Introduction:

In today's world of increasing awareness about sexual health, it's crucial to understand the risks associated with sexually transmitted infections (STIs) and the preventive measures available. Among these, genital warts and the human papillomavirus (HPV) stand out due to their prevalence and the availability of a highly effective vaccine.1

Genital warts are a common sexually transmitted infection that manifests as soft growths on the genital areas. These warts are caused by certain strains of the human papillomavirus (HPV), making them one of the most frequently encountered STIs worldwide.1

Appearance and location:

Genital warts can vary in appearance, but they often share some common characteristics:

They are typically flesh-coloured or slightly darker.

Their texture can be soft and sometimes resembles a cauliflower shape.

Warts can be flat or raised, appearing as a single growth or in clusters.

The size of genital warts can range from barely visible to several centimetres in diameter.1

These warts commonly occur in areas that are exposed during sexual contact. In women, they may appear on the vulva, vagina, cervix, or around the anus. In men, genital warts often develop on the penis, scrotum, or around the anus. It's important to note that genital warts can also appear in the mouth or throat of individuals who have had oral sexual contact with an infected partner.1

Symptoms:

One of the challenges in identifying genital warts is that they often don't cause any noticeable symptoms. When symptoms do occur, they may include:

Discomfort or mild pain in the affected area

Itching or irritation

Bleeding, especially during intercourse 1

It's worth noting that many people with genital warts may not realise they have them, especially if the warts are small or located internally. This underscores the importance of regular sexual health check-ups, particularly for sexually active individuals.1

What is HPV?

To fully understand genital warts, it's essential to delve into the virus that causes them: the Human Papillomavirus (HPV). HPV is not a single virus but a group of more than 200 related viruses. These viruses are categorised based on the types of tissue they affect and their potential to cause serious health problems.2

Transmission

HPV is primarily spread through direct skin-to-skin contact during sexual activity. This includes vaginal, anal, and oral sex. It's important to understand that HPV can be transmitted even when the infected individual has no visible signs or symptoms. This ease of transmission contributes to the high prevalence of HPV infections worldwide.2

HPV types

The numerous types of HPV are generally classified into two categories:

Low-risk HPV types: These include HPV types 6 and 11, which are responsible for about 90% of genital warts cases. While these types can cause discomfort and emotional distress, they are not associated with cancer.

High-risk HPV types: These include HPV types 16 and 18, among others. These types are associated with various cancers, including cervical, anal, penile, and oropharyngeal cancers. It's estimated that HPV 16 and 18 alone are responsible for about 70% of cervical cancer cases worldwide.2

Understanding the distinction between these HPV types is crucial, as it informs both prevention strategies and the potential health risks associated with HPV infection.

Prevention of genital warts

Given the prevalence and potential health impacts of HPV infections, prevention is a key focus in public health strategies. The most effective tool in preventing genital warts and HPV-related cancers is the HPV vaccine.3

The HPV Vaccine

The development of the HPV vaccine represents a significant breakthrough in preventive medicine. These vaccines work by stimulating the body's immune system to produce antibodies that target specific types of HPV, preventing infection if the individual is exposed to the virus in the future.3

Types of HPV Vaccines

There are currently three HPV vaccines available:

Gardasil 9: This is the most comprehensive HPV vaccine available. It protects against nine types of HPV, including those responsible for most genital warts (types 6 and 11) and several high-risk types associated with cancers (including types 16 and 18).

Gardasil: An earlier version that protects against four HPV types, including those causing most genital warts and some cancers.

Cervix: This vaccine focuses on two high-risk HPV types (16 and 18) associated with cervical cancer. It does not protect against the types that cause genital warts.3

Effectiveness

The HPV vaccine is most effective when administered before an individual becomes sexually active. This is because the vaccine prevents new HPV infections but does not treat existing ones. Studies have shown that the vaccine can prevent over 90% of cancers caused by HPV when given at the recommended age.3

Who Should Get the HPV Vaccine?

The recommendations for HPV vaccination have evolved as more research has become available. Current guidelines suggest a broad approach to ensure maximum protection across the population.3

Age recommendations

Children: The CDC recommends that both boys and girls receive the HPV vaccine, typically starting at ages 11-12. However, the vaccine can be given as early as age 9.

