Genital warts

ICD-10 code

А63.0 Anogenital (venereal) warts
В07 Viral warts
В97.7 HPV-associated genital infections

Infectious agent: low risk HPV types (HPV 6 and 11 in 90% of cases)

Clinical aspects: Genital warts are finger-like structures protruding on the skin and mucosa surface. They form typical marked and/or loop-like pattern and are concentrated in the urinary meatus, labia minora, vaginal orifice, vagina, cervix uteri, pelvic area, perineum and anal region, and more often within maceration regions.

Diagnosis

Clinical and visual method is one of the highly informative and available methods in genital wart diagnosis. Clinical aspects of genital warts are identified during the pelvic examination or during vulvoscopy and colposcopy. The examination and assessment of the vulvar skin and mucosa can be performed with 7-, 15-, and 30-fold magnification using the colposcope. In order to improve the visualization of genital warts, the solution of 5% acetic acid is applied, after which warts turn grey and white for some time and the vascular pattern is enhanced. To clarify the colposcopy pattern we need to assess the following aspects: presence or absence of the epithelial mass with the finger-like irregular projection that turn white after applying the solution of 5% acetic acid.

PCR, RT-PCR is the HPV DNA identification within the biomaterial (cervical smears, genital wart biopsy) with the following detection of the virus type.

High-frequency ultrasound scan (HFUS) of the skin and vulvar mucosa is performed using the ultrasound scanner, which operates according to the following principles: the generator produces a short electric impulse that is transformed with the help of piezo-crystal into the ultrasound signal with the frequency of 22-75 MHz depending on the transducers. These signals are transmitted into the skin and are reflected, absorbed and dispersed there due to the inhomogeneity of the tissues (cell structures, intercellular space). The reflected echo signals are received by the same transducer and then transformed into the electric impulses again. The signals received are processed, saved by the computer and are digitally transformed and then the picture is formed which is demonstrated on the screen. This method enables us to scan the skin during various periods of time, recording all the features as well as receiving the quantitative parameters: epidermal and dermal thickness, warts size within the area scanned, echodensity of the epidermis, dermis and subcutaneous tissue.

Treatment of genital warts

Today the following treatment methods are used: cryolysis; laser, radio-wave and surgical dissection; chemotherapy, systemic and local immune therapy. Immune therapy can be conveniently divided into three types: local, systemic and combined, depending on the possibility of application whether it is self-treatment or an inpatient treatment.

Cryolysis (С) makes it possible to remove the tissue within a limited area without spreading to the surrounding tissues. Cryolysis can be performed with the equipment: liquid nitrogen is linked up with the papilloma by means of the metal tubes of various sizes and diameters. Also cryolysis can be performed manually, when liquid nitrogen is applied to the location of lesion using the cotton bud. Cryo headpiece of the equipment helps to control the depth of the tissue freezing, while the cotton bud is helpless here..

Cryolysis has the following stages:

preparation stage: the patients with a low pain threshold with very large warts undergo anesthesia of the damaged area (by applying 10% lidocaine on the skin and mucosa)

cryolysis stage: freezing of the damaged area is performed, and the length of the whole procedure at one point takes several seconds.

final stage: the doctor performs the disinfection of the treated area.

One of the most effective methods of HPV treatment is СО2 laser vaporisation (С), especially of the keratinized area. Genital warts are removed by the coagulation of their basis using a 5-7 W surgical laser (SELLAS 015. Korea) in a continuous mode or by the electron-beam vaporisation of the same wattage. The manipulation should be performed merely touching the skin and mucosa. Genital warts dissection by DEKA lasers is performed using Smart Pulse energy 200.0 mJ mode at 2 W, at frequency of 10 MHz. In case of very large warts, surgery is performed in 3-4 steps. Regenerative process takes no more than two weeks without leaving any cosmetic defects.

Radio-wave dissection (С) of the warts is performed without any physical manual pressure, carbonization or tissue destruction. This is an atraumatic method of dissection of the skin and mucosa growths with the single-step vascular coagulation using 3.8-4.0 MHz radio-waves of high frequency. To treat the genital warts on the skin and vulvar mucosa we recommend using the “Blend” and “Fulguration” modes together with the loop electrodes of various sizes and configurations which are used in the standard sets (Surgitron™DFS5). After applying local anesthesia, the dissection of the pathological growths is performed in the “Blend” mode using loop electrodes at 80 W. Depending on the localization, size and density of the genital warts, mode “Fulguration” at 40 W is chosen. This method is more preferable for the treatment of small vulvar, vaginal and cervical warts. The dissection of the genital warts is also performed together with hemostasis.

