Diseases & Conditions
Papilloma virus, human (HPV)
A very common and extremely contagious virus that can cause abnormal tissue growth on the feet, hands, vocal cords, mouth, and genital organs. More than 60 types of human papilloma virus (HPV) have been identiﬁed; each type infects certain parts of the body. Some cause WARTS, including PLANTAR WARTS on the feet, common hand warts, juvenile warts, and genital warts (see WARTS, GENITAL). They also cause other invisible genital HPV infections. A wide variety of benign and cancerous growths also may be associated with HPVs, which has been demonstrated to cause vulvar or cervical cancer in some women.
Up to one out of 10 Americans have genital HPV infections, and between 500,000 and a million new cases of genital warts occur every year. Some studies show that about one-third of all sexually active teenagers have genital HPV infections. Because they do not have symptoms or do not recognize them, millions of others do not know that they carry HPV. The majority of those now seeking treatment for genital warts are teens and young women between the ages of 15 and 29.
HPV infections cause a variety of problems, but there may be no symptoms of infection at all. Genital warts caused by HPV may be found on the vulva, in the vagina, and on the cervix, penis, anus, and urethra of infected women and men, but they are found very rarely in the mouth or throat. They often are ﬂesh-colored and soft and may look like miniature cauliﬂowers. Usually they grow in more than one location and may cluster in large masses. Genital warts usually are painless but may itch. If allowed to grow, they can block the openings of the vagina, urethra, or anus and become very uncomfortable. Depending on their location, genital warts can cause sores and bleeding.
Genital warts often grow more rapidly during pregnancy. An increase in the size and number of genital warts occurs when a person’s immune system is weakened by diabetes, an organ transplant, Hodgkin’s disease, HIV/AIDS, or other conditions. There are other genital HPV infections that cannot be seen with the naked eye. Some are more dangerous than genital warts because they are associated with cancers of the cervix, vulva, vagina, or penis.
Genital HPVs can spread whether or not warts are present, usually by vaginal or anal intercourse. Because genital HPV infections are often unseen, they can be spread by sex partners who do not know they are infected. It may also be possible by contact with the virus through such potential vehicles as toilet facilities, steam room benches, shared swimsuits, or underwear.
People most at risk for genital HPV infections are people who:
• have weakened immune systems
• are sexually involved with a number of different partners
• have sex partners who are sexually involved with a number of different partners
• have infected partners
Medical examination is the ﬁrst step in determining if there is a genital HPV infection. Many times a woman does not notice warty lesions, but her physician may see something unusual while performing a routine gynecologic examination or Pap smear. Pap smear results can be used to screen for
tissue changes in the cervix and help corroborate ﬁndings of other tests such as colposcopy, which allows a doctor to see the cervix with a special microscope and to sample any suspicious tissue.
HPV is a persistent and hard-to-cure organism, so treatment must usually be repeated. Moreover, an infected woman should be monitored throughout her life for recurrence or development of precancerous changes, whether or not warts are apparent. Because the virus remains in the lesions it creates, treatment for HPV consists of controlling infection by removing visible warts or precancerous lesions.
They can be removed by surgery, by freezing, or by locally applied chemicals. The method depends on the extent of infection, accessibility of lesions, and malignancy potential.
Surgery is sometimes used to cut away warts if treatment without anesthesia would cause discomfort, or warts are so extensive that simultaneous reconstructive surgery is required. Surgery may permit a more thorough removal of infected sites, although its cost must be weighed against potential beneﬁts and risks. Surgery may either mean an excisional biopsy done as an outpatient procedure or a more involved procedure performed under anesthesia.
In superﬁcial cryotherapy, liquid nitrogen is applied by cotton swab to minor external warts. Extensive lesions can be frozen faster and to a greater depth with a cold cautery device which pinpoints warts. Cold cautery cryotherapy is usually performed within a week after menstruation, and it cannot be used in pregnant women. After cryotherapy women may experience cramping, abdominal pain, infection, or rarely, cervical scarring. Painkillers given before cryotherapy will ease pain, and ice packs applied externally after the procedure will reduce any swelling or inﬂammation. Considerable watery vaginal discharge for 10 to 20 days after cryotherapy is normal, but fever, pain unrelieved by analgesics, or unusually prolonged discharge should be reported to the doctor.
Laser treatment involves a high-intensity beam of light that vaporizes lesions, particularly those that are external or in less accessible locations. In the hands of a well-trained physician, laser therapy is highly effective in removing multiple lesions. The procedure is usually more expensive than other types of treatment and carries risks of removing too much tissue, and delayed healing, scarring, or pain.
Acids such as trichloroacetic acid (TCA) or bichloroacetic acid (BCA) may be painted on visible warts using a small cotton swab or wooden applicator. To be effective, TCA or BCA must be applied in proper concentrations, but these sometimes cause a burning sensation after treatment. Local and systemic painkillers will help relieve pain. Scarring and chronic pain are potential aftereffects.
5-Fluorouracil (5-FU) cream applied to the vulva on a regular regimen can help control external lesions. However, it should not be used by pregnant women and may cause serious skin irritation.
Interferon, a newer drug approved for injection into a muscle or select lesions, can be used, but it is expensive, has signiﬁcant systemic side effects, and cannot be used during pregnancy. Podophyllin was once a popular treatment, but it is used less often now because it cannot be used during pregnancy or for most internal lesion sites and because it may cause cancer or toxic reactions.
After any HPV treatment, the treated area should be kept clean and dry with cornstarch dusting, cotton underwear, and loose clothing. Sexual intercourse should be avoided until healing has occurred externally and internally, usually within two to four weeks. Follow-up colposcopy and Pap smears are usually scheduled at three-month intervals after treatment of HPV, and yearly thereafter. These tests monitor that the cervix remains free of precancerous or cancerous tissue. A woman with HPV should notify any sexual partners of her infection, use latex condoms with every partner (unless in a mutually monogamous relationship), and urge that the partner be treated for HPV if his physician has identiﬁed HPV lesions.
Condoms are recommended for all sexual contacts other than a monogamous relationship. Condoms prevent transmission of infection to a partner and lower the risk of becoming infected with a different form of HPV or other sexually transmitted diseases.
Applying spermicides with nonoxynol-9 to affected or treated areas may be helpful in reducing transmission of the virus. Everyone with genital lesions, and all partners of persons with genital lesions, should alert new sexual partners about HPV infection risk and take precautions to limit spread of HPV.