|
INTRODUCTION |
ˇ@ |
Background: The viral nature of
genital warts was first recognized in 1907 when Ciuffo induced warts after
autoinoculation of cell-free wart extracts (Ciuffo, 1907). With the development
of molecular biology techniques, the human papillomavirus (HPV) was identified
as the virus responsible for condyloma acuminatum. In the mid-1970s, zur Hansen
proposed that HPV was likely important in the etiology of genital tract
neoplasias (zur Hansen, 1976). The DNA of the first genital wart was
characterized in 1980. Today, over 80 distinct HPV subtypes have been
identified. This group of viruses is strongly linked to the development of
cervical dysplasia, cervical cancer, and vulvar dysplasia.
Genital warts are spread by sexual contact. Approximately two thirds of
individuals who have sexual contact with an infected partner develop genital
warts. The exact incubation time is unknown, but most investigators believe the
incubation period is 3 months (Becker, 1987).
ˇ@
Pathophysiology: HPV is a group of double-stranded DNA
viruses. The genome encodes 6 early open reading frames (E1, E2, E4, E5, E6, E7)
and 2 late open reading frames (L1, L2). The E genes encode proteins important
in regulatory function, and the L genes encode for viral capsid proteins. This
group of viruses can infect many different sites, including the larynx, skin,
mouth, esophagus, and the anogenital tract.
Approximately 20 different types of HPV can infect the anogenital tract.
Infection caused by the HPV virus results in local infections and appears as
warty papillary condylomatous lesions. HPV infections in the genital area are
sexually transmitted (Gissmann, 1980).
HPVs associated with genital tract lesions have been divided into low risk
and high risk based on each genotype’s association with benign or malignant
lesions. Most genital condylomata are due to infection by HPV-6 or HPV-11. These
HPV types replicate as an episome and rarely incorporate their genetic material
into the host DNA. In contrast, HPV-16 and HPV-18 can be recovered in
approximately 70% of squamous cell carcinomas of the cervix. These high-risk HPV
types, along with types 31, 33, and 45, incorporate a portion of their genetic
material into the host DNA. The E6 and E7 genes can produce oncoproteins that
alter cell growth regulation. Specifically, E6 oncoprotein inactivates the tumor
suppressor gene p53, and the oncoprotein produced by E7 inactivates
pRB (retinoblastoma) (Koutsky, 1997).
ˇ@
Frequency:
ˇ@
- In the US: Frequency of HPV infection in the population
is difficult to estimate accurately. Studies reporting the diagnosis of HPV by
visual inspection of genital condyloma report the lowest prevalence rates. Not
surprising, the highest prevalence rates are reported by studies typing HPV
from exfoliated genital tract cells. Regardless of the conflicting prevalence
figures, HPV is a major sexually transmitted disease (Koutsky, 1988; Nuovo,
1994).
Condyloma acuminata are clinically apparent in 1% of the sexually active
population. Molecular studies indicate 10-20% of men and women aged 15-49
years have been exposed to HPV. Prevalence of HPV is higher in certain
populations. Data from sexually transmitted disease clinics indicate a
prevalence rate of 4-13%.
Based on clinical observations, incidence of HPV infection clearly has
increased in the last 35 years. Data from the National Disease and Therapeutic
Index, which is a random survey of private physicians, indicate that, in 1966,
169,000 people consulted a physician about genital warts. By 1984, this number
had risen to 1,150,000 consultations. Today, researchers believe at least 1
million new cases of genital warts are diagnosed each year. Genital HPV
infection now is the most common sexually transmitted disease (Bosch, 1995).
Several investigators report an increased prevalence of anogenital HPV
infections during pregnancy. During pregnancy, the prevalence of condyloma
increases from the first to third trimester and decreases significantly in the
postpartum period. The risk of condyloma acuminata in pregnancy is 2-fold.
First, the lesions can become large enough to obstruct labor. Secondly, with
an abdominal delivery, the virus can be transmitted to the infant, resulting
in laryngeal papillomas (Peng, 1990; Rando, 1989; Schneider, 1987; Shah,
1986).
- Internationally: Outside of the United States, HPV
infections are common (Syrjanen, 1990). A study in Finland in the mid-1980s
demonstrated an annual incidence of cytologic cervical HPV infection of 7% (Kjaer,
2000). A study of Finnish males found 6.5% had evidence of HPV in exfoliative
cells obtained from the urethra and genital epithelium (Hippelainen, 1993).
