. J Cutan Med Surg 2013; 17 Suppl 2:S55.
- Cone MM, Whitlow CB. Sexually transmitted and anorectal infectious diseases. Gastroenterol Clin North Am 2013; 42:877.
- Chae JY, Bae JH, Yoon CY, et al. Female urethral condyloma causing bladder outlet obstruction. Int Neurourol J 2014; 18:42.
- Kilciler M, Bedir S, Erdemir F, et al. Condylomata acuminata of external urethral meatus causing infravesical obstruction. Int Urol Nephrol 2007; 39:107.
- Lawrence S, Walzman M, Sheppard S, Natin D. The psychological impact caused by genital warts: has the Department of Health's choice of vaccination missed the opportunity to prevent such morbidity? Int J STD AIDS 2009; 20:696.
- Lacey CJ, Woodhall SC, Wikstrom A, Ross J. 2012 European guideline for the management of anogenital warts. J Eur Acad Dermatol Venereol 2013; 27:e263.
- Woodhall S, Ramsey T, Cai C, et al. Estimation of the impact of genital warts on health-related quality of life. Sex Transm Infect 2008; 84:161.
- Dong H, Shu D, Campbell TM, et al. Dermatoscopy of genital warts. J Am Acad Dermatol 2011; 64:859.
- Handsfield HH. Clinical presentation and natural course of anogenital warts. Am J Med 1997; 102:16.
- Yanofsky VR, Patel RV, Goldenberg G. Genital warts: a comprehensive review. J Clin Aesthet Dermatol 2012; 5:25.
- Doorbar J. Latent papillomavirus infections and their regulation. Curr Opin Virol 2013; 3:416.
- Blomberg M, Friis S, Munk C, et al. Genital warts and risk of cancer: a Danish study of nearly 50 000 patients with genital warts. J Infect Dis 2012; 205:1544.
- Paul S, Cheng CE, Kroshinsky D. Combination Systemic Fluorouracil and Radiation for the Treatment of Recalcitrant Condyloma with Associated Squamous Cell Carcinoma in an Immunocompromised 15-Year-Old Girl. Pediatr Dermatol 2015; 32:e148.
- Veasey JV, Framil VM, Nadal SR, et al. Genital warts: comparing clinical findings to dermatoscopic aspects, in vivo reflectance confocal features and histopathologic exam. An Bras Dermatol 2014; 89:137.
- Pirog EC, Chen YT, Isacson C. MIB-1 immunostaining is a beneficial adjunct test for accurate diagnosis of vulvar condyloma acuminatum. Am J Surg Pathol 2000; 24:1393.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- Juckett G, Hartman-Adams H. Human papillomavirus: clinical manifestations and prevention. Am Fam Physician 2010; 82:1209.
- von Krogh G, Lacey CJ, Gross G, et al. European course on HPV associated pathology: guidelines for primary care physicians for the diagnosis and management of anogenital warts. Sex Transm Infect 2000; 76:162.
- Wikström A, Hedblad MA, Johansson B, et al. The acetic acid test in evaluation of subclinical genital papillomavirus infection: a comparative study on penoscopy, histopathology, virology and scanning electron microscopy findings. Genitourin Med 1992; 68:90.
- Sturgiss EA, Jin F, Martin SJ, et al. Prevalence of other sexually transmissible infections in patients with newly diagnosed anogenital warts in a sexual health clinic. Sex Health 2010; 7:55.
- Zaak D, Hofstetter A, Frimberger D, Schneede P. Recurrence of condylomata acuminata of the urethra after conventional and fluorescence-controlled Nd:YAG laser treatment. Urology 2003; 61:1011.
- RISK FACTORS
- CLINICAL MANIFESTATIONS
- CLINICAL COURSE
- ASSOCIATION WITH MALIGNANCY
- Physical examination
- ADDITIONAL EVALUATION
- Other sexually transmitted diseases
- Internal involvement
- DIFFERENTIAL DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS