Genital infections

In the USA, an estimated 1% of sexually active people have genital warts
In the UK, warts are the commonest reason for attending a sexual health (genitourinary medicine) clinic. In 2002, more than 70 000 people attended with a first attack of genital warts
Genital warts are becoming more common. In the UK, the 2003 figures were 2% higher than in the previous year
There is a particularly noticeable increase in genital warts among teenagers. In women, about 60% of genital warts are in the 16–24-year-old age group and, in men, about 45%

Genital warts are caused by a virus – HPV (human papillomavirus). HPV is caught during sexual contact with someone who is already infected with it. If you develop genital warts, try not to feel too upset – remember they are very common and lots of people have them, they are not dangerous and there are many effective ways of treating them.

You may feel angry with the person you think you caught them from. But in fact that person may not know that he or she had HPV for the following two reasons.

Some people carry HPV, but do not have any warts. In fact 15–40% of people under 40 are carriers of HPV, though it is less common in older people. In most people who carry HPV, it goes away in a year or two.
A man may not know that he has a wart, because it can be hidden inside the urethral opening (‘pee hole’). Similarly, a woman can have a wart on the cervix (that is, deep inside the vagina) that she does not know about.

Preventing warts
Although you can catch the virus from sexual contact with someone who carries it but has no warts, infection is more likely from someone who has warts. This is because the surface of a wart is teeming with the virus. After infection, warts can develop 3 weeks to a year later (3 months is the average), so do not assume that you caught them from a recent sexual contact.

Recent research among university students in the USA shows that condoms halve the risk of becoming infected with HPV (New England Journal of Medicine 2006;354:2645–54).

Where genital warts occur
In women, genital warts usually occur around the opening of the vagina (vulva), but they may occur in the folds of skin alongside the vaginal opening, or between the vagina and the anus, and around the anal opening. The figures (Archives of Dermatology 1984;120:472) are as follows:

around the opening of the vagina (vulva) – 66%
in the vagina – 37%
between the vagina and anus – 29%
around the anus – 23%
on the cervix (neck of womb) – 8%
at the opening of the urethra (where the urine comes out) – 4%.

In men, genital warts often occur just under the foreskin, but can be anywhere on the penis, on the scrotum, in the groin or around the anus. The figures (Archives of Dermatology 1984;120:472) are as follows:

on the shaft of the penis – 51%
around the anus – 34%
on the glans (head of the penis) – 10%
inside the hole (opening of the urethra) – 10%
under the foreskin – 8%
between the anus and scrotum – 3%
on the scrotum – 1%.

What warts look like
In women, genital warts begin as small, gritty-feeling growths, which then enlarge and become more frond-like. They can join together so they resemble miniature cauliflowers. Occasionally they are flat, like warts on the fingers. They are not painful, but can feel itchy or vaguely uncomfortable.

In men, warts on the scrotum or shaft of the penis usually resemble the ordinary warts that occur on the hands. Under the foreskin and round the anus, they are usually a shiny pinkish-white. A lone wart may also occur inside the opening of the urethra (‘pee hole’); here it will be a pinkish colour and may look speckled. An individual may have dozens of warts, or just one or two.

What to do

If you think you have genital warts, the only positive thing you can do yourself is stop smoking, because warts probably persist longer in smokers.
Do not try to treat genital warts with any of the wart lotions you can buy from pharmacists; these are for use on the hands only.
You need to see a doctor, either your family doctor or a doctor at a genitourinary medicine clinic, whichever you feel most comfortable with. The advantage of going to a genitourinary medicine clinic is that you will have tests for other infections; 1 in 5 people with genital warts has another infection that they are probably unaware of. Also, the staff are very used to diagnosing and treating warts. You do not need a referral from your doctor and you simply phone the clinic yourself (see useful contacts click here).

There are several treatments for genital warts. The usual treatments – because they are simple and effective – are podophyllotoxin or imiquimod. Other treatments (such as freezing, burning with acid or laser treatment) are sometimes used, depending on the type and size of wart.

Annoyingly, whatever the treatment, there is a 30% chance that the warts will come back – usually after a few weeks or months. This is because the treatments destroy the wart itself, but cannot get rid of the HPV in the skin beneath the wart.

Podophyllotoxin is a plant extract that comes as a liquid or cream. The clinic will show you how to use it and may give you a supply to take home. You usually have to apply it twice a day for 3 days, followed by a break of 4 days. You then repeat this process until the wart disappears (maximum of 4–5 weeks treatment). The cream is easier to use than the liquid for warts in awkward places (such as around the anus). It should not be used if you are pregnant or trying to get pregnant.

Imiquimod is a cream that the clinic may suggest if podophyllotoxin does not work. It is applied three times a week before you go to sleep, so it can remain on the skin for about 8 hours. It seems to work by stimulating the body’s own immune system to destroy the warts. On average, women need 8 weeks of treatment and men need 12 weeks, but it can be used for up to 16 weeks. The disadvantage is that itching, redness and soreness often occur. Its effect is slow and it may be several weeks before you notice any improvement.

Genital warts and cervical cancer
There are about 120 different types of HPV. Each type has been given a number to identify it. Visible genital warts are usually caused by HPV types 6 and 11.

There is a strong link between HPV types 16 and 18 and cervical cancer. These types of HPV seem to agitate the cells of the cervix (neck of the womb) and encourage pre-cancerous changes. But HPV 16 and 18 do not usually cause visible warts. Therefore if you have genital warts, you are not at a particularly increased risk of cervical cancer.

This also means that people with only the more high-risk type of HPV (types 16 or 18) do not know that they have it, because they probably will not have warts. At present, you cannot be tested under the NHS in the UK to see if you are a carrier of types 16 or 18, but this may be possible in the future. The Department of Health is trying out a screening programme by testing several thousand women for the high-risk strains.

Genital warts in pregnant women
Pregnancy seems to encourage genital warts – they often become bigger or more numerous. Unfortunately, podophyllotoxin may harm the baby, and it is not known whether imiquimod is safe in pregnancy. If very troublesome, they can be treated by freezing (cryotherapy). The good news is that, after the baby is born, genital warts often become smaller or disappear.

The future – a vaccine?
Scientists have developed a vaccine against HPV 16 and 18, and two other types, 6 and 11. It has been tried out in a study involving more than 1000 women, and seems to be very effective (British Medical Journal 2005;331:916–8). However, it will be several years before it becomes generally available.

The vaccine would not prevent visible warts. It is directed against the types of HPV that cause cervical cancer and not those that cause visible warts.

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