Mortality/Morbidity: Condyloma acuminatum often is
asymptomatic.
- Pruritus or occasional bleeding may lead the patient to seek medical care.
- Patients who do not develop immunity to HPV can develop potentially
serious sequelae.
- HPV infection of the vulva can result in the development of vulvar
intraepithelial neoplasia (dysplasia) or squamous cell carcinoma of the vulva.
Most research indicates that HPV infection is strongly associated with the
development of cervical dysplasia and cervical carcinoma. Vaginal dysplasia
also is associated with exposure to HPV.
Race: No racial predilection exists.
Sex: The prevalence of condyloma acuminata seems to be
similar in men and women. One study from a sexually transmitted disease clinic
in the state of Washington found 13% of men and 9% of women had condyloma
acuminata (US Department of Health and Human Services 1996, Koutsky, 1988).
Age: The highest rates of genital HPV infection are found in
sexually active women younger than 25 years, even after correcting for the
number of lifetime sexual partners. Most of these infections seem to be
transient (Ho, 1998; Burk, 1996; Figueroa, 1995).
- A cytologic screening of the cervix in over 400,000 women supports the
higher incidence of HPV in young women. This study found that the rate of HPV
infection is twice as frequent in women younger than 30 years as it is in
women older than 30 years (Meisels, 1992).
- The reason for the higher prevalence in younger women is not completely
understood. Some investigators hypothesize that older women have fewer sexual
partners and, consequently, less exposure to the HPV. An alternative theory is
that by age 30 years, women have acquired immunity to HPV (Evander, 1995).
- The presence of genital condyloma in the pediatric population presents a
diagnostic and therapeutic challenge. Vertical transmission of HPV can occur
via in utero exposure to amniotic fluid or transmission of HPV from the
maternal genital tract. An incubation period of several months usually is
required between virus infection at delivery and clinical manifestations in
the infant. The average latency period is 3 months, but periods as long as 20
months have been reported (Davis, 1989). Unfortunately, most cases of
childhood condylomata outside a reasonable incubation period after vertical
transmission should arouse the suspicion of child abuse. Treatment of
condyloma in the infant would include excision under general anesthesia or the
use of podophyllin (Shelton, 1986).
|
CLINICAL |
ˇ@ |
History:
- Most patients seek medical care when they notice “lumps?on the vulva,
perianal area, or periclitoral area.
- These lesions generally are not painful, but they can be associated with
pruritus.
- Bleeding can be observed if the lesions become confluent and are
irritated by clothing.
Physical:
- Inspection of the female genital area requires good lighting.
- On gross inspection, typical condyloma usually is a discrete papillary
growth that may arise from a single stalk.
- Condyloma acuminata can involve a large area in a sessile fashion.
- Subclinical infection is another common presentation of condyloma. Tiny,
slightly raised areas can be felt or visualized on the vagina or cervix.
- These flat warts are best visualized using 3-5% acetic acid and a
colposcope. Areas infected with HPV appear acetowhite.
- Often, a biopsy is needed to distinguish these lesions from cervical
squamous intraepithelial lesions or vaginal intraepithelial lesions.
- The sexual partner(s) of a woman with condyloma should be examined by a
physician and treated if indicated. Often the examination of the male fails to
reveal any visible condyloma.
Causes: Approximately 20 different types of HPV can infect
the anogenital tract.
- Infection caused by the HPV virus results in local infections and appears
as warty papillary condylomatous lesions.
- HPV infections in the genital area are sexually transmitted.
|
WORKUP |
ˇ@ |
Lab Studies:
ˇ@
- Patients who present with condyloma acuminata do not necessarily need
other laboratory studies; however, patients who are diagnosed with condyloma
are at an increased risk for other sexually transmitted diseases.
- Consider testing for chlamydia, gonorrhea, syphilis, hepatitis B,
hepatitis C, and HIV depending on the clinical situation.
- These patients need a Papanicolaou (Pap) test of the cervix if a Pap
test has not been performed in the last 12 months.
- The need to determine the HPV type is controversial (Kaufman, 1999).
- HPV typing has been proposed to supplement Pap test screening (Cuzick,
2000).
- This typing can be used as a secondary triage of patients with atypical
squamous cells of undetermined significance (ASCUS) on Pap tests (Cox,
1996).
- Other clinicians have proposed to use HPV typing in primary screening as
an adjunct to Pap tests (Goodman 2000).
- In both of these scenarios, HPV typing can detect low-risk and high-risk
HPV types found in the cervix.
