HPV and Genital Warts: Testing and Treatment
HPV Testing Recommendations
HPV testing is NOT recommended for men, partners of women with HPV, or for screening purposes outside of cervical cancer screening in women. 1, 2
Who Should Be Tested for HPV
- Women aged 30 years and older: HPV testing or co-testing (HPV + Pap) is appropriate for cervical cancer screening 1, 3
- Women aged 21-29 years: HPV testing is NOT recommended due to high prevalence and likelihood of spontaneous clearance 3
- Women under 21 years: No HPV testing should be performed 3
- Men: No clinically validated HPV test exists for men; testing is explicitly not recommended 1, 2
Critical Testing Pitfalls to Avoid
- Do not test male partners of women with HPV—both partners are usually already infected by the time of diagnosis 1, 2
- Do not test for low-risk HPV types (6 and 11)—this provides no clinical benefit 3, 2
- Do not use HPV testing to decide whether to vaccinate 2
- FDA-cleared HPV tests are only validated for cervical specimens, not oral or anal specimens 2
Diagnosis of Genital Warts
Visual examination is the primary and sufficient diagnostic method for genital/anal warts. 4
When to Perform Biopsy
Biopsy is indicated only in specific circumstances 4:
- Uncertain diagnosis
- Lesions unresponsive to standard therapy
- Worsening during therapy
- Immunocompromised patients
- Atypical lesions (pigmented, indurated, fixed, or ulcerated)
Do not apply acetic acid as a screening test—it is not specific for HPV infection. 4
Treatment of Genital Warts
First-line treatments include cryotherapy with liquid nitrogen, trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90%, or surgical removal. 1, 4
Provider-Applied Treatments
Cryotherapy with liquid nitrogen 1, 4:
- Can be repeated weekly if necessary
- Most accessible first-line destructive treatment
- Apply only to warts
- If excess acid is applied, powder the area with talc, sodium bicarbonate, or liquid soap to remove unreacted acid
- Can be repeated weekly
- Includes excision, electrocautery, or laser therapy
- More effective than cryotherapy but requires specialized equipment
Patient-Applied Treatments
Imiquimod cream 5:
- Apply 3 times per week for up to 16 weeks
- In clinical trials, 50% of patients achieved complete clearance (72% in females, 33% in males) 5
- Median time to clearance: 10 weeks 5
- Contraindicated in pregnancy 1
- Common side effects: local erythema (65% females, 58% males), erosion (31% females, 30% males), itching (32% females, 22% males) 5
Podofilox (podophyllotoxin) 6:
- Patient-applied option with good evidence of efficacy
- Contraindicated in pregnancy 1
Podophyllin resin 1:
- Provider must apply and wash off after 1-4 hours
- Contraindicated in pregnancy 1
Sinecatechins 1:
- Contraindicated in pregnancy 1
Special Populations
Pregnancy
- Avoid imiquimod, sinecatechins, podophyllin, and podofilox during pregnancy 1
- Genital warts can proliferate and become friable during pregnancy 1
- Treatment resolution may be incomplete until pregnancy is complete 1
- Cesarean delivery is NOT indicated solely to prevent HPV transmission to the newborn 1
- Cesarean delivery is only indicated if warts obstruct the pelvic outlet or would cause excessive bleeding with vaginal delivery 1
Immunocompromised Patients
- Warts may be larger or more numerous 4
- Response to therapy may be poorer 4
- Recurrence rates may be higher 4
- Increased risk of squamous cell carcinomas arising in or resembling genital warts 4
- Biopsy should be considered for atypical lesions 4
Intra-anal and Rectal Warts
- Should be managed in consultation with a specialist 1
- Persons with anal warts may also have rectal warts 1
- Consider digital examination, standard anoscopy, or high-resolution anoscopy to inspect rectal mucosa 1
Anal Cancer Screening Considerations
Routine anal cancer screening with anal cytology is NOT recommended for the general population. 1
High-Risk Populations with Elevated Anal Cancer Incidence
- MSM with HIV infection: 80-131 cases per 100,000 person-years 1
- Men with HIV infection: 40-60 cases per 100,000 person-years 1
- Women with HIV infection: 20-30 cases per 100,000 person-years 1
- MSM without HIV infection: 14 cases per 100,000 person-years 1
An annual digital anorectal examination (DARE) may be useful to detect masses in persons with HIV infection and possibly in MSM without HIV with history of receptive anal intercourse. 1, 4
Essential Patient Counseling
About HPV Infection 1
- HPV infection is extremely common—most sexually active adults will acquire HPV at some point in their lives 1, 7, 8
- Most infections clear spontaneously without causing health problems 1, 7
- HPV is transmitted through genital contact during vaginal, anal, and oral sexual contact 1
- Within an ongoing relationship, both partners are usually already infected when one is diagnosed 1, 2
- A diagnosis of HPV in one partner does NOT indicate sexual infidelity in the other partner 1
- Treatment targets visible warts but does not eliminate the virus itself 1, 4
- HPV does not affect a woman's fertility or ability to carry a pregnancy to term 1
About Genital Warts 1
- Genital warts are not life-threatening 1
- If left untreated, warts may resolve spontaneously, remain unchanged, or grow in size or number 1
- Genital warts will not turn into cancer except in very rare cases 1
- Recurrence is common (approximately 30%), especially in the first 3 months after treatment 1, 4
- Warts can be transmitted even when no visible signs are present and even after treatment 1
Risk Reduction Strategies 1
- Correct and consistent condom use may lower transmission risk but is not fully protective because HPV can infect areas not covered by condoms 1, 4, 2
- Limiting number of sexual partners can reduce risk, but persons with only one lifetime partner can still acquire infection 1
- Complete sexual abstinence is the only definitive method to avoid HPV infection 1
Vaccination 1
- HPV vaccines protect against types 16 and 18 (which cause 70% of cervical cancers) 1
- Quadrivalent vaccine (Gardasil) also protects against types 6 and 11 (which cause 90% of genital warts) 1, 4
- Vaccines are most effective when administered before sexual contact 1
- Recommended for 11-12 year olds; catch-up vaccination for females aged 13-26 years and males aged 9-26 years 1
Screening Recommendations for Women 1
- Women should continue regular Pap tests as recommended, regardless of vaccination or genital wart history 1
- Women with genital warts do not need more frequent Pap tests than recommended 1
- After treatment for high-grade precancer, surveillance should continue for at least 25 years, even beyond age 65 1, 3