What is the primary care approach for treating a patient suspected of having Human Papillomavirus (HPV) before referral to an Obstetrician-Gynecologist (OB-GYN)?

Primary Care Management of Suspected HPV Infection

For patients with suspected HPV infection in primary care, treatment should focus on visible lesions (genital warts) as there is no cure for the virus itself, while providing appropriate counseling and screening before referral to OB-GYN.

Initial Assessment and Diagnosis

• Visual examination is the primary diagnostic method for genital warts, which are caused predominantly by HPV types 6 and 11 1
• Biopsy is indicated only in specific circumstances: uncertain diagnosis, lesions unresponsive to standard therapy, worsening during therapy, immunocompromised patients, or pigmented/ulcerated lesions 1
• Type-specific HPV nucleic acid tests are not recommended for routine diagnosis or management of visible genital warts 1
• Most genital warts are asymptomatic, but patients may experience pruritus, pain, tenderness, or friability 1

Treatment Options for Genital Warts in Primary Care

External Genital Warts

• First-line treatments that can be administered in primary care include:
  • Cryotherapy with liquid nitrogen (applied by provider) 2
  • Patient-applied therapies:
    • Imiquimod 5% cream applied 3 times per week for up to 16 weeks 3
    • Podofilox 0.5% solution or gel applied twice daily for 3 days, followed by 4 days of no therapy, for up to 4 cycles 2

Vaginal Warts

• Cryotherapy with liquid nitrogen (avoid using cryoprobe due to risk of vaginal perforation) 2
• TCA or BCA 80-90% applied only to warts, repeated weekly if necessary 2

Urethral Meatus Warts

• Cryotherapy with liquid nitrogen 2
• Podophyllin 10-25% in compound tincture of benzoin (applied by provider) 2

Anal Warts

• Cryotherapy with liquid nitrogen 2
• TCA or BCA 80-90% applied only to warts 2
• Intra-anal warts should be managed in consultation with a specialist 2

Important Counseling Points

• HPV infection is very common; most sexually active adults will acquire HPV at some point 2
• In most cases, HPV infection clears spontaneously without causing health problems, though some infections progress to genital warts, precancers, or cancers 2
• The types of HPV that cause genital warts (types 6 and 11) are different from the high-risk types that can cause cancer 2
• Treatment targets visible warts but does not eliminate the virus itself 2
• Recurrence is common (approximately 30%) regardless of treatment method 1
• Correct and consistent condom use might reduce but does not eliminate transmission risk 2

Screening Recommendations Before OB-GYN Referral

• All women with suspected HPV infection should have cervical cancer screening 2
• For HIV-negative women: Follow standard age-appropriate cervical cancer screening guidelines 2
• For HIV-positive women: Cervical Pap test should be performed upon initiation of care, repeated at 6 months, and annually thereafter if results are normal 2
• Women with abnormal Pap test results (including ASC-US, ASC-H, atypical glandular cells, LSIL, HSIL, or squamous carcinoma) should be referred for colposcopy and directed biopsy 2

Special Populations

Pregnant Women

• Imiquimod, podophyllin, and podofilox should not be used during pregnancy 2
• Many experts advocate removal of genital warts during pregnancy as they can proliferate and become friable 2
• Cesarean delivery is not recommended solely to prevent HPV transmission to the newborn 2

Immunocompromised Patients

• May not respond as well to therapy and may have more frequent recurrences 2
• Are at higher risk for squamous cell carcinomas arising in or resembling genital warts 2
• HIV-infected patients with HPV infection are at increased risk for anal dysplasia and cancer 2

HPV Prevention

• HPV vaccination is recommended for:
  • All females aged 9-26 years 2
  • All males aged 9-21 years 2
  • Males aged 22-26 years if not vaccinated at younger ages 2

When to Refer to OB-GYN

• Women with abnormal cervical cytology 2
• Patients with cervical warts (management should include consultation with a specialist) 2
• Patients with extensive or treatment-resistant warts 1
• Patients with intra-anal warts 2
• Immunocompromised patients with concerning lesions 1

Common Pitfalls to Avoid

• Don't assume HPV infection indicates sexual infidelity, as the virus can remain dormant for long periods 2
• Don't use HPV DNA testing for screening in men, partners of women with HPV, adolescent females, or for conditions other than cervical cancer 2
• Don't perform cesarean delivery solely to prevent HPV transmission to newborns 2
• Don't use acetic acid soaks as a screening test for subclinical HPV infection due to high false-positive rates 2
• Don't forget that treatment reduces but does not eliminate infectivity 1