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Anogeneital warts

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  • 1. Management Of Anogenital Warts ((Condyloma Acuminata B y .Dr. Yehia El Garem, M.D Lecturer of Andrology & Dermatology Alexandria University
  • 2. (Human P apilloma Virus (HP V Double-stranded DNA viruses. Papillomaviruses. Sexual transmission Non -sexual transmission (autoinoculation) IP averages 3 to 4 months, with a range from 1 month  2 years.
  • 3. HP Genotypes Causing V Condyloma Acuminata Low risk HPV: 6, 11 42, 43, 44 High risk HPV: 16, 18 31, 33, 35, 39, 45, 55, 58.
  • 4. Condyloma Acuminat a Clinical Types External Warts Single, multiple papules or plaque Flat , verrucous, pedunculated Reddish or brown smooth raised papules Dome-shaped lesions on keratinized skin Internal Warts Affect mucous membranes Discomfort, pain, bleeding, difficult intercourse.
  • 5. Giant Condyloma (Buschke Lowenstein)
  • 6. Diagnosis  Clinical picture  Acetic acid 3-5%: (false +ve, false –ve)  Pap smear  HPV typing Consider biopsy if:  Diagnosis is uncertain  Lesions are unresponsive to or worsen during therapy  Warts are pigmented, indurated, fixed, or ulcerated  Individual warts are larger than 1 cm
  • 7. Histopathology
  • 8. Pap Smear for Cervical (Intraepithelial Neoplasia (CIN
  • 9. Pap Smear for Cervical (Intraepithelial Neoplasia (CIN
  • 10. Subclinical Genital HPV Infection (Without Exophytic Warts) (Condyloma P lana)  Manifestations of infection in the absence of genital warts.  Infection is detected on the cervix by Pap test, or biopsy.  Appearance of white areas after application of acetic acid.
  • 11. Subclinical Inf ection
  • 12. Subclinical Inf ection
  • 13. Dif f erential Diagnosis • Dome-shaped or hairlike projections on the corona or shaft adjacent to the corona on 10% of male patients. Normal. Pearly White Papules
  • 14. Dif f erential Diagnosis Shining, pearly white umbilicated papules A semisolid white material can be . expressed from the central umbilication Molluscum Contagiosum
  • 15. Dif f erential Diagnosis  On less keratinized surfaces: tend to be broader based, flatter topped, and less friable than warts.  On keratinized skin: the papules are copper colored and surmounted by scale.  Inguinal adenopathy is often present . Condyloma Lata
  • 16. Dif f erential Diagnosis  Multiple papules with smooth or verrucous surface  Usually pigmented  HPV 16 presents in most cases Bowenoid Papulosis
  • 17. Rec om ended Regi m m ens f or Ext er nal Geni t al W t s ar • Patient-Applied: • Podofilox 0.5% solution or gel:  Antimitotic drug that destroys wart  Twice a day for 3 days, followed by 4 days of no therapy/ four cycles.  The total wart area treated should not exceed 10 cm2/ podofilox limited to 0.5 mL per day.  Most patients experience mild/moderate pain or local irritation after treatment.
  • 18. Rec om ended Regi m m ens f or Ext er nal Geni t al W t s ar Imiquimod 5% cream:  Topically active immune enhancer that stimulates production of interferon and other cytokines  Three times a week for up to 16 weeks.  The treatment area should be washed with soap and water 6--10 hours after the application.  Moderate erythema, erosions and tenderness.
  • 19. Rec om ended Regi m m ens f or Ext er nal Geni t al W t s ar • Provider-Administered: Cryotherapy with liquid nitrogen or cryoprobe. • Causes epidermal necrosis • Repeat applications every 1--2 weeks.
  • 20. Rec om ended Regi m m ens f or Ext er nal Geni t al W t s ar Podophyllin resin 10%-25% in a compound tincture of benzoin:  Cytotoxic, antimitotic  A small amount should be applied to each wart and allowed to air dry.  The treatment can be repeated weekly, if necessary.  To avoid the possibility of complications  application be limited to <0.5 mL or an area of <10 cm2 of warts per session.  The preparation should be thoroughly washed off 1-4 hours after application to reduce local irritation.
  • 21. R ecommended R egimens f or External Genital Warts • Trichloroacetic acid (TCA) 80%--90%.  Destroy warts by chemical coagulation of the protein  A small amount should be applied only to warts and allowed to dry  white "frosting" develops.  The treated area should washed by sodium bicarbonate to remove unreacted acid.  This treatment can be repeated weekly, if necessary.  Intense burning sensation, ulceration.
  • 22. R ecommended R egimens f or External Genital Warts Surgical removal Electrocautery. Care must be taken to control the depth of electrocautery to prevent scarring. Tangential excision with a pair of fine scissors or a scalpel or by curettage. Carbon dioxide LASER
  • 23. Factors that may inf luence selection of treatment  Wart size  Wart number  Anatomic site of wart  Wart morphology  Patient preference  Cost of treatment  Adverse effects  Provider experience
  • 24. Location Therapeutic modalities Vaginal, cervical Cryotherapy Electrosurgery, LASER TCA Urethral meatus Cryotherapy Electrosurgery, LASER Podophyllin 25% Anal Cryotherapy TCA 80-90% Imiquimod 5%
  • 25. Treatment Of Subclinical Inf ection  The diagnosis of subclinical genital HPV infection is often not definitive, and no therapy has been identified that eradicates infection.  In the absence of coexistent SIL, treatment is not recommended for subclinical genital HPV  In the presence of coexistent SIL, management should be based on histopathologic findings.
  • 26. Pr egnancy The physiologically impaired immune status of the mother enhances the grow of genital warts. The choice of therapy must not endanger the fetus.  Do not use imiquimod, podophyllin, or podofilox in pregnant women because of potential risk to the fetus. Physician-applied topical treatment with TCA, freezing with liquid nitrogen, or electrocautery
  • 27. Patient Education: General Information Reassure the patient that HPV is a common viral infection and that is not a result of poor hygiene. Inform the patient that warts may disappear by themselves or may recur after treatment. Explain that HPV infection may or may not persist Explain that the goal of treatment is to get rid of the warts, not to eliminate the HPV infection.
  • 28.  Discuss and explain available treatments: Explain each treatment and its limitations and side effects.  Explain that healing after wart treatment takes time, and that abstinence or condom use are needed until the area is completely healed.  Explain that the patient sexual partner is almost certainly infected with HPV (and may even have transmitted it to the patient).
  • 29.  Stress the importance of female patients and female sexual partners having regular Pap smears because HPV can cause cervical cancer.  Explain to the patient and his or her sexual partner that genital warts do not necessarily imply infidelity, because it is usually not possible to determine when the virus was initially acquired.