Condyloma (HPV)

What are condyloma?

Condylomata or condylomas, also known as genital warts, are one of the most common varieties of the sexually transmitted infections (STI, formerly referred to as sexually transmitted diseases or STDs). They result from an infection by the Human Papilloma Virus (HPV is a commonly heard acronym). There are greater than 80 types of HPV documented.

How common are condyloma ?

It is estimated that there are approximately one million new cases of condyloma each year in the United States. In Canada, it is felt that between 20 and 40 % of the sexually active adult population will be infected by HPV this year, while the majority of those individuals infected by the virus will not suffer any visibly apparent symptoms.

How is the virus responsible for condyloma transmitted ?

Typically, the virus (HPV) is transmitted or contracted through direct genital to genital contact with a partner infected by HPV, and this with or without penetration. Frequently, lesions may go unnoticed given their small size early on in their development. At times lesions may be present only on the internal skin surfaces of the genital organs (i.e. rectum, vagina or cervix). Transmission may also occur via contact with infected genital secretions. It is extremely improbable that condyloma be transmitted amongst members of a family (without sexual contact).

What are the symptoms of condyloma ?

At the beginning of an infection, or after transmission, the virus typically invades the skin without any apparent symptoms...most people are not even aware of its presence. The usual incubation period for genital warts is in the order of one to eight months, however, much longer incubation periods have been reported and are probably not that unsusual (may even remain dormant for years…). Given the extremely variable incubation period, it is difficult to determine the time of infection and the partner responsible for your warts. An infection by HPV is detected when the virus stimulates the growth of the skin into small outgrowths or warts localized to the genital organs, anus and peri-anal region (around the anus), in the rectum and very rarely in the mouth. Condyloma of the mouth are much more frequent in patients who have underlying problems with their immune system (cancer, leukemia, or advanced HIV-AIDS infection). The shape and color of HPV warts vary greatly according to their location, the strain of virus and your own skin type. Lesions may resemble small lumps or bumps, flat plaques, irregular or unusual outgrowths that may at times resemble a cauliflower. Lesions may be pink, red, grey, brown or simply skin color…patients often mistake condyloma for ingrown hairs or "beauty marks". If you notice the appearance of a new or changing skin lesion in your genital region…please consult! Condylomata are not usually painful – unless they have been manipulated or have become infected. They may be accompanied by symptoms of irritation or itchiness, and this most commonly when they are in their growth phase. Only infrequently will condyloma bleed. At times, condyloma (HPV) will infect the skin and never develop into visible lesions.

Men and condyloma

In men, the most common site of infection is the penis. The scrotum, the anus (up to 25 % of heterosexual men) and rarely the mouth may be afflicted in men. A frequent question at our clinic is « Why do I have anal warts if I have never engaged in anal sex or penetration? » Remember, HPV may also be transmitted by contact without penetration, or via infected vaginal secretions during sexual relations. In summary, warts are most often external in men.

Women and condyloma

In women, the uterine cervix is the most frequently afflicted site. The vaginal passage, the vulva and external genitalia and anus may also be sites of infection in women. Once again, it is rare for condyloma to be found in the mouth. In women, warts may commonly be found internally (and not seen), externally or both.

How are condyloma diagnosed ?

Condyloma are sometimes difficult to detect - they may be flat and the same color as your skin. External condylomata (i.e. vulvar or penile) are readily detectable via the visual examination in our offices. Most of the time lesions are classical and require no further analysis – only treatment. In the event that your condyloma are not typical, or if there is doubt in the mind of your physician…he will perform a simple biopsy on the spot. When necessary, this enables a concrete pathological diagnosis. At times one of our physicians may employ the « vinegar test » allowing an improved visualization of smaller lesions – this is not often necessary. Lesions at the level of the uterine cervix are routinely screened and detected with the annual cervical cytology or « PAP test ». The PAP test is useful in screening for cervical cancer and related condyloma. Aside from cervical cytology (and perhaps anal cytology in MSM), there are no screening tests for HPV. The clinical visual exam is the basis of an evaluation for genital warts caused by HPV. We are excited to inform you that the newer HPV screening tests are now available at our clinic for cervical lesions! – and allow us to detect for the presence of HPV and whether they are of a high-risk or low-risk type. This is discussed in greater detail further on.

Is there a treatment available for condyloma ?

