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HPV and genital warts

This article was reviewed in March 2025.

Genital warts are a sexually transmitted condition which is actually on the decrease in this country!

The Gardasil effect

Prevalence of genital warts in the UK has fallen by 35% due to the vaccination programme.
In 2017, there were only 441 diagnoses of genital warts in 15–17-year-old girls. This represented a 90% reduction since 2009.
A decline of 70% was seen in same-aged heterosexual males even prior to extension of the vaccination scheme to boys, suggesting substantial herd protection.

Despite the reduction, genital warts remain the second commonest infection diagnosed in sexual health clinics (16% of diagnoses made) (PHE Health Protection Report 2018;12(20)).

Genital warts in primary care

Because of the connotations of HPV infection and a general fear of managing sexual infections in general practice, it is tempting to refer patients with genital warts to GUM.

However, some genital warts can be managed safely in primary care. The BASHH and RCGP have issued guidance, and this article is based on this (BASHH Guideline on the Management of Anogenital Warts 2024, RCGP STI in Primary Care, 2013).

What are genital warts?

Anogenital warts are benign epithelial skin tumours.

90% of anogenital warts are caused by HPV types 6 and 11 (which are not oncogenic). There are over 100 identified wart genotypes, and many people have subclinical disease or latent infection.

30–50% of sexually active adults have HPV genital infection, but less than 10% have visible lesions.

Mode of transmission is most commonly sexual but perinatal transmission can occur. Auto-transmission from hands has been reported, especially in children.

Incubation period is variable, generally 3w–8m, but may be up to 18m or longer. Some apparent new presentations will actually be recurrence – so appearance of warts does not indicate infidelity of a partner.

Location

Warts may be found in the:

Anogenital area.
Mouth.
Vagina.
Cervix.
Larynx.
Urethra.
Conjunctiva.
Nose.
Anal canal (perianal warts are not indicative of penetrative anal intercourse, but anal canal warts are).

Diagnosis

Clinical appearance is diagnostic. Lesions can be flat or raised, single or multiple, soft or keratotic, small or large ‘cauliflower’ lesions, flesh coloured or pigmented.

Warts are usually asymptomatic, but anal, vaginal and urethral lesions may bleed. Urethral lesions may distort urine flow.

Think about anogenital neoplasia if there is pigmentation, depigmentation, pruritus, underlying immune-deficiency, or prior history of intraepithelial neoplasia on the same or distant anogenital sites.

If diagnosis is in doubt, or appearance atypical – refer to GUM, or via urgent suspected cancer pathway, depending on our clinical judgement.

Investigations

Examine the entire external anogenital area and urethral meatus. If the lesions are atypical, consider referral for biopsy.

Offer STI screen if indicated.

Speculum examination is not necessary in all cases, but should be performed if there are warts visible at the introitus without a visible upper limit.

Management

Is possible in primary care! Treatment is cosmetic, not ‘curative’.

No treatment is an option because, in around 30% of patients, lesions can resolve spontaneously within 6m.

Choice of treatment depends on number, distribution and morphology of warts, as well as patient preference.

Previous partner notification is not necessary. Current partners may wish to attend for examination, STI screen and education about HPV disease.

General advice

Give patient information leaflet about condition (see BASHH patient information leaflet in the Useful resources box at the end of the article).
Wart treatments can give surrounding skin irritation.
Consistent condom use can reduce the risk of acquisition of HPV infection and genital warts by 30–60%.
Imiquimod may weaken latex condoms.
All treatments have significant failure and relapse rates. However, complete clearance usually occurs eventually.

Remember, the psychological effects of genital warts may be the worst aspect of the condition.

Treatment options

In primary care, we are most likely to be prescribing the self-applied treatments, podophyllotoxin and imiquimod. These have similar safety and efficacy, but podophyllotoxin is cheaper and has a faster action so may be our preferred first choice (BASHH Guideline on the Management of Anogenital Warts 2024).

