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1. Management of Genital HPV
IFCCP Jeddah Jan 2014
James Bentley
Professor Dept. Obstetrics and Gynecology
Dalhousie University
Halifax, Canada

2. Introduction
• Genital warts, condyloma acuminata
– one of the most common STIs
• 90% caused by HPV 6 & 11
• Incubation: 1-8 months
• Risk factors: lifetime # of sexual partners
• Prevention:
– Vaccination
– Condoms may help

3. Management: Condyloma Acuminata
• Inspection, vaginal speculum examination
– Bright light source , magnification may help
– Possibility of other STI : offer screening
• Cytology: Women with anogenital warts
– 25% have cervical or vaginal acuminate warts
– 50% have flat lesions or CIN
• Acetic Acid:
– not recommended unless colposcopy performed
• HPV typing :
– Not recommended, usually associated with low risk HP virus

4. What to biopsy
When Where
All cervical lesions (colposcopy) Most abnormal area
Uncertain diagnosis
Treatment failure Base and side of lesion
Large, pigmented, ulcerated,
papular or macular vulvar
lesions
>35y vulvar lesions With adjacent normal tissue
Immunocompromised

5. Clinical Presentation: Genital warts
• Asymptomatic, subclinical infection which
clears spontaneously most common
• Symptoms
– Itching, burning, bleeding, vaginal discharge
• Location:
– posterior forchette> labia majora> labia minora
• Appearance
– Multiple papillomatous growths, less frequent
papules, macules
Von Krogh G, Sex Transm Inf 2000;76:162-8
Dunne E, CID 2006;43:624-9

7. Vulvar papillomatosis

8. Cervical Condyloma

9. Cytology
• Koilocytes with nuclear atypia and delayed
maturation
Sedlacek T, Clinical Obs and Gyn 1999;42:206-20

10. Histology
• Koilocytes in superficial Malpigian and
granular layers
• Hyperkeratosis, acanthosis, parakeratosis,
dyskaryosis
Nebsio C, International J Dermatology 2001;40:373-9

11. Differential Diagnosis
• Normal anatomy: micropapillomatosis,
sebaceous glands
• Benign conditions: seborrheic keratosis,
fibroepitheloma, intradermal nevi
• Infection: Molluscum contagiosum, condylomata
lata of secondary syphilis, genital herpes
• Intraepithelial neoplasia, malignancy

12. Papillomatosis
• Papillary projections inner surface of labia
minora & introitus
• Single base vs warts fused at base
• 1% of women
Von Krogh G, Sex Transm Inf 2000;76:162-8
Salvini C, CMAJ;179:799-800

13. Treatment Indications genital warts
• Spontaneous resolution 20-30% in 3 months
• Alleviate symptoms
• Psychological distress
• Counseling: treatment does not eliminate
presence of virus, infectivity

14. Treatment: Patient Applied
• Podophilox: CondylineTM, WartecTM
– 0.5% solution of purified podophyllotoxin, a mitotic
poison
– Apply BID x 3 days then 4 days off
– Maximum 6 weeks duration & 0.5ml/d & <10cm2/d
• Clearance rate 45-90%, Recurrence 30-60%
• Contraindication
– Pregnancy: teratogenic
– Abraded skin, vagina, cervix, anus: neurotoxin

15. Patient-applied Therapy
• Imiquimod: AldaraTM
– Immune response modifier
– 3 times weekly at HS up to 16 weeks, at least 1
day in between applications, wash in AM
• Clearance 56%, Recurrence 10-50%
– One study found lowest recurrence rate of any
treatment
• Contraindication: pregnancy
Edwards L, Arch Derm 1998;134:25-30
Canadian Guidelines on STI 2008

16. Office Treatment
• Cryotherapy: Liquid nitrogen, carbon dioxide
(Histofreeze) or nitrous oxide with cryoprobe
– After freezing tissue necroses (hypopigmentation)
– Apply directly 30-60s ice ball includes lesion and 1-
2mm surrounding tissue
– Weekly
• Clearance 60-90%, Recurrence 40%
• Safe in pregnancy
• Contraindications: not in vagina