There is no one treatment that is able to completely erradicate an infection by HPV. The goal of treatment is to eliminate visible lesions thereby decreasing the amount of virus and risk of transmission. Treatment assists the body in combatting the infection by your own immune system. There are many different methods employed in the treatment of condylomata. In some cases, the treatment may be self-administered (i.e. gel or liquid podophyllin – a beetle extract that is toxic, or a newer immune-stimulating cream called Imiquimod„ or Aldara„). The indications for self-administered treatments depend on the extent, the location and duration of your condyloma infection…talk with one of our physicians. In many cases, treatment will be administered during your clinic consulation i.e. liquid nitrogen [cryotherapy], podophyllin, trichloro-acetic acid or a combination of these products may be applied to lesions. In the event that your condyloma are resistant to treatment (some types of HPV are very tough to erradicate) or recur, our physicians may refer you for definitive surgical removal. In the latter case, the affected skin region is anesthetized and lesions are removed via excision, laser or electical current (cauterization).

What if I don’t treat my condylomata ?

It must be said that in many cases, an HPV infection will resolve on its own without treatment. When this occurs, there are no resultant complications. Nonetheless, the presence of HPV can, but does not always increase the risk of cervical cancer and, rarely vulvar, vaginal, penile or anal cancer.

External genital warts (i.e. vulvar or penile) that are readily visible are typically easy to treat and are rarely associated with progression towards cancer. Those lesions or HPV that persist at the level of the uterine cervix are more of a concern for us, and are associated with an increased risk of progression towards cancer (note : this is a treatable and preventable form of cancer if not ignored!!)

This is the reason why your doctor will recommend regular « Pap tests » or cervical cytology. This test permits the early detection of lesions, prior to their progression towards pre-cancer or cancer. Early on, these abnormalities are amenable to treatment – this is one of the rare cases where cancer CAN BE PREVENTED! One of our physicians may suggest that a « genotype » be performed (this is a test whereby the type of virus is identified, thereby determining if it is of a high-risk sort for cancer). Your physician may also recommend a special gynecological test called a « colposcopy »…this is an up-close examination of the uterine cervix whereby a microscope allows improved detection and treatment of abnormal zones or lesions.

Who are at risk of contracting condyloma ?

The risk of contracting genital warts such as condyloma is increased when insertive sexual relations (penetration) are unprotected with :

• A new sexual partner (male or female), who has not been examined for condyloma or other sexually transmitted diseases. Remember, a stable sexual partner may develop lesions years after a contact;
• A sexual partner who has another or multiple sexual partners (whether this be a known or unkown factor)
• More than one sexual partner;
• An unknown or anonymous partner.

How can I decrease the risk of transmitting my condyloma?

During your treatment process for condyloma, it is often recommended to use a condom (male or female condom) with those partners that you have been with for less than six months. When a couple has been together for longer periods of time, the risk that transmission has already occurred is such that protected sexual relations are probably futile (too late). We also routinely recommend that you refrain from sharing sexual objects (particularly those used for penetration). The risk from shared undergarments or towels is small and is limited to a very short time-frame after contact with infected body parts.

It is recommended that your sexual partner(s) consult a physician, even in the absence of apparent lesions or symptoms…this will enable early treatment intervention, when indicated. In this detail, your physician may be able to assist you in the notification of your sexual partners.

Once your treatment has been declared « finished », and your lesions have been eliminated, the virus may remain present for some time. This is one of the reasons why there are occasional recurrences of condylomata over time – this is not the rule, but it does occur. Consequently, the use of a condom, particularly with a new or recent sexual partner ( six months) is recommended for at least one year. It is important to pursue regular follow-up examinations (determined by your doc) and to consult your physician if there is any doubt in your mind. Remember, you may be competent in the surveillance and detection of external lesions, however, only your physician can assist you in the surveillance and detection/treatment of internal lesions (whether anal, vaginal or cervical).

It is important to note that 85 % of individuals will succeed in eventually eliminating the virus completely from their system. Nonetheless, 15 % will remain carriers of the HPV virus for life. Do not panic!…The virus is contagious and transmissible primarily when lesions or warts are present.

According to several experts, stable monogamous couples (i.e in a relationship for more than one year) have much less of a risk of reinfecting each other during sexual relations than those individuals with multiple sexual partners. The use of condoms in a stable partnership has little effect on decreasing the number of recurrences, particularly when they have been together for several months once the diagnosis of condylomata is finally made. It is believed that your own immune system will protect you against a potential reinfection. This helps to explain in part why the use of condoms for the year following the diagnosis of condyloma is recommended

How can I avoid contracting condyloma ?

Use a 100% latex condom (male, female condom or dental dam) at all times with all recent (less than one year relationship) sexual partners. Once again, the risk of warts via oral sex is VERY, VERY low.

Abstinence or a stable monogamous sexual relationship with a known and trusted partner (free of STI) is another effective method of decreasing the risk of contracting genital warts or condyloma, and other STI’s in the sexual active adult population.

How do condylomata affect my pregnancy ?

