Genital warts (Condylomata acuminata)

Condylomata acuminata (also known as condyloma, genital warts, genital warts) is a sexually transmitted disease caused by infection with the human papilloma virus (HPV).

Visible symptoms are the genital warts - small benign growths that usually occur in large numbers on the genitals, anus and rectum and vary in colour between reddish, whitish and grey-brownish. The warts tend to form beds, which means that the initially small warts develop into larger, confluent (joining) warts over time.

Genital warts are one of the most common sexually transmitted diseases, along with clamydia and genital herpes. They often appear between the ages of 20 and 25. It is estimated that about one percent of all sexually active people between the ages of 15 and 25 in the United States and Europe have genital or anal warts.

An infection with the human papilloma virus does not necessarily lead to the development of genital warts; there is also the possibility of a latent disease without recognizable symptoms. This exists in about one tenth of people in this age group.

Genital warts are almost always caused by an infection with low-risk types (low risk of developing cancer) of the human papilloma virus (HPV). There are about 200 known types of this virus, of which about 50 can cause genital warts. Most of these are the relatively harmless variants HPV-6 and HPV-11, but genital warts can rarely be triggered by the variants HPV-16 and HPV-18, which have a high degeneration potential and increase the risk of certain forms of cancer such as cervical cancer, penile cancer and anal cancer.

The route of transmission is usually smear infection during sexual contact, with the risk increasing sharply during sexual intercourse with frequently changing partners and unprotected sex. Indirect transmission (for example via a soiled towel) or infection of the child during birth are also possible, but relatively rare.

Preconditions for the development of genital warts after HPV virus infection are mainly small skin lesions, moisture and existing inflammations. Factors such as smoking, drug use or immunosuppressive drugs additionally increase the risk of development.

In most cases, infections with human papilloma viruses do not cause any symptoms and therefore go unnoticed. At the earliest, genital warts can appear two to four weeks after the first contact, but in most cases several months pass. Condylomas can appear singly or in groups of 5 to 15 warts, and after a longer period of time they can grow together to form a larger structure, which can sometimes be an indication of immune deficiency or diabetes mellitus.

In affected men, they mostly occur on the shaft of the penis or on the foreskin, but can also be located at the mouth of the urethra, on the anus or in the rectum.

In women, they usually affect the labia and cervix, and rarely the vagina or the area around the urethral orifice.

Normally, genital warts do not cause any discomfort such as itching or burning, but there may be slight bleeding due to tears in the skin around the warts.

Since genital warts are usually easily recognizable by the doctor due to their typical appearance, the diagnosis is usually made by a simple examination of the genitals or the anus.

If the warts are very difficult to see, diluted acetic acid can be applied to the affected area of skin, which then makes the genital warts stand out as white fields. The detection of the human papilloma virus (HPV) with molecular biological methods also secures the diagnosis.

In the case of an existing superficial genital wart disease, it is recommended to also examine the rectum for the presence of genital warts by means of a rectoscopy and, in male patients, to have the first centimetres of the urethra checked by means of a uretrocystoscope. Whether female patients also have an infestation of the cervix can easily be checked by the gynaecologist by means of a colposcopy.

In addition to a condyloma infection, numerous other skin diseases can also cause similar symptoms - but these can be ruled out by a histological examination (tissue examination under the microscope).

When treating a genital wart disease, it is important that not only the patient him/herself but also his/her sexual partners are treated, as otherwise it is very likely that an infection will occur again and genital warts can thus develop.

Which therapy is used depends primarily on factors such as the size and location of the genital warts and the state of the immune system. Basically, two types of therapy can be distinguished

• causaltherapy: combating the cause (human papilloma viruses) and subsequently eliminating warts

• symptomatic therapy: removal of the genital warts

Today, there is no treatment that guarantees a successful therapy - it is therefore recommended to use different treatment methods in combination.

Causal therapy

Over a period of several weeks, an ointment containing the active ingredient Imiquimod is applied three times a week to the areas affected by genital warts. Imiquimod causes a stimulation of the immune system and thus promotes the body's own defence against HPV. In about 50% of patients, the treatment causes the genital warts to regress and disappear completely - in women, this therapeutic approach has an even higher probability of success. Within six months after the end of treatment, about 20 to 70% of those treated have genital warts again (recurrence). However, surgical removal of the warts before treatment begins can increase the likelihood of success of the therapy. During treatment with Imiquimod, reddening of the skin and a burning sensation may occur in the affected areas.

Treatment with interferons is used following surgical removal of the warts. These are antiviral messengers of the immune system that help the body fight against HPV viruses. These interferons are applied in the form of a gel to the affected areas five times a day for a period of about four weeks. This reduces the risk of a recurrence of genital warts.

Treatment with imiquimod and interferons is prohibited during pregnancy. Treatment with these substances should also not be given for genital warts in the vagina or rectum.

Symptomatic therapy

Podophyllotoxin: Dabbing genital warts with an ointment containing podophyllotoxin leads to cauterization of the warts, which usually causes them to disappear. The treatment is carried out by the patient himself in a cycle that is repeated four times. In each cycle, podophyllotoxin is applied to the affected areas twice a day for three days, followed by a break in the therapy for four days. Skin irritation and associated pain may occur during treatment. As podophyllotoxin has a teratogenic (fertility-damaging) effect, women of childbearing age must be sure to use an effective method of contraception.

Trichloroacetic acid: Therapy is administered once or twice a week by the doctor, who applies the acid directly to the genital warts. This cauterizes the genital warts, which can lead to pain and a strong burning sensation on the affected skin areas during the treatment and for a short time afterwards.

Cryotherapy: In cryotherapy, the doctor freezes the genital warts with liquid nitrogen (temperature - 196°C) at weekly intervals, which destroys them. The recurrence rate is not known, but the treatment helps up to 75% of patients, at least temporarily.

Photodynamic therapy: 5-aminolevulinic acid (5-ALA) is applied to the affected areas and then irradiated with light of a specific wavelength. The effect is based on the fact that 5-ALA penetrates primarily into the pathologically altered skin of the genital warts, where it is converted into a reactive substance by the irradiation, causing the warts to be damaged and die.

Surgical procedures: This involves removing genital warts under local anesthesia using a scalpel, laser, or electrocoagulation. However, in about three quarters of patients, the warts recur later. The development of scars is also possible.

The success of treatment of genital warts varies greatly from patient to patient. In some cases, the warts heal spontaneously even without therapy. In about a quarter of cases, they recur despite treatment. Nevertheless, a disease should be treated immediately, otherwise the warts may spread rapidly.

Since certain subtypes of the human papilloma viruses (HPV-16 and HPV-18) can also lead to cervical cancer, women should have a cervical smear taken once or twice a year, even after successful therapy, in order to be able to detect and treat a possible cancer at an early stage.

Since HPV viruses are mostly transmitted during sexual intercourse, the use of condoms can significantly reduce the risk of infection. Changing sexual partners greatly increases the risk of infection - however, the development of genital warts in only one relationship partner is not a reliable indication of sexual contacts of the other outside of the partnership, as there can be extremely long and variable periods of time between an infection with the HPV viruses and the development of warts.

In case of an infection, both sexual partners should always be treated in order to avoid re-infection.

Vaccination against cervical cancer (caused by the virus subtypes HPV-16 and HPV-18) can also provide a certain degree of protection against genital warts.