Treatment	Indications/instructions
Cryotherapy: liquid nitrogen or cryoprobe	Causes cytolysis and local necrosis. Good options for keratinised warts or small numbers. Given at weekly intervals. Consider alternative if no response after 4w.
Antimitotics (podophyllotoxin)	Licensed for genital but not extra-genital (e.g. anal warts) or in pregnancy. Good for soft, non-keratinised warts. Comes as a cream (0.15% Warticon) and solution (0.5% Condyline). Creams are easier to apply. Suitable for self-administration (medical supervision recommended if lesion area is >4cm²). Apply twice daily for 3d followed by 4d break. If no improvement after 1m, try alternative.
Immune response modifier (imiquimod)	Not suitable for internal genital warts or in pregnancy. Comes as 5% cream (Aldara), and is more expensive than other treatment choices. Apply nightly for 3 nights a week (usually Mon/Wed/Fri) and then wash off each morning. Treat for up to 16w. Latex condoms may be weakened if in contact with Imiquimod. Immune deficiency, e.g. HIV, is not a contraindication.
Excision (under local anaesthetic)	Useful if pedunculated warts, or small warts at anatomically accessible sites.
Cataphen 10% ointment (green tea leaf extract) containing epigallocatechingallate	Licensed in 2015 for treatment of external anogenital warts in immunocompetent adults. Mechanism of action is unknown – likely causes local irritation. Apply 3x/d for up to 16w. Once open, must be discarded after 6w.

Other treatment modalities include trichloroacetic acid, 5-fluorouracil, interferon treatments, and laser and electrosurgical techniques. These are not commonly used or recommended as first-line options, so should be considered only in a specialist GUM clinic.

Treatment algorithm

This flowchart is based on the recent BASHH guidance and does not apply to pregnant women (refer them to GUM).

Internal warts

These may be vaginal, urethral, cervical or anal.

As with all warts, no treatment is an option. However, if the patient requests treatment, I would refer to GUM for their expertise and wider treatment options.

Wart location	Management options
Vaginal	Cryotherapy, electrosurgery, trichloroacetic acid.
Cervical	Colposcopy not indicated UNLESS there is diagnostic uncertainty. Cryotherapy, electrosurgery, trichloroacetic acid, laser ablation or excision.
Urethral meatus	Cryotherapy, electrotherapy, laser ablation, podophyllotoxin, imiquimod (off-licence). Lesions deeper in the urethra should be surgically ablated using direct vision/meatoscope (usually by urologist)
Intra-anal	Cryotherapy, imiquimod (off-licence), electrosurgery, laser ablation, trichloroacetic acid.

Genital warts in pregnancy

Refer to GUM as:

Although treatment is not always warranted, minimal lesions should be present at birth to reduce neonatal exposure.
The only serious complication is respiratory papillomatosis in the newborn, which is rare (4/100,000 births).
Caesarean section is not indicated, unless there is significant obstruction of the vaginal outlet or gross cervical warts.
Podophylotoxin and imiquimod are potentially teratogenic so should be avoided.
Cryotherapy, excision and ablative methods are the safest options.

So, who needs referral to GUM?

Suspicious/uncertain/internal lesions.
Recalcitrant lesions (consider HIV test).
Immunosuppressed patients.
Pregnant women.
Children (refer to Paediatrics and consider safeguarding assessment).

Genital warts

On the decrease.

Mostly caused by HPV types 6 and 11 which are not oncogenic.

Up to half of sexually active adults have HPV infection, but less than 10% have visible lesions.

Diagnosis is clinical, but offer STI screen and do a speculum check if there are lesions visible at the introitus without a clear upper margin.

Treatment is not mandatory as can spontaneously resolve.

Topical treatment, cryotherapy and surgery are treatment options.

Refer persistent, suspicious, internal lesions, or if patient is immunosuppressed, pregnant or a child.

Useful resources:
Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge)

BASHH – genital warts

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