This document discusses vulvar warts (condylomata acuminata), caused by human papillomavirus (HPV). It covers HPV types/strains associated with warts, acquisition, presentation, treatment options including medical therapies like podophyllotoxin and surgical excision, considerations for pregnant women and children, and risks of fetal transmission. Treatment aims to remove visible warts while clearing HPV, with recurrence rates of 30-70% requiring multiple approaches.

1. Vulvar warts
Condylomata acuminata
Anwar Moria MD,SSCOG,FMIGS
Consultant Gynecologist Oncologist and
Minimal Invasive Surgeon
Chairman of the Department of Obstetrics and Gynecology
Dr. Suliman Fakeeh Hospital

2.  Papilloma viruses are double-stranded
DNA viruses.
 It is highly specific human papilloma
viruses (HPV), infect only humans.
 There are more than 100 serotypes of
HPV, which can be subdivided into
cutaneous or mucosal categories based
upon their tissue tropism

4.  35 types are specific for the anogenital epithelium and have varying
potentials to cause malignant change, such as cervical or anal
cancer.
 HPV serotypes 16 and 18 are most commonly associated with
squamous cell carcinoma.
 Low-risk subtypes, such as HPV 6 and 11, do not integrate into the
host genome and are most frequently associated with benign
condyloma and low grade intraepithelial neoplasia .
 Intermediate risk subtypes can cause high grade dysplasia, which
persists but rarely progresses to the invasive stage.

5. Acquisition
 Women
 Disease in women is primarily caused by vaginal or
anal intercourse and number of sexual partners.
 Most infections are transient and cleared within two
years.
 Prevelence in women younger than 25 years 36%,
over 45 years 2%
(Burk,1996)
 Men
 Penile or Perianal lesions, the later is common
among Homosexuals.
 Immuno-compromised
 higher in HIV positive
 sexually transmitted diseases

6.  Children
 None-genital Warts occur in 10 percent of children, with a peak
incidence between the ages of 12 and 16
 Genital warts prevlance in unknown in children, however average
age at which they present with range between 2.8 and 5.6 years
(Allen,2000)
 Heteroinoculation – Transmission during nonsexual contact
(bathing or diaper changing).
 Autoinoculation – Children may acquire anogenital lesions from
self due to transmission of HPV from other cutaneous or
mucosal sites of infection.
 Sexual abuse
 Perinatal or prenatal transmission
 Transmission via fomites :contaminated towels or underwear

7. Presentation
 Warts are often asymptomatic
 Pruritus, bleeding, burning, tenderness,
vaginal discharge, or pain.
 Large warts can obscure
the vaginal orifice
and interfere with defecation

8. Treatment
Determining the human papillomavirus (HPV) type
of the warts is unnecessary as this information
does not affect clinical management.
Biopsy, when are indicated?
 The diagnosis is uncertain.
 The lesion has any suspicious features, such as
irregular and unusual pigmentation (red, blue,
black, brown), induration, bleeding, ulceration,
sudden recent growth.
 The patient is postmenopausal or
immunocompromised.
 The lesion is refractory to medical therapy.

9. Medical therapy
 Cytodestructive therapies
 Podophyllotoxin
 Podophyllum resin
 Trichloroacetic acid and bichloroacetic acid
 5-Fluorouracil
 Immune-mediated therapies
 Imiquimod
 Sinecatechins
 Interferons

10. Podophyllotoxin and
podophyllum resin
 Podophyllotoxin contains the biologically active
compound from podophyllum resin (a plant-
based resin that blocks cell division at metaphase
and leads to cell death).
 Application with a cotton swab twice daily for three
days, followed by 4 days without treatments
 Treatment is continued for 4 weeks
 Can be done by the patient
 Podophyllum resin
 Needs to be applied by physician due to
higher toxicity
 Treatment for 4-6 weeks

11. Trichloroacetic acid and
bichloroacetic acid
 TCA and BCA are caustic acids that destroy the wart
tissue via chemical coagulation of tissue proteins
 80-90% TCA applied only to the wart tissue with a
cotton swab
 the wart turns white as the solution dries
 Applied only by the physician
 Patient can only leave after the solution has dried out.
 Treatment are done weekly for 4-6 weeks
 Can be used in the vaginal lesions

12. 5-Fluorouracil
 (5-FU) is a pyrimidine antimetabolite that
causes cell death by interfering with DNA
synthesis.
 Not FDA approved ,contraindicated in
pregnancy
 Causes burning, pain, inflammation, edema,
and painful ulcerations.
 Preferred not to be primary therapy
 Available in gel form and can be injected
intra-lesionally.

13. Immune-mediated
therapies
 Imiquimod
 a positive immune response modifier, and a stimulator of
local cytokine induction.
 Topical treatment of warts increases local production of
interferon and reduces human papillomavirus (HPV) virus
load
 Safety in pregnancy not established
 Aldara (5 % imiquimod)
 Can be applied by patient at bedtime
 Response rate 72 to 84 %, complete clearance rates of 40 to
70 %
 There are two regimens approved by the US Food and Drug
Administration:
 Application of a 5% cream three times per week for up to 16
weeks
 Application of a 3.75% cream once per day for up to 8 weeks
 Treatment is very costly

14. Sinecatechins
 botanical drug product for self-administered topical
treatment of external anogenital warts
 The active ingredient is kunecatechins, which are a
mixture of catechins and other components of green tea
 they have both antioxidant and immune enhancing
activity
 Safety in pregnancy not established
 ointment is placed on each wart and a finger is used to
cover the wart with a thin layer of the ointment 3 times
each day for up to 16 weeks
 Efficacy 54 to 57% versus 34 to 35 % to placebo
Tatti, 2008

15. Interferons Alpha
 Interferons have antiviral, antiproliferative,
and immune-stimulating effects.
 Intralesional therapy is more effective than
systemic.
 Intralesional injection of 0.5 to 1.5 miU is
administered 2-3 times per week for up to 9
weeks
 Can cause flu-like symptoms, fatigue,
anorexia, and local pain.

