EM2 - Modern Management of External Anogenital Warts

Chairs: A. Ferenczy and J. Monsonego

Epidemiology and Natural History
S. Tyring

• Almost all cases of genital warts in adults are transmitted sexually.
• The prevalence of genital warts in the general population is unknown.
• Current epidemiology estimates that ano-genital warts afflict about 1% of the sexually active population and the incidence is in the order of 1/1000 sexually active individuals per year.

Clinical presentation of ano-genital warts
S. Tyring

• Acuminate warts are multi-form, multi-focal and multicentric and most are caused by lowrisk HPV types 6, 11.
• Acuminate warts are clinically typical and do not require routine biopsy. For all other lesions, histologic examination is required.
• Differential diagnoses include VIN and dermatoses.
• The acetic acid test is not specific it may be valuable for identifying and delineating subclinical lesions associated with EGWs.

External Genital Warts: Management
A. Ferenczy

• Condylomata acuminata constitute a risk marker for external ano-genital cancer particularly in the immuno-suppressed and to a lesser degree, for cervical cancer.
• Conventional treatment of genital condylomata acuminata has been disappointing. Analysis of available data relating to cytotoxic or destructive therapy has shown that persistence and recurrences occur in about 50% of the cases.
• The 2 main reasons for this are the treatments may be incomplete and do not focus on the etiologic virus, i.e., HPV 6/11.
• Both basic research and clinical practice indicate that immunity, and in particular local cellular immunity, is an essential feature of the development, persistence and regression of this disease.
• The recent introduction of topical immune system modifiers is considered to be a significant progress in our efforts to provide improved topical therapy for EGWs.
• The best therapeutic approach is based on a mutual decision made by the patient and her health-care provider of a choice of home versus provider-administered treatment and long-term follow-up of patients with EGWs.

External Genital Warts: Screening and Counselling
A. Ferenczy

• No practical screening tests are available for EGWs and screening is not recommended.
• Contact-tracing: i.e., partner(s) of patients with EGWs may be examined and this is an opportunity for patient education and counselling.
• Patients should be counselled in light of today's knowledge of transmission, genital cancer-risk, therapy and outcome.
• Issues of life-style modification including mutual monogamy and long-term follow-up should be stressed.
• Cesarean section to prevent juvenile onset of recurrent respiratory papillomavirus in pregnant patients with EGWs is not recommended at present. Cesarean section is appropriate in cases of extreme ano-genital condylomatosis at term.