- Histologic examination of the vulvar lesions to detect vulvar condyloma
sometimes is difficult.
- Non-HPV conditions, such as vestibular papillomatosis and inflammatory
squamous metaplasia, may be difficult to distinguish from condyloma with light
microscopy.
- The pathologist may issue a pathology report suggesting the microscopic
features of a vulvar biopsy are changes suggestive but not diagnostic of HPV.
- When the histologic diagnosis of condyloma is questionable, HPV testing
may be useful.
- A wide variety of methods to detect HPV have been used since 1983.
- Currently, the 2 most accurate methods use 2 consensus primer polymerase
chain reaction (PCR) systems. The commercially available system is the
Hybrid Capture system with differential testing for 9 high-risk HPV types
and 5 low-risk HPV types.
- Testing for HPV confirmation of equivocal vulvar histology results
provides an objective method for confirming a diagnosis of condyloma.
Imaging Studies:
ˇ@
- No imaging studies are indicated.
Procedures:
ˇ@
- Patients who present with typical appearing condyloma acuminata do not
need a vulvar biopsy.
- If clinical doubt about the diagnosis exists, perform a biopsy.
- The base of the lesion is injected with 1% lidocaine.
- A biopsy can be performed easily with an alligator mouth biopsy forceps.
- Silver nitrate applied to the base of the biopsy site controls any
bleeding.
- Rarely, a suture is required to obtain hemostasis.
Histologic Findings: Biopsy of the vulvar skin associated
with condyloma shows evidence of hyperkeratosis, acanthosis, and parakeratosis.
A chronic inflammatory infiltrate often is observed within the dermis.
Koilocytosis, which is perinuclear cytoplasmic halos, commonly is observed in
the superficial epithelial cells. Other microscopic findings include basilar
hyperplasia with binucleated and multinucleated cells and enlarged parabasal
cells with a foamy nuclear chromatin.
Staging: No staging system exists for condyloma acuminata.
|
TREATMENT |
ˇ@ |
Medical Care: A variety of medical
treatments exists for condyloma acuminata, and no single treatment regimen is
superior.
- The treatment strategy is to eliminate as many of the visible lesions as
possible until the host immune system can control viral replication.
- Because most HPV infections spontaneously regress when the immune system
controls viral replication, the need to treat subclinical or mild disease is
controversial.
- Treatment usually is reserved for patients with visible vulvar condyloma.
- The type of treatment is influenced by previous therapies, sexual
behavior, immune status, and the patient's willingness to comply with therapy.
- Patients who are HIV positive or immunosuppressed due to immunosuppressive
drugs usually require more than one treatment method. Often, the condyloma in
these patients is refractory to therapy.
- Regardless of the mode of therapy chosen, recurrence rates are high for
any patient with condyloma acuminata. This can result in a high level of
frustration for the patient and the physician.
ˇ@
- For most patients, medical therapy should be the first option. These
different medical treatment modalities can by performed in the physician's
office or at home. Morbidity is low. Surgery should be reserved to treat
condyloma resistant to medical therapy. Most patients should not need surgical
therapy unless the condylomatous lesions are too large to treat medically or
if the lesions would interfere with an abdominal delivery.
Surgical Care: Surgical treatment of condyloma acuminata
usually is reserved for patients in whom local therapy has failed. Several
options are available, including local excision, laser therapy, cryotherapy, and
electrosurgical excision.
- Simple excision
ˇ@
- Simple excision usually is performed in an outpatient surgical suite.
ˇ@
- After general or regional anesthesia is administered, the individual
lesions are removed with a knife.
ˇ@
- This procedure is reserved for refractory cases or extensive disease.
ˇ@
- Reports in the literature indicate that within one year of surgery,
complete wart clearance occurs in 35-72% of individuals treated with
surgical excision. One report found surgical excision as effective as laser
surgery (Duus, 1985).
ˇ@
- Patients with a few small lesions can have vulvar condyloma removed in the
office. The underlying skin should be anesthetized with 1% Xylocaine and the
condyloma removed with a #15 knife blade. One or 2 sutures may be needed to
reapproximate the healthy skin.
- Carbon-dioxide laser therapy (Duus, 1985; Reid, 1992)
ˇ@
- Laser treatment of vulvar condyloma acuminata effectively destroys the
condyloma while sparing adjacent healthy tissue.
ˇ@
- This procedure is performed in outpatient surgery with general or
regional anesthesia.