17. Office treatment
• Bi- or Trichloracetic acid (50-90% solution in
70% alcohol)
– Caustic, causes necrosis
– Cotton tip applicator weekly
• Clearance 70-80%, Recurrence 36%
• Advantage: cost, pregnancy, cervix, vagina
• Caution do not over apply
– ulceration into dermis; caution on mucosa

18. Office Treatment:
• Podophyllin: preferably avoid this therapy
– Nonstandardized resin extract from Podophyllum
plant in tincture of benzoin 10-25% solution
– Weekly application x4, wash off few hours later
– Maximum 1-2ml/ application
• Adverse effects
– Chemical burns, rare systemic toxicity ( neurological,
hematological)
• Contraindication
– Pregnancy, abraded skin, mucosa

19. Surgery:
anaesthesia, colposcopy clinic or operating theatre
CO2 Laser IR light absorbed and tissue vapourized
Colposcopic guidance
Best depth control : endpoint underlying
papillary dermis visible
Preserve normal anatomy
Viral particles in smoke plume
Loop Electrosurgical Excision
Procedure
LEEP
Difficult to control depth
Not in vagina
Electrofulguration More pain and potential scarring
Surgical Excision Skin grafts may be required
Loss of normal anatomy

20. Treatment not recommended
• 5 Fluorouracil 5% cream, Efudex
• Pyrimidine antimetabolite prevents DNA synthesis
• Topical or vaginal application; frequent ulceration
• Contraindicated in pregnancy
• Interferon intralesional
• Proteins with antiviral properties, lengthen cell cycle
and increase lysis
• Flu like symptoms, pain
• Contraindicated in pregnancy

21. Pregnancy
• Considerations:
– Worsening lesions: relative immunosuppression
warts proliferate or may have recurrence
– Indication for treatment: symptoms or potential
obstruction of birth canal
– Choice of treatment: avoid potentially teratogenic
medical therapy
– Transmission to fetus: is Caesarian section
indicated?

22. Genital HPV Infection in Pregnancy
• Treatment not necessary unless potentially
obstructive or symptoms
• TCA most effective in 2nd half of pregnancy
– fewer recurrences, lesions stable at this time
• Laser in 3rd trimester for extensive
condylomata
• Spontaneous regression or resolution
postpartum
ACOG Practice Bulletin 2005;61:905-918

23. Recurrent Respiratory Papillomatosis
RRP
• Most common benign
neoplasm of larynx
• Usual cause HPV 6 & 11
• Presents in childhood or
adult: hoarseness
• Possible modes of
transmission to infant:
– Vertical during labour and
delivery
– Vertical in utero ascending
or transplacental
– Direct casual contact
– Sexual abuse
Kosko J, Int J Ped Otorhinolaryngol 1996;35:31-38
Papillomas

24. Respiratory Papillomatosis
• Mode of transmission not established
• C/S with intact membranes has been
associated with RRP in child
• Treatment of condyloma during pregnancy
does not eradicate latent HPV
• Caesarian section for sole indication of
prevention of RRP not recommended
Kosko J, Int J Ped Otorhinolaryngol 1996;35:31-38
ACOG Practice Bulletin 2005;61:905-918

25. Immunosuppression & HIV/ AIDS
• Extensive lesions, resistant to therapy, more
recurrences
• Imiquimod 1st line therapy
• Laser: ablative, multiple biopsies
• Increased malignant transformation: BIOPSY
– Immunocompetent women 90% warts HPV 6 & 11
– Immunosuppressed up to 50% warts high risk
oncogenic HPVwww.utdol.com/online/content/topic.do?topicKey=gen_gyne
(accessed Apr 13, 2009)

26. Summary: Condyloma Acuminata
• Common
– Lifetime risk HPV 70%, warts 10%
• Spontaneous resolution:
– Placebo controlled trial 20-30% in 3 months
• Biopsy not required in healthy women <35y
• Treatment choice
– Patient preference, provider experience, pregnancy
– Combination therapy
• Latent virus
– Recurrences 30%, transmission to partner