5 prof james bently mgmt genital hpv 2014

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5 prof james bently mgmt genital hpv 2014

  1. 1. Management of Genital HPV IFCCP Jeddah Jan 2014 James Bentley Professor Dept. Obstetrics and Gynecology Dalhousie University Halifax, Canada
  2. 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. 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. 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. 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
  6. 6. Vulvar papillomatosis
  7. 7. Cervical Condyloma
  8. 8. Cytology • Koilocytes with nuclear atypia and delayed maturation Sedlacek T, Clinical Obs and Gyn 1999;42:206-20
  9. 9. Histology • Koilocytes in superficial Malpigian and granular layers • Hyperkeratosis, acanthosis, parakeratosis, dyskaryosis Nebsio C, International J Dermatology 2001;40:373-9
  10. 10. 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
  11. 11. 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
  12. 12. Treatment Indications genital warts • Spontaneous resolution 20-30% in 3 months • Alleviate symptoms • Psychological distress • Counseling: treatment does not eliminate presence of virus, infectivity
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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?
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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)
  25. 25. 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

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