ˇ@
- The amount of energy needed to remove a condylomatous lesion with the
laser will depend on parameters controlled by the surgeon. These parameters
include the setting of the machine in watts, the length of time the beam is
fired, and the spot size on the tissue. Some researchers calculate the power
density, which equals the power (watts)/area (cm2). No exact
power density is needed to remove vulvar or vaginal condyloma. The surgeon
needs to be flexible in the application of the laser for each patient. If
the laser is calibrated to 20 watts, continuous mode, the spot size can be
adjusted easily to provide the proper power density (Lopow, 1986).
ˇ@
- Most patients experience significant discomfort beginning 24 hours after
surgery and require narcotic analgesia.
ˇ@
- Laser therapy should be reserved for recalcitrant cases of condyloma or
extensive disease.
ˇ@
- Complete wart clearance after laser surgery has been reported to occur
in 23-52% of patients within 3 years of surgery.
ˇ@
- The recurrence rates are similar to surgical excision.
- Electrosurgery (Simmons, 1981)
ˇ@
- For isolated lesions unresponsive to topical therapy, electrosurgical
techniques can be performed in the office with local anesthesia.
ˇ@
- The most popular method is to use a loop electrode that removes the
lesion(s).
ˇ@
- Pain after surgery is common and can be treated with narcotic
analgesics. Topical analgesics, such as lidocaine jelly, can be beneficial
to some patients.
ˇ@
- A recurrence rate in one trial was 22% compared to 44% for podophyllin
resin.
- Cryotherapy (Godley, 1987)
- Cryotherapy should be limited to small lesions that can be treated with
small cryoprobes.
- Data from several clinical trials report a 63-88% clearance 3 months
after therapy.
- The recurrence rate of 22% is similar to electrosurgery.
- This therapy is safe to use in pregnancy.
- The primary drawbacks are discomfort, ulceration, or scabbing at the
treatment site.
Activity:
- The patient should refrain from sexual contact after any surgical
procedure for condyloma acuminata.
- Soaking the genital area in warm water or sitz baths usually offers
excellent pain relief.
- The genital area should be dried gently with a towel or a hair dryer.
- Loose fitting cotton underwear is helpful to avoid chafing.
- No other activity restrictions exist, although patients often have trouble
sitting for long periods of time in the first week after surgery.
- Patients who have condyloma removed from the periurethral area may
experience dysuria. Sitz baths and topical analgesics are beneficial.
|
MEDICATION |
ˇ@ |
No one superior treatment exists for condyloma
acuminata (Auborn, 2000). Simple topical therapies are the initial treatments of
choice for most patients. They are cost-effective and result in minimal
toxicities. Most result in a 30-90% success rate in eliminating visible
condyloma; however, many clinical studies using topical therapies are not well
designed, making comparisons between therapies difficult.
ˇ@
Drug Category: Antimitotics -- Arrests
dividing cells in mitosis, resulting in death of proliferating cells.
Drug Name
ˇ@ |
Podophyllin (Podocon-25, Podofin) --
Treatment results in necrosis of visible wart tissue. Exact mechanism of
action is unknown. Great variability exists in the potency of podophyllin
between batches. American podophyllum contains one-fourth the amount of the
Indian source. Warts visible after 6 treatments usually do not respond to
further therapy (Hellberg, 1995). |
Adult Dose |
Apply concentration of 25% sparingly
onto lesions; wash treatment area 4 h after application; repeat q1-2wk until
eliminated |
Pediatric Dose |
Apply as in adults |
Contraindications |
Documented hypersensitivity; diabetes;
impaired peripheral circulation; avoid use on mucous membranes, eyes,
bleeding warts, moles, birthmarks, or unusual warts with hair |
Interactions |
None reported |
Pregnancy |
X - Contraindicated in pregnancy |
Precautions |
Powerful caustic and severe irritant;
do not use if surrounding tissue is swollen or irritated; do not use large
amounts; avoid contact with cornea; should be applied by a physician or
trained nurse; redness or burning of the skin can occur 6-24 h after
treatment |
Drug Name
ˇ@ |
Podofilox (Condylox) -- Topical
antimitotic that can be synthesized chemically or purified from plant
families Coniferae and Berberidaceae (eg, species of Juniperus and
Podophyllum).
