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GENITAL GROWTHS
The last STD syndrome complex discussed in this presentation are growths. These include human papilloma virus infections, condylomata lata and molluscum contagiosum.
HPV
Human papilloma virus infections may be the most common sexually transmitted infection in adolescents. There have been over 100 serotypes of HPV identified. Types 6 and 11 are most commonly associated with benign papillary, acuminate and flat condylomas while types 16, 18, 31,33, 35, 52, 55 have been associated both with condylomas, and intraepithelial neoplasias. Type 16 and 18 are found in 80% of individuals with cervical cancer. However, it is critical to be aware that the converse is NOT true. Most individuals with any type of HPV infection do not go on to develop cervical cancer. Below are typical external genital warts. These lesions have been covered with podophyllin.
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The prevalence of HPV infection detected through the use of polymerase chain reaction detection methods varies from 1.5% among those who have never been sexually active to 46% among sexually active women in college.
Transmission of HPV is primarily through sexual contact but not exclusively. External genital condylomata may be contracted by autoinoculation or inoculation with HPV DNA from skin warts and from viral exposure during delivery. HPV types that cause skin warts are transmissible by fomites but it is not known whether fomites represent an important source of transmission of genital HPV.
Lesions first appear about 3 months after infection but the incubation period can vary from 3 weeks to 8 months and there may be even a much longer latency period. The risk of infection increases with the number of sexual partners increasing in one study of university students from 3% with 0 partners to 5% with one partner to 31% with 2-4 partners to 52% with five lifetime partners.
The differential diagnosis includes:
- Micropapillomatosis labialis of labia minora : These lesions have separate bases that do not converge as do the papillae of condylomata acuminata
- Condylomata lata: The lesions of secondary syphilis were seen previously ( go to stis - ulcers ). These usually have a positive dark-field examination and are associated with positive serologic testing.
- Molluscum contagiosum : These are dome-shaped globular lesions as seen below with central umbilication that contains an expressible cheesy material. These lesions are caused by a Poxvirus. They are frequently seen in younger children but not contacted through sexual transmission. The lesions can be treated by opening the lesion with a needle and expressing the material inside. Treatment with trichoracetic acid following opening of the lesion can also be done.
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click for full-size image
- Seborrheic keratosis
- Benign neoplasias including fibromas, lipomas, hidradenomas, and adenomas
- Pink pearly penile papules (in males): These are normal lesions of the penis that appear as parallel rows of lesions at the corona of the penis that demonstrate hypertrophic papillae histologically. They are found in about 15% of the male population. An example is seen below:
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Diagnosis
Most warts can be diagnosed by clinical inspection. A bright light and magnifying glass may assist in the diagnosis. Speculum exam is mandatory for all women with external genital warts. Men and women with recurrent perianal warts and/or a history of anoreceptive intercourse should undergo anocopsy.
Treatment
Treatment of HPV infections can be a complicated issue. A significant part of curing the infection involves an intact immune system. The major goal of treating external warts is the removal of symptomatic warts. It is not clear whether treatment alters the natural history of the infection or whether it reduces the infectivity of the individual. Treatment may render the individual wart free but virus may persist in surrounding normal appearing tissue. Treatment guidelines are outlined in the CDC STD guidelines but include
- Patient applied: imiquimod, podofilox 0.5% solution
- Clinician applied: Liquid nitrogen, topical chemotherpies (tricholoracetic acid, bichloroacetic acid, podophyllin and surgery.
Treatment of vaginal warts, urethral warts and anal warts can be more complicated and should be seen by an expert in this area.
A major issue with HPV infections is the development of cervical dysplastic lesions. As previously discussed, a high number of sexually active women have HPV infections detected by DNA amplification methods. However, the majority are asymptomatic and most infections resolve spontaneously. Even in those teens that develop abnormal Pap smears, the majority of lesions are low-grade squamous intraepithelial lesions (LSIL) and most of these resolve over time. Certain women are at higher risk if they have the HPV types discussed above, particularly types 16 and 18. Criteria for the use of Pap smears, thin prep testing and DNA amplification testing are still in evolution.
Involvement of other areas than external genitalia with HPV infections are demonstrated in these slides:
The first are intravaginal warts
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The next two demonstrate a HPV infection of the cervix. The first is before the use of acetic acid (vinegar) and the second is after the application of vinegar.
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click for full-size image
The bottom slide shows acetowhite areas that are very indicative of HPV infection and cervical dysplasia.