16. Other Medical
 Topical cidofovir
 FDA approved for the treatment of
cytomegalovirus retinitis in patients with
AIDS
 In a double-blind, randomized trial Cidofovir
showed complete resolution of warts in 47%
of patients compared to placebo
(Snoeck,2001)
 Bacillus Calmette-Guerin (BCG)
 Mycobacterium w vaccine

17. Surgical therapy
 ablative and excisional
 advantage
 Fewer visits for treatment are needed compared with
medical therapy
 disadvantage
 Hypo- or hyperpigmentation.
 Generally require anesthesia and often need to be
performed in an operating room
 Surgical therapy may result in scarring, especially
when the subdermal layer is destroyed.
 All of the surgical options can be used in pregnant
women and on both the vulva and vagina.

18. Cryoablation
 liquid nitrogen or nitrous oxide
 Needs local anethesia
 applied directly to the vulvar or vaginal
lesion with a cotton swab or a fine spray.
 The treatment is applied for 30 to 60
seconds, until an ice ball forms and
encompasses the lesion and 1 to 2 mm
surrounding area
 skin irritation, edema, blistering, and
ulceration and hypopigmentation.

19. Laser ablation
 Thermal damage and ablation.
 (CO2 or NdYag) Carbon dioxide laser is the most commonly
utilized
 Colposcope is useful for directing laser therapy
 Tissue destruction should not go beyond 1 mm in depth
 Advantages
 useful for treating cervical and vaginal warts when access is
difficult
 maintains normal vulvar anatomy
 Good for extensive or multifocal lesions
 Disadvantages
 requires specific training and specialized equipment
 Causes pain and hypopigmentation.
 Requires careful attention to vulvar hygiene post treatment.

20. Others
 Excision
 If tissue is needed for histological diagnosis.
 Exophytic lesions are can be excised or
shaved to the level of normal skin
 Then the base of the lesion is cauterized .
 For larger lesions, wide local excision is
often required.
 Adverse effect : pain, dyspareunia, scar
formation, and infection

21. Others
 Electrocautery
 More effective than cryo, however
requires OR and Anesthesia.
 Ultrasonic aspiration
 (Cavitron ultrasonic aspirator-CUSA)
 Infrared coagulation

22. What to choose?
 Regardless of the method of treatment the
recurrence rates of 30 to 70 %
(Jablonska,1998)
 Spontaneous regression can occur within
three months in 20 to 30 %
 There is no evidence to suggest that one
treatment is significantly superior to
another or appropriate for all patients and
all types of warts

23. What to choose?
1. No Pregnancy
 Vulva
 Limited: Imiquimod (Aldara), podeophyllotoxin,
Sinecatechins (Veregens). If failed for TCA in
office.
 Extensive: Surgery or Laser.
 Vagina
 TCA, interferon and Laser therapy.
 Refractory disease needs to be biopsied to role
out neoplasia, treatment better be combimed
surgical and medical (e.g. Surgery + TCA)

24. What to choose?
2. Pregnant women
Disease may worsens during pregnancy.
There is a significance increase in HPV
prevalence during pregnancy.
Rando,1989
 TCA, all surgical therapy can be used.
 Treatment better be done in the third
trimester specially if warts are obscuring
the birth canal.

25. What to choose?
 Children
 most condylomata acuminata in children
resolve within a few years,
 Treatment is not required for most children with
asymptomatic lesions
 Children with symptomatic lesions, lesions that
fail to spontaneously resolve,
immunosuppression, or lesions that lead to
emotional distress or social problems, it can be
treated with imiquimod 5% or 3.75% cream or
podophyllotoxin 0.5% gel or solution

26. What to choose?
 immunocompromised women
 Usually develop extensive lesions.
 Vulvar biopsy is indicated.
 HIV affected individuals can harbour many
HPV subtypes including high-oncogenic risk
HPV types
 Imiquimod (Aldara) is the best therapy,
followed by surgery if needed.
 Topical cidofovir can also be used

27. Fetal Transmission
 Children of affected mothers can develop mucosal,
conjunctival, or laryngeal disease, or rarely Juvenile-
onset recurrent respiratory papillomatosis
 No randomised controlled trails compared affect
women Vs unaffected Vs treated, however the
following information has been obtained from national
data and small trials.
 Rate of fetal transmission from affected mother in Normal
delivery is 7/1000
 Cesarean delivery was not found to be protective against
respiratory papillomatosis
(Silverberg, 2003)
 Treatment of warts may not affect the transmission rate.
 Cesarean delivery is indicated if vulvar or vaginal warts
obstruct the birth canal

28. Recurrent respiratory
papillomatosis (RPR)
 Incidence in children 14 years or younger 4.3 per 100,000. 15
years and older 1.8 per 100,000
(Armstrong,1999)
 RRP has a bimodal age distribution and manifestation
 common in children younger than 5 years (juvenile-onset) or in
persons in the fourth decade of life (adult-onset).
 JORRP is more common and more severe than AORRP
 Treatment usually involves repeated debulking of the warty
growths by laser or microdebridement coupled with intralesional
cidofovir.
 In 3-5% of patients, respiratory papillomas may undergo malignant
degeneration to squamous cell carcinoma, and the prognosis for
patients with these cancers is quite poor

29. Other issues
 Sexual activity can be resumed when patients
are pain free after treatment.
 Hygiene is important after treatment with sitz
bath and prevention of wound infection.
 Follow up of treated patients every 6 months.