SOAP Note: Genital Warts (Condylomata Acuminata)
SUBJECTIVE
Chief Complaint: Multiple genital lesions
History of Present Illness:
- Sexually active adult presenting with flesh-colored genital growths
- Duration of lesions: [document timeline]
- No associated pain, bleeding, or discharge
- No systemic symptoms (fever, malaise, weight loss)
- Sexual history: number of partners, types of sexual contact (genital, anal, oral), condom use
- Previous history of genital warts or other STIs
- Partner notification status
Past Medical History:
- HIV status: negative
- Immunocompetent (no immunosuppressive conditions or medications)
- Previous STI screening results
- Vaccination history: HPV vaccine status
Social History:
- Sexual practices and partner information
- Tobacco/alcohol use
OBJECTIVE
Physical Examination:
- Genital examination: Multiple flesh-colored, exophytic papules consistent with condylomata acuminata
- Location: [specify external genitalia, perianal, or both]
- Number: [document approximate count]
- Size: [measure largest lesion]
- Distribution: [clustered vs scattered]
- Total area affected: [estimate in cm²]
- Morphology: pedunculated vs sessile, cauliflower-like appearance
- Inguinal lymph nodes: Non-palpable/non-tender
- Skin examination: No extragenital lesions noted
Laboratory/Diagnostic Studies:
- HIV test: negative
- Consider full STI panel (syphilis, gonorrhea, chlamydia) given sexual transmission
- HPV typing generally not indicated for routine external genital warts 1
- For women: Pap smear status and cervical screening per guidelines
ASSESSMENT
Primary Diagnosis: Condylomata acuminata (genital warts), HPV-related
- ICD-10: A63.0
Clinical Context:
- Immunocompetent patient with external genital warts
- Caused by HPV types 6 and 11 in 90% of cases 2
- Most genital warts respond within 3 months of therapy 1
- Spontaneous resolution possible; treatment not mandatory but addresses cosmetic concerns and may reduce viral load 1, 3
PLAN
Treatment Options
Treatment selection should be based on: wart size, number, anatomic location, patient preference, cost, and provider experience 1. For this immunocompetent patient, I recommend initiating treatment with either patient-applied or provider-administered modalities based on the following algorithm:
Patient-Applied Options (preferred if patient can identify and reach all warts):
Imiquimod 5% cream 1
- Apply once daily at bedtime, 3 times weekly for up to 16 weeks
- Wash off with soap and water 6-10 hours after application
- Expected side effects: local inflammation, redness, erosions, hypopigmentation
- Contraindication: Pregnancy (safety not established)
- May weaken condoms/diaphragms
Podofilox 0.5% solution or gel 1
- Apply twice daily for 3 days, then 4 days off (repeat cycle up to 4 times)
- Limit to <10 cm² total area and <0.5 mL per day
- Provider should demonstrate initial application
- Expected side effects: mild to moderate local pain/irritation
- Contraindication: Pregnancy
Sinecatechin 15% ointment 1
- Apply 3 times daily until clearance (maximum 16 weeks)
- Do not wash off; avoid sexual contact while ointment present
- Expected side effects: erythema, burning, ulceration
- May weaken condoms/diaphragms
Provider-Administered Options:
Cryotherapy with liquid nitrogen 1
- Recommended as first-line provider treatment for most patients
- Repeat every 1-2 weeks until clearance
- Expected: pain, necrosis, blistering
- Consider local anesthesia for extensive disease
Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90% 1
- Apply small amount to warts, allow to dry until white frosting appears
- Can neutralize with soap/sodium bicarbonate if excessive pain
- Repeat weekly as needed
- Risk: can damage adjacent tissue if overapplied
Surgical removal 1
- Best option for large number/area of warts
- Methods: tangential scissor/scalpel excision, curettage, electrosurgery
- Advantage: single-visit clearance
- Requires local anesthesia
Podophyllin resin 10-25% 1
- Apply to each wart, air dry, wash off in 1-4 hours
- Limit to <0.5 mL or <10 cm² per session
- Repeat weekly as needed
- Contraindication: Pregnancy
Specific Recommendations for This Patient:
For limited, accessible warts: Start with imiquimod 5% cream (patient-applied) or cryotherapy (provider-administered) 1
For extensive warts: Consider surgical excision for single-visit clearance 1
Follow-Up and Monitoring
- Change treatment modality if no substantial improvement after complete course or if severe side effects occur 1
- Follow-up in 2-4 weeks to assess response and side effects
- Most warts respond within 3 months 1
- Warn patient about common complications: hypopigmentation/hyperpigmentation with ablative therapies, rare chronic pain syndromes 1
Counseling and Prevention
- HPV transmission: Partners likely already exposed; condom use recommended for new relationships 3
- Recurrence: High recurrence rates even with treatment due to subclinical HPV 3
- Cancer risk: HPV 6/11 (genital warts) rarely cause cancer, but screen for high-risk HPV types per guidelines
- HPV vaccination: Discuss catch-up vaccination if age ≤26 years; shared decision-making for ages 27-45 4
- Partner notification: Recommend evaluation of sexual partners
- Complete STI screening today
Additional Testing
- Full STI panel (syphilis, gonorrhea, chlamydia)
- For women: ensure up-to-date cervical cancer screening
Patient Education
- Treatment removes visible warts but does not eradicate HPV infection 2, 3
- Spontaneous resolution possible without treatment 1
- Avoid sexual contact during active treatment with topical agents
- Return if warts persist after 3 months, worsen, or new symptoms develop
Common Pitfalls to Avoid
- Do not use podophyllin or podofilox in pregnancy 1
- Do not exceed recommended treatment areas (<10 cm²) or volumes with cytotoxic agents 1
- Ensure adequate healing time between ablative treatments to prevent scarring 1
- For cervical warts: Biopsy required to exclude high-grade squamous intraepithelial lesion before treatment 1