By means of argon plasma coagulation (С) («EHVCha-140-02-”FOTEK», Ekaterinburg) it is possible to perform the destruction of genital warts together with hemostasis. High frequency current energy is transmitted on to the tissue contactlessly, by means of ion gas (argon) with the production of the plasma plume between the electrode and the tissue. The tissue contact results in its local warming and coagulation, the depth of which is no more than 3 mm and depends on the length of the procedure, modes and wattage chosen. In order to treat the genital warts on the skin and vulvar mucosa, it is recommended to use the “Blend” mode together with the loop electrodes of various sizes and configurations, which can be found in a standard set. After applying local anesthesia, the dissection of pathological warts is performed in the “Blend” mode at 50-70 W using a loop electrode. When using the recommended wattage the dissection is performed effectively and quickly. Coagulation depth is around 1 mm, which is enough for safe hemostasis and does not influence the quality of the material during the histologic examination. The dissection of warts is performed together with the hemostasis processing. The method is more preferable on keratinized warts of large sizes on the skin and vulvar mucosa. When using СО2 laser, radio-wave and argon plasma methods the dissection of warts should be performed together with the smoke evacuator.

The improved method of a surgical dissection of genital warts is performed with the help of a Dermo Punch needle stylet, which is widely used in dermatology and presents a round metal blade with a plastic ribbed handle that allows the specialist to keep it safely in hand and therefore control the procedure. There is a wide range of blade diameters (2-8 mm). The size of the instrument is individually chosen, depending on the wart diameter. The instruments are sterile and disposable. After the antiseptic preparation of the external genitalia and the following preventive anesthesia with a 10% lidocaine, the surgical dissection then is performed by means of a Dermo Punch needle stylet of a suitable diameter (depending on the wart size) to a depth of the subdermal stroma, 2-5 mm. The wart is removed using the forceps. If needed hemostasis is performed at the place of the dissection by means of a collagen sponge.

Podophyllotoxin, 5-fluorouracil, inorganic acids (Solcoderm), silver nitrate and etc. are used for chemical coagulation of exophytic genital warts. Intraepithelial and intracondylomic administration of interferon, as well as creams and gels for topical use (5%- imiquimod, interferons, synthetic immune modulators) are applied for local immune therapy.

Treatment regimen:

• Podophyllotoxin (А) (0.5% topical cream Condyline®, 0.15% topical cream Wartec®) is applied locally two times a day, three days successively with the following pause for four days; maximal period of applying is 5 weeks. It is contraindicated during pregnancy and breastfeeding.
• Inorganic acids solution (Solcoderm®)(С) is a topical application (during each procedure there can be treated not more than 2-3 damaged areas with a total space of not more than 2-3 cm2; large affected areas are recommended for a stepwise treatment, with a 4-week interval). The therapy for this category of patients by means of Solcoderm is to be prescribed only in the cases, when its potential benefits for the mother outweigh the possible risk for the fetus or newborn.
• Imiquimod (5% creams Aldara®, Kerawort®) (А) is applied locally for 6-8 hours three times a week till the complete disappearance of the damaged areas; maximal period of applying is 16 weeks. It is contraindicated during pregnancy.

For systemic immune therapy:

• 500 000 to 1 million IU of α-Interferon (twice a day, for ten days, vaginally or per rectum (А)
• Inosinum pranobexum, 500 mg per os three times a day for 20 days (А)
• 500 000 IU of γ-Interferon subcutaneously once a day, every second day, 5 injections per treatment (А)

Treatment of genital warts in pregnant patients

Active proliferation of anogenital warts is possible during pregnancy. The therapy during pregnancy is performed till the 36th week of gestation with the use of such methods that do not have systemic effect: cryolysis, laser destruction or electrical coagulation with the participation of obstetricians and gynecologists. In large genital warts operative delivery is indicated (in order to prevent laryngeal condylomatosis in neonates). These methods may be complemented with an immune therapy (13-40 weeks): α-interferon units (Genferon ®, 500 000 or 1 million IU), twice a day, for ten days, vaginally or per rectum.