Catch-up vaccination: For those who did not receive the vaccine at the recommended age, catch-up vaccination is recommended up to age 26.

Adults: Some adults aged 27-45 may benefit from HPV vaccination. The decision to vaccinate in this age group should be made in consultation with a healthcare provider, considering individual risk factors and potential benefits.3

Diagnosis and treatment of genital warts

Despite preventive measures, some individuals may develop genital warts. Understanding the diagnosis and treatment options is crucial for managing this condition effectively.4

Diagnosis

Diagnosing genital warts typically involves the following methods:

Physical examination: In many cases, a healthcare provider can diagnose genital warts through a visual inspection of the affected area.

Pap smear: For women, a routine Pap smear can detect changes in the cervix that might be caused by HPV infection.

HPV test: This test can detect the presence of high-risk HPV types in cervical cells. It's often used in conjunction with a Pap smear, especially for women over 30 or those with abnormal Pap results.4

Treatment Options

While there's no cure for the HPV virus itself, there are several treatment options available for genital warts:

1. Topical Medications:

Imiquimod cream: This medication boosts the immune system's ability to fight HPV.

Podophyllin and podofilox: These work by destroying the tissue of the wart.

Sinecatechins: A green tea extract that has shown effectiveness in treating genital warts.

1. Procedures:

Cryotherapy: Freezing off the warts using liquid nitrogen.

Surgical removal: Cutting away the warts under local anaesthesia.

Laser treatment: Using an intense beam of light to destroy the wart tissue.

1. Electrocautery:

Burning off the wart with an electrical current.4

Being diagnosed with genital warts can have significant emotional and psychological impacts. It's crucial to address these aspects alongside the physical treatment of the condition.4

Conclusion

The HPV vaccine represents the most effective tool in preventing genital warts and HPV-related cancers. Early vaccination, ideally before becoming sexually active, offers the best protection. For those who are sexually active, regular sexual health check-ups and screenings (such as Pap smears for women) are essential for early detection and management of HPV-related conditions. While there's no cure for HPV itself, there are effective treatments available for genital warts. However, recurrence is possible, emphasising the importance of ongoing monitoring and care. Managing genital warts involves addressing both the physical symptoms and the emotional impact of the diagnosis. Support from healthcare providers and loved ones is crucial in this process.4 In conclusion, while genital warts and HPV infections pose significant public health challenges, the availability of effective vaccines and treatments offers hope. By promoting vaccination, regular screening, and open dialogue about sexual health, we can work towards reducing the impact of these conditions on individuals and communities.4

References:

Malheiro R, Magalhães C, Dias CC, Rodrigues AG, Lisboa C. Genital Warts in Women Vaccinated against HPV in Childhood: A Systematic Review. Vaccines [Internet]. 2024 [cited 2025 Feb 13]; 12(5):548. https://pubmed.ncbi.nlm.nih.gov/38793799/

Nygård S, Nygård M, Orumaa M, Hansen BT. Quadrivalent HPV vaccine effectiveness against anogenital warts: A registry-based study of 2,2 million individuals. Vaccine [Internet]. 2023 [cited 2025 Feb 13]; 41(37):5469–76. https://pubmed.ncbi.nlm.nih.gov/37516572/

Herzum A, Ciccarese G, Occella C, Gariazzo L, Pastorino C, Trave I, et al. Treatment of Pediatric Anogenital Warts in the Era of HPV-Vaccine: A Literature Review. JCM [Internet]. 2023 [cited 2025 Feb 13]; 12(13):4230. https://pubmed.ncbi.nlm.nih.gov/37445264/

Muñoz-Quiles C, López-Lacort M, Díez-Domingo J, Rodrigo-Casares V, Orrico-Sánchez A. Human papillomavirus vaccines effectiveness to prevent genital warts: A population-based study using health system integrated databases, 2009–2017. Vaccine [Internet]. 2022 [cited 2025 Feb 13]; 40(2):316–24. https://pubmed.ncbi.nlm.nih.gov/34865874/