Condyloma – Genital wart

What is a condyloma (genital wart)?

It is a viral infection with the (human) papillomavirus (HPV) of the genital area. The virus infects the mucosa (mucosa) of the anal canal or the skin around the anus. It can reside in the skin or mucosa without showing symptoms or manifest itself as a wart (a condyloma) and in rarer cases as a precancerous lesion or even cancer.

It is very frequent!. It is the most common sexually transmitted disease (STD).

It can be transmitted vaginally, anally and orally.

More than 85% of sexually active adults become infected at some point during their lifetime, often without being aware of it. It is 100x more common than it is clinically apparent.

Preferred age 16 – 25 years.

Frequency increases with:

– Number of sexual partners

– Age of first sexual contact

– Smoking

– Long-term oral contraception

– Co-infection with other sexually transmitted diseases

(gonorrhea, syphilis, chlamydia)

It is a highly contagious virus.

It is transmitted in 60-70% of cases during a first sexual contact.

Women are infected more often than men.

For the virus to infect you, there must be micro-trauma of the mucosal membrane in which the virus resides. Therefore, anal sex, which is more traumatic, increases the risk of infection.

Apart from sexual contact, you can get infected by:

• Self-infection (by scratching, during toilet hygiene) Infection can occur from the vagina to the anus and vice versa
• During childbirth
• Indirectly through soiled objects/instruments or underwear

It is impossible to establish when the infection occurred. 3 to 12 months can elapse between infection and the appearance of condylomas. Sometimes the virus remains present for years without ever being noticed. The virus can probably disappear spontaneously as well.

– In most cases, there are no symptoms.

– Itching.

– Palpation of small vegetations (warts) in the skin.

– Bleeding due to trauma to the warts (rubbing, scratching)

After confirmation by a doctor:

• consideration should be given to the extent of the lesions. In 40% of cases, the lesions are multifocal.

– Penis, pubic bone, anus

• Lesions are not always present.
• 25 – 67% of lesions resolve spontaneously (2 years).

Conservative treatment

Imiquimod 3.75 – 5% (Aldara®)

Application

Apply imiquimod ointment to the affected area 3 times a week before bedtime. Examples application 3 times a week: Monday, Wednesday, Friday, or Tuesday, Thursday, Saturday. Apply a thin layer of ointment to the cleansed and dried skin and rub it in gently. Do not use the ointment in the vagina. Wash your hands after using the medicine. Do not apply a bandage that is airtight (no plastic bandages).

Leave the ointment on the skin for 6 to 10 hours and remove it afterwards by washing it off with mild soap and water. Continue applying the ointment until the warts have completely disappeared, don’t extend application longer than 16 weeks.

The treated spots should be washed with water and mild soap. This is especially important when treating lesions under the foreskin of uncircumcised men.

– Duration: 3 to 16 weeks

– Healing: 45 – 56%

– Recurrences: +/- 16%

– Side effects: local erosion of the skin, erythema, burning sensation

Podophyllotoxin (Condyline® 5 mg /ml)

Application

2 times a day, 3 days in a row. The product is applied with a cotton swab to the lesions afterwards followed by 4 days of rest.  Max 0.5 ml/day. To protect the skin around the lesions, petroleum jelly may be applied to the skin to prevent burns from skin contact with podophyllin.

– Duration: up to 5 weeks

– Healing: 50 – 80%

– Recurrence: 22%

– Side effects:

• Inflammation (redness, mild pain, swelling) in the treated area. These side effects are usually not serious, treatment should not usually be discontinued.
• Skin irritation with pain or redness and ulceration of the skin if the solution comes into contact with healthy skin.

– Contraindications for the use of Condyline®

• Children under the age of 15 years
• Pregnancy
• Breastfeeding

Contraception is necessary before and during treatment.

In case of accidental contact with the skin, mucous membranes and especially the eyes, they should be rinsed abundantly with water.

→ Condyloma removal by electrocoagulation – laser

See surgery : Condyloma removal by electrocoagulation – laser

What is the relationship between HPV and anal cancer?

Human papiloma virus (HPV) is responsible for 90% of anal cancers. The incidence of anal cancer is 1.8 per 100,000 population per year.

It is increasing by 2.4% per year.

The average age at diagnosis is 62 years.

• HIV male or female
• Chronic immunosuppression (after transplantation…)
• History of cancer or infectious lesions due to HPV (human papillomavirus)
• Homosexual
• Condyloma

Cancer of the anus can be prevented by vaccination and selective screening of those at risk.

Although infection is very frequent, these infections lead to very few cancers (incidence low) to justify screening of the whole population.

On the other hand, patients at increased risk of developing cancer deserve to be screened before they develop a cancer.

Before developing a cancer, patients develop premalignant lesions that can be treated in a less invasive and aggressive way. The time between the development of a premalignant lesion and its evolution into a cancer is estimated to be +/- 5 years.

There is no consensus in the medical community on how to screen the high-risk group.

HIV+ patients are at highest risk of developing cancer, therefore annual smear or anal canal screening is suggested.

For other high-risk groups, screening is suggested every 2-3 years.

There are +/- 200 different types of HPV.

Not all HPV types cause cancer (type 16, 18…) or condylomas (warts) (type 11, 6…).

The vaccines protect against the types causing cancer  and also against virus types that give rise to condylomas.

Preferably, the vaccine is administered before the first sexual contact.

There are 3 vaccines:

“Injection se fait dans le muscle (intra-musculaire IM). Il faut donner 3 doses à 0 – 2 – 6 mois, sauf en secondaire (école) de 9 à 15 ans, il faut seulement 2 injections 0 – 6 mois.”

– Cervarix (type 16 – 18 ) 

– Gardasil 4 (type 16- 18 – 11 – 6)

– Gardasil 9 (type 16 – 18 – 11 – 6  31 – 33 – 45 – 52)

• Free through school vaccination program in 2nd secondary (Wallonia-Brussels) 1st secondary (Flanders) or at a doctor of your choice.
• At your doctor’s office, partial reimbursement (€12.10/injection) for girls aged 12 to 18. Medical consultation is also partially reimbursed.

From the age of 19, girls can be vaccinated, but without reimbursement. It costs €69.14 for a 2-valent vaccine and €134.84 for a 9-valent vaccine.

• From the 2019-2020 school year: Free through school vaccination program in 2nd secondary (Wallonia-Brussels), 1st secondary (Flanders) or at a doctor of your choice.

• Outside the school vaccination, boys can be vaccinated but there is no reimbursement yet. It costs €69.14 for a 2-valent vaccine and €134.84 for a 9-valent vaccine.

Vaccination is indicated on a case-by-case basis up to the age of 45 years (CDC Centre for Disease Control).