Active agent of podophyllin resin and is available as a 0.5% solution. Can
apply solution to warts at home.
|
Adult Dose |
Apply 0.5% solution to warts bid for 3
d; repeat qwk for up to 4 wk |
Pediatric Dose |
Apply as in adults |
Contraindications |
Documented hypersensitivity |
Interactions |
None reported |
Pregnancy |
C - Safety for use during pregnancy has
not been established. |
Precautions |
Avoid contact with eyes; if eye contact
occurs, immediately flush eye with copious quantities of water and seek
medical advice; not for use on mucous membranes of genital area, including
urethra, rectum, and vagina; do not exceed frequency of application or
duration of usage |
Drug Category: Antineoplastic agents --
Topical preparation containing the fluorinated pyrimidine, 5-fluorouracil.
Antineoplastic and antimetabolite agent.
Drug Name
ˇ@ |
Fluorouracil (Efudex) -- Interferes
with DNA synthesis by blocking methylation of deoxyuridylic acid, inhibiting
thymidylate synthetase and, subsequently, cell proliferation. Limited data
exist concerning the efficacy of this therapy for genital warts. Three case
series indicate wart clearance in 10-50% of participants (Krebs, 1990).
Experimental treatments injecting 5-FU with epinephrine and bovine collagen
currently are in trials. |
Adult Dose |
Apply 5% solution to warts 1-3 times
per wk; wash off after 8 h |
Pediatric Dose |
Not established |
Contraindications |
Documented hypersensitivity;
potentially serious infections |
Interactions |
None reported |
Pregnancy |
X - Contraindicated in pregnancy |
Precautions |
Incidence of inflammatory reactions may
occur with occlusive dressings; porous gauze dressing may be applied for
cosmetic reasons without increase in reaction; adjacent healthy skin around
warts should be coated with a protective gel before application;
reproductive age group should use adequate contraception during therapy |
Drug Category: Desiccants -- These are acids
that are most effective when applied to moist warts. They are nontoxic and can
be used in pregnancy.
Drug Name
ˇ@ |
Trichloroacetic acid (Tri-Chlor) --
Cauterizes skin, keratin, and other tissues. Although caustic, causes less
local irritation and systemic toxicity than others in the same class;
however, response often is incomplete and recurrence occurs frequently
(Abdullah, 1993). |
Adult Dose |
Apply 50-85% solution to warts q1-2wk
in physician's office; wash off after 4-6 h |
Pediatric Dose |
Administer as in adults |
Contraindications |
Documented hypersensitivity; not for
use on premalignant or malignant lesions |
Interactions |
None reported |
Pregnancy |
C - Safety for use during pregnancy has
not been established. |
Precautions |
External use only; restrict use to
treatment areas only; skin adjacent to warts needs to be protected; severe
burning may occur |
Drug Category: Immune response modifiers --
Stimulates production of cytokines and has demonstrated strong antiviral
activity.
Drug Name
ˇ@ |
Imiquimod (Aldara) -- Induces secretion
of interferon alpha and other cytokines. Mechanism of action unknown
(Edwards, 1998). |
Adult Dose |
Apply 5% cream 3 times per wk hs; leave
on skin for 6-10 h; treatment period not to exceed 16 wk |
Pediatric Dose |
Administer as in adults |
Contraindications |
Documented hypersensitivity |
Interactions |
None reported |
Pregnancy |
B - Usually safe but benefits must
outweigh the risks. |
Precautions |
Not recommended for treatment of
rectal, cervical, intravaginal, urethral, and intra-anal human papilloma
infection; following surgery or drug treatment, do not use topical imiquimod
until genital/perianal tissue is healed; local skin erythema, erosion, or
abrasion can occur |
Drug Name
ˇ@ |
Interferon alfa 2b (Intron) --
Interferons have been used in the United States for the treatment of genital
warts in various doses and preparations. Topical, intralesional, and
systemic therapy have been used. Currently, no convincing evidence suggests
that topical or systemic therapy is better than placebo (Eron, 1986;
Monsonego, 1996; Welander, 1990; Bornstein, 1997). |
Adult Dose |
1 million U per lesion administered
directly into the wart 3 times per wk for 3 wk; no more than 5 warts should
be treated at once |
Pediatric Dose |
Administer as in adults |
Contraindications |
Documented hypersensitivity |
Interactions |
Theophylline may increase toxicity;
cimetidine may increase antitumor effects; zidovudine and vinblastine may
increase toxicity |
Pregnancy |
C - Safety for use during pregnancy has
not been established. |
Precautions |
Depression and suicidal ideation may be
adverse effects of treatment; flulike symptoms (eg, fever, dizziness,
malaise, myalgia, headache) may occur |
|
FOLLOW-UP |
ˇ@ |
Further Outpatient Care:
ˇ@
- Patients who complete therapy for condyloma acuminata should have a
clinical examination 3 months and 6 months after treatment.
