Anogenital Warts
NICE CKS Warts – anogenital. Last revised: May 2024.
BASHH Anogenital warts 2024. Last updated: Aug 2024.
Definition
Anogenital warts are benign, proliferative growths occurring in the genital, perineal, anal, and perianal areas.
Aetiology
Anogenital warts are caused by human papillomavirus (HPV)
- Most commonly caused by low-risk, non-oncogenic genotypes 6 and 11
- In contrast, high-risk, oncogenic genotypes 16, 18, 31, 33 are associated with cervical cancer and anal cancer.
HPV is transmitted through direct skin-to-skin contact
- Most common: sexual contact
- Rarely: from hand warts or perinatally
- Orogenital transmission is also possible
Clinical Features
| Morphological types | There are 4 main morphological types:
*Condylomata acuminata is NOT the same as condylomata lata, which is seen in secondary syphilis Other features:
|
| Distribution / location | Commonly occur in areas of friction, anywhere throughout the anogenital skin and mucosa.
Common sites include:
|
| Symptoms | Usually asymptomatic
If symptomatic:
|
Complications
Anogenital warts are associated with increased risk of cervical and anal cancer.
Note that this is primarily due to co-infection with high-risk HPV types (16, 18, 31, 33) rather than the wart-causing types (6, 11) themselves.
Investigation and Diagnosis
Anogenital warts are primarily a clinical diagnosis
Other examinations / investigations:
- Dermatoscope / colposcope can be useful for identifying small lesions
- DRE and proctoscopy should be offered if warts are at the anal margin / anal symptoms are present
- Speculum examination is required if internal warts are suspected
- Colposcopy is recommended for all suspected HPV-related cervical lesions to differentiate between low-grade and high-grade lesions
- Urgent biopsy is recommended for atypical features (e.g. bleeding, ulceration, any clinical suspicion of malignancy) / diagnostic uncertainty / non-response to treatment
Management
General Advice / Conservative Management
Advice on risk reduction:
- Recommend consistent condom use to reduce onward transmission
- Provide smoking cessation advice (as smoking is associated with higher recurrence)
Partner Notification and Management
Internal Warts: Surgical/ablative treatments (laser, electrosurgery, excision) should be offered first-line as these areas are less accessible for topical application
Routine evaluation or notification of sexual partners is NOT required.
Pharmacological Management – General Population
Key factors that influence the choice of treatment:
- Internal vs external warts
- Internal warts = ablative therapy (laser / electrosurgery / excision) is explicitly 1st line
- External warts = topical therapy or cryotherapy
- Recurrent warts = ablative therapy is preferred
- Persistent warts = switch to an alternative therapy
- Pregnancy
- AVOID self-applied (topical) treatments
- Safe options: ablative therapy (laser / electrosurgery / excision) / cryotherapy / TCAA
- Ablative therapy is generally preferred over the other options
- Surgical excision is particularly useful for a small number of warts or pedunculated lesions
Self-applied (topical) treatments:
| Treatment | Recommended situation / preference |
|---|---|
| Podophyllotoxin (solution / cream) | Preferred 1st choice due to lower cost, shorter treatment duration, and faster action
Solution vs cream:
|
| Imiquimod 5% cream | Recommended for external warts (equivalent safety / efficacy to podophyllotoxin)
Preferred for reducing recurrence following CO2 laser treatment |
| Sinecatechins 10% ointment | Recommended for external warts
Note that frequent dosing (3x daily) may impair patient adherence |
Clinician-applied (topical and ablative) treatments:
| Treatment | Recommended situation / preference |
|---|---|
| Ablative therapy (laser / electrosurgery / excision) | Description: one-session performed under local anaesthetic
1st line for:
Offers the highest clearance rates Safe in pregnancy |
| Cryotherapy |
|
| TCAA 80-90% |
|
| Nitrizinc complex | May be considered when other recommended treatments failed / unsuitable |