Genital warts may appear both externally (e.g., on the penis, anus, or external female genitalia) and internally (e.g., in the anal canal or vagina). These benign, flesh-colored tumors classically appear as a granular, elevated surface with finger-like projections; warts associated with oncogenic HPV types are more likely to have a flat, smooth surface. Anogenital warts usually cause no symptoms, but may be itchy, painful, or friable (liable to bleed during sexual intercourse or easily crumbled into smaller pieces). Multiple warts may grow together into prominent and extensive lesions resembling cauliflower, especially in persons with HIV infection. People with compromised immune systems also tend to experience high rates of recurrence after treatment.

Careful visual examination by a clinician is usually sufficient for making a diagnosis of anogenital warts. Viewing the anal area with an anoscope following the application of a 3% acetic acid solution (vinegar) allows dysplasia as well as very small or smooth warts to be more easily detected (see "Step II: Anoscopy" for more information on this procedure).

Genital warts are treated with medicinal and surgical interventions. Since no available therapy acts specifically against HPV, elimination of visible warts and prevention of their recurrence are considered successful treatment outcomes. Therapeutic interventions against anogenital warts, as with anal neoplasia in general, tend to be less effective in immunosuppressed persons. As a result, a combination of medicinal and surgical therapeutic approaches is recommended for people with HIV.

Surgical removal of anogenital warts is considered a primary therapeutic strategy. Although warts often can be removed successfully, the size, location, and extent of lesions as well as treatment cost, side effects, and individual preferences are factors in choosing this form of intervention over drug therapy.

Current drug therapies for HPV infection are used topically (applied onto the surface of a lesion) or intralesionally (injected directly into a lesion); some are administered by a clinician and others may be self-applied or applied by a partner. Usually only external anal warts are treated with topical or injected drug therapy, as the interior anal mucosal tissue is highly sensitive and vulnerable to adverse effects. Provider-administered therapies include podophyllin resin 10-25% in tincture of benzoin solution and trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90%. Intralesional interferon (IFN), a local immune modifier, is another option, although its efficacy is relatively low and potential for causing side effects high, depending on the dose used. Those who have the option of applying their own medication may use podofilox (Condylox) 0.5% solution or gel, or imiquimod (Aldara) 5% cream. Clinicians have also been studying the use of cidofovir (Vistide), a treatment for cytomegalovirus (CMV) retinitis, in a 1% gel formulation to be self-applied before bedtime. Immune system status does not affect the action of topical cidofovir, which means it may prove to be more effective than most other drug treatments in people with HIV. In addition to these medicinal interventions, cryotherapy (destruction of lesions using extreme cold therapy) with liquid nitrogen or a device called a cryoprobe may also be administered by a clinician.

Special thanks to Dr. Joel Palefsky for his assistance in preparing this article.

Nicholas Cheonis is Associate Editor of BETA.

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