- Most patients who develop recurrent or persistent disease are diagnosed
within 6 months of therapy.
- If the patient appears disease free at the 6-month visit, yearly visits
are recommended.
- The sexual partner(s) of a woman with condyloma should be examined by a
physician and treated if indicated. Often the examination of the male fails to
reveal any visible condyloma.
Deterrence/Prevention:
ˇ@
- Because genital warts are sexually transmitted, the risk of acquiring HPV
primarily is dependent on several factors related to sexual activity.
- These factors include the number of sexual partners, frequency of sexual
intercourse, and the presence of genital warts on the sexual partners.
- Latex condoms offer some, but not complete, protection in the
transmission of HPV.
- Women should avoid skin-to-skin contact with partners if genital warts
are visible.
Complications:
ˇ@
- The major complication from exposure of the vulva, vagina, or cervix to
HPV is the development of dysplasia.
- Patients who develop condyloma acuminata usually have been exposed to
low-risk HPV types such as HPV-6 and HPV-11. These HPV infections are
associated with mild dysplasia that often is transient in nature.
- Many patients with mild dysplasia of the vulva, vagina, or cervix
experience spontaneous regression of these lesions.
- Patients who are exposed to high-risk HPV types, such as HPV-16 or HPV-18,
are at risk for developing high-grade dysplasias or carcinomas. The
development of cancer occurs in a small percentage of these patients who do
not have therapy for dysplasia.
Prognosis:
ˇ@
- The prognosis of immunocompetent women diagnosed with condyloma acuminata
is excellent.
- HPV infections are transient in the vast majority of these women.
- Unless the woman constantly is exposed to different HPV types, the
infection eventually abates when the host immune system stops viral
replication.
- Women who are immunocompromised due to immunosuppressive drugs or HIV
infection are at higher risk of developing persistent disease. These women
have a higher incidence of developing dysplasia of the vulva, vagina, or
cervix.
Patient Education:
ˇ@
- Inform patients that genital HPV is a sexually transmitted disease.
- The only way to prevent HPV infection is to avoid direct contact with
the virus, which is transmitted by skin-to-skin contact.
- If the sexual partner has visible genital warts, sexual contact should
be avoided until treatment is completed.
- Latex condoms offer some, but not complete, protection from
transmission.
- Condoms should be used with vaginal, anal, or oral sex, because the
virus may be found in the semen in the absence of visible warts.
|
MISCELLANEOUS |
ˇ@ |
Medical/Legal Pitfalls:
ˇ@
- Patients who appear to have classic condyloma acuminata and do not respond
to therapy should have a biopsy of one of the lesions. This will avoid
continued treatment of lesions that are not HPV-related.
- Postmenopausal women who present with condyloma-appearing lesions should
have a biopsy before initiation of therapy. These women have a greater chance
of having vulvar dysplasia or vulvar cancer than younger women.
Special Concerns:
ˇ@
- Many investigators report higher rates of HPV infections in pregnant
women. If condyloma develops, rapid growth can be observed. Factors
responsible include suppression of immunity during pregnancy and hormonal
changes (Meisels, 1992).
- Small asymptomatic lesions do not need to be treated. Larger lesions can
be treated with bitrichloroacetic acid or cryotherapy (Bergman, 1984).
Occasionally, condyloma in pregnant women becomes large and macerated,
requiring surgical excision after the first trimester. Interferon, podophyllin,
and 5-fluorouracil should not be used in pregnancy.
- Pregnant women with genital warts can transmit the virus to the newborn.
- Infants can develop laryngeal papillomatosis in the first 5 years of
life.
- The method of transmission is unknown.
- Approximately 60% of mothers with infants with laryngeal papillomatosis
report having genital warts.
- Based on the frequency of HPV infection in this country, approximately
5% of all births are at risk for neonatal HPV exposure.
- The frequency of childhood laryngeal papillomatosis is extremely low,
approximately 2000 cases per year in the United States. This would imply the
transmission rate from mother to infant is low and does not warrant
recommending a cesarean delivery for prevention of laryngeal papillomatosis.