The transmission of condyloma from mother to newborn at the moment of passage through the vaginal canal during childbirth is extremely rare (a risk of 0,04 %). A frequent question at our clinic is « will I need to have a c-section? » Fortunately, the presence of condyloma in and of themselves is not a reason to undergo a caesarien section or c-section. A c-section would only be indicatied if the lesions were so large that they caused a physical obstruction to spontaneous vaginal delivery. This is a very rare situation! Some good news…While condyloma often increase in size and number during pregnancy (likely hormonally related), they often will regress spontaneously in the post-partum period (after delivery).

What is new?

Recently available genotypic tests may help us to confirm the presence of HPV and to determine the type of virus (HPV) responsible. These newly available tests are used in the detection of cervical lesions, and may eventually be used in the detection of anal lesions in MSM. This is helpful in identifying those types of HPV that are at high-risk for progression towards cancer. If not, then you have saved yourself a visit to the gynecologist and a colposcopy. Colposcopy will only be recommended when high-risk lesions or HPV are detected. Newer, and more sensitive Pap tests are also available – the liquid Pap test is much better at identifying abnormalities at the level of the uterine cervix…this should translate into earlier detection or lesions, pre-cancer and cancer.

Vaccination against HPV

HPV vaccines have been in development for many years.  The first vaccine approved for use in Canada in July 2006 is Gardasil. This vaccine protects from infection with 4 of the most common types of HPV (Types 6, 11, 16 and 18). HPV vaccines are currently being studied for use in men. The results from these clinical trials will yield information in the coming year.

Who is elibible for the vaccine?

Canada
The vaccine has been approved for use in Canada for females 9-26 years of age. The vaccine requires 3 doses to be given over the course of 6 months (0, 2 and 6 months). Recommendations for use, which come from the National Advisory Committee on Immunization (NACI), were released in February 2007.

The primary age group recommended for vaccination according to NACI is females aged 9 to 13. HPV is a sexually transmitted infection, and ideally, the vaccine should be administered to females before they become sexually active in order to ensure maximum benefit. They also recommend the vaccine for females 14 to 26 years of age as there still is the potential for benefit regardless of previous sexual activity, Pap abnormalities, cervical cancer, anogenital warts or a known HPV infection. 

The vaccine is not recommended for pregnant women, females under nine years of age, or males. Although no recommendations were made for women older than 26 years, its use can be considered in individual circumstances. For more details see http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/07vol33/acs-02/index_e.html

What type of protection does Gardasil offer?

The vaccine will protect against infection with two high-risk types of HPV (16 and 18) and two low risk types (6 and 11). HPV types 16 and 18 cause approximately 70% of cervical cancers. HPV types 6 and 11 cause approximately 90% of anogenital warts.

The vaccine does not protect against any other types of low or high risk types of HPV. The HPV vaccine is not known to have an impact on an existing infection or any of the outcomes of an existing HPV infection, such as anogenital warts, however the therapeutic efficacy is under study.

Does the vaccine work?

The HPV vaccine has demonstrated a very high efficacy in preventing the four types of HPV infection mentioned above (HPV types 6, 11, 16 and 18).

The vaccine does not protect against any of the other low or high risk types of HPV. However, if you are infected with one of the four HPV types in the vaccine, the vaccine will still protect against the other types in the vaccine. For example, if you are infected with HPV type 6, the vaccine will still protect you from types 11, 16, and 18. HPV DNA testing is not recommended prior to vaccination.

Are there worrisome side effects?

The vaccine is safe. Few side effects were reported among the participants in the recent studies for the vaccine. The most common side effect was a brief soreness at the site of injection. Also, you cannot become infected with HPV from the vaccine and the vaccine does not contain any antibiotics or preservatives, including mercury or thimerosal.

Does vaccination eliminate the risk for PAP testing/cervical cancer screening?

The HPV vaccine does not protect against all types of HPV, it only protects against the four most common types of HPV that cause cervical cancer and anogenital warts. Even when someone is vaccinated it is still possible to become infected with one of the less common types of HPV that the vaccine does not protect against. Therefore, it is important that vaccinated girls/women continue to have regular Pap tests. 

How long does Gardasil protect for? Will a booster shot be needed?

Recent studies have indicated good protection against HPV for five years of follow-up. Studies are ongoing to determine if further immunization or a booster dose is necessary for vaccinated females to have continued protection.

How do I obtain the vaccine? Do I need to pay for the vaccine?

Currently, Gardasil vaccination is not covered by the Quebec provincial formulary, however, the issue is currently under evaluation.  You may enquire as to the possibility that the vaccine be covered under your "private" medical insurance - speak with your health-care provider and/or pharmacist.