If the mother has huge condyloma that interferes with labor or delivery, a
cesarean delivery may be needed.
|
BIBLIOGRAPHY |
ˇ@ |
- Abdullah AN, Walzman M, Wade A: Treatment of external genital warts
comparing cryotherapy (liquid nitrogen) and trichloroacetic acid. Sex Transm
Dis 1993 Nov-Dec; 20(6): 344-5[Medline].
- Auborn KJ, Carter TH: Treatment of human papillomavirus gynecologic
infections. Clin Lab Med 2000 Jun; 20(2): 407-22[Medline].
- Becker TM, Stone KM, Alexander ER: Genital human papillomavirus infection.
A growing concern. Obstet Gynecol Clin North Am 1987 Jun; 14(2): 389-96[Medline].
- Bergman A, Bhatia NN, Broen EM: Cryotherapy for treatment of genital
condylomata during pregnancy. J Reprod Med 1984 Jul; 29(7): 432-5[Medline].
- Bornstein J, Pascal B, Zarfati D: Recombinant human interferon-beta for
condylomata acuminata: a randomized, double-blind, placebo-controlled study of
intralesional therapy. Int J STD AIDS 1997 Oct; 8(10): 614-21[Medline].
- Bosch FX, Manos MM, Munoz N: Prevalence of human papillomavirus in
cervical cancer: a worldwide perspective. International biological study on
cervical cancer (IBSCC) Study Group. J Natl Cancer Inst 1995 Jun 7; 87(11):
796-802[Medline].
- Burk RD, Ho GY, Beardsley L: Sexual behavior and partner characteristics
are the predominant risk factors for genital human papillomavirus infection in
young women. J Infect Dis 1996 Oct; 174(4): 679-89[Medline].
- Ciuffo G: Imnesto positiv con filtrado di verrucae volgare. Giorn Ital Mal
Venereol 1907; 48: 12-17.
- Cox JT: Clinical role of HPV testing. Obstet Gynecol Clin North Am 1996
Dec; 23(4): 811-51[Medline].
- Cuzick J, Sasieni P, Davies P: A systematic review of the role of human
papilloma virus (HPV) testing within a cervical screening programme: summary
and conclusions. Br J Cancer 2000 Sep; 83(5): 561-5[Medline].
- Davis AJ, Emans SJ: Human papilloma virus infection in the pediatric and
adolescent patient. J Pediatr 1989 Jul; 115(1): 1-9[Medline].
- Dreicer R, Love RR: High total dose 5-fluorouracil treatment during
pregnancy. Wis Med J 1991 Oct; 90(10): 582-3[Medline].
- Duus BR, Philipsen T, Christensen JD: Refractory condylomata acuminata: a
controlled clinical trial of carbon dioxide laser versus conventional surgical
treatment. Genitourin Med 1985 Feb; 61(1): 59-61[Medline].
- Edwards L, Ferenczy A, Eron L: Self-administered topical 5% imiquimod
cream for external anogenital warts. HPV Study Group. Human PapillomaVirus.
Arch Dermatol 1998 Jan; 134(1): 25-30[Medline].
- Eron LJ, Judson F, Tucker S: Interferon therapy for condylomata acuminata.
N Engl J Med 1986 Oct 23; 315(17): 1059-64[Medline].
- Evander M, Edlund K, Gustafsson A: Human papillomavirus infection is
transient in young women: a population-based cohort study. J Infect Dis 1995
Apr; 171(4): 1026-30[Medline].
- Figueroa JP, Ward E, Luthi TE: Prevalence of human papillomavirus among
STD clinic attenders in Jamaica: association of younger age and increased
sexual activity. Sex Transm Dis 1995 Mar-Apr; 22(2): 114-8[Medline].
- Gissmann L, zur Hausen H: Partial characterization of viral DNA from human
genital warts (Condylomata acuminata). Int J Cancer 1980 May 15; 25(5): 605-9[Medline].
- Godley MJ, Bradbeer CS, Gellan M: Cryotherapy compared with
trichloroacetic acid in treating genital warts. Genitourin Med 1987 Dec;
63(6): 390-2[Medline].
- Goodman A: Role of routine human papillomavirus subtyping in cervical
screening. Curr Opin Obstet Gynecol 2000 Feb; 12(1): 11-4[Medline].
- Hellberg D, Svarrer T, Nilsson S: Self-treatment of female external
genital warts with 0.5% podophyllotoxin cream (Condyline) vs weekly
applications of 20% podophyllin solution. Int J STD AIDS 1995 Jul-Aug; 6(4):
257-61[Medline].
- Hippelainen M, Syrjanen S, Hippelainen M: Prevalence and risk factors of
genital human papillomavirus (HPV) infections in healthy males: a study on
Finnish conscripts. Sex Transm Dis 1993 Nov-Dec; 20(6): 321-8[Medline].
- Ho GY, Bierman R, Beardsley L: Natural history of cervicovaginal
papillomavirus infection in young women. N Engl J Med 1998 Feb 12; 338(7):
423-8[Medline].
- Kaufman RH, Adam E: Is human papillomavirus testing of value in clinical
practice? Am J Obstet Gynecol 1999 May; 180(5): 1049-53[Medline].
- Kjaer SK, Svare EI, Worm AM: Human papillomavirus infection in Danish
female sex workers. Decreasing prevalence with age despite continuously high
sexual activity. Sex Transm Dis 2000 Sep; 27(8): 438-45[Medline].
- Koutsky L: Epidemiology of genital human papillomavirus infection. Am J
Med 1997 May 5; 102(5A): 3-8[Medline].
- Koutsky LA, Galloway DA, Holmes KK: Epidemiology of genital human
papillomavirus infection. Epidemiol Rev 1988; 10: 122-63[Medline].
- Krebs HB: Treatment of extensive vulvar condylomata acuminata with topical
5- fluorouracil. South Med J 1990 Jul; 83(7): 761-4[Medline].
- Lipow M: Laser Physics Made Simple. Current Problems in Obstetrics,
Gynecology and Fertility 1986; 9: 445-493.
- Meisels A: Cytologic diagnosis of human papillomavirus. Influence of age
and pregnancy stage. Acta Cytol 1992 Jul-Aug; 36(4): 480-2[Medline].
- Monsonego J, Cessot G, Ince SE: Randomised double-blind trial of
recombinant interferon-beta for condyloma acuminatum. Genitourin Med 1996 Apr;
72(2): 111-4[Medline].
- Nuovo GJ: Detection of human papillomavirus DNA in the lower genital
tract. Infections in Urology 1994; 87-93.
- Peng TC, Searle CP 3rd, Shah KV: Prevalence of human papillomavirus
infections in term pregnancy. Am J Perinatol 1990 Apr; 7(2): 189-92[Medline].
- Rando RF, Lindheim S, Hasty L: Increased frequency of detection of human
papillomavirus deoxyribonucleic acid in exfoliated cervical cells during
pregnancy. Am J Obstet Gynecol 1989 Jul; 161(1): 50-5[Medline].
- Reid R, Greenberg MD, Pizzuti DJ: Superficial laser vulvectomy. V.
Surgical debulking is enhanced by adjuvant systemic interferon. Am J Obstet
Gynecol 1992 Mar; 166(3): 815-20[Medline].
- Schneider A, Hotz M, Gissmann L: Increased prevalence of human
papillomaviruses in the lower genital tract of pregnant women. Int J Cancer
1987 Aug 15; 40(2): 198-201[Medline].
- Shah K, Kashima H, Polk BF: Rarity of cesarean delivery in cases of
juvenile-onset respiratory papillomatosis. Obstet Gynecol 1986 Dec; 68(6):
795-9[Medline].
- Shelton TB, Jerkins GR, Noe HN: Condylomata acuminata in the pediatric
patient. J Urol 1986 Mar; 135(3): 548-9[Medline].
- Simmons PD, Langlet F, Thin RN: Cryotherapy versus electrocautery in the
treatment of genital warts. Br J Vener Dis 1981 Aug; 57(4): 273-4[Medline].
- Stone KM, Becker TM, Hadgu A: Treatment of external genital warts: a
randomised clinical trial comparing podophyllin, cryotherapy, and
electrodesiccation. Genitourin Med 1990 Feb; 66(1): 16-9[Medline].
- Syrjanen K, Syrjanen S: Epidemiology of human papilloma virus infections
and genital neoplasia. Scand J Infect Dis Suppl 1990; 69: 7-17[Medline].
- Van Le L, Pizzuti DJ, Greenberg M: Accidental use of low-dose
5-fluorouracil in pregnancy. J Reprod Med 1991 Dec; 36(12): 872-4[Medline].
- Welander CE, Homesley HD, Smiles KA: Intralesional interferon alfa-2b for
the treatment of genital warts. Am J Obstet Gynecol 1990 Feb; 162(2): 348-54[Medline].
- zur Hansen H: Condyloma acuminata and human genital cancer. Cancer Res
1976; 36: 530.