Anal Warts


DEFINITION
AKA Condyloma Acuminatum

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INCIDENCE

Most common sexually transmitted disease.
Increasing since the 1960s.
~1% of population.

Risk factors
Sailors and whores.
Having a husband who's a milkman.
Lots of sex with lots of partners.
- and not using condoms.
Most pts with anal warts have a history of anal-receptive intercourse

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AETIOLOGY

HPV.
- double-stranded DNA virus
- 70 types.
- 30 types are genital.
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BIOLOGICAL BEHAVIOUR

Natural History
HPV species are site specific (so can't be transferred from a hand to genitals).
Intact virions invade high turnover epithelium.
Invade through abrasions, sexual contact, or birth
- fomite transmission described.
Infect basal keratinocytes and their proliferation causes the wart.
Affect squamous epithelium, transitional zone, genitals and cervix.

Natural history
Initial flare may be cleared but then lie quiescent.
Late recurrences are due to activation of latent virus.
Small warts may later resolve spontaneously.
Some types, eg HPV 6 & 11 are associated with benign warts
HPV-16 and 18 are oncogenic, commonly associated with AIN and SCC.

Giant form
Rare; 5-10cm
Termed 'Busheke-Lowenstein disease'
- marked by local invasion and half contain an SCC focus (cf <2% in normal warts)
- but locally recur and invade regardless of SCC status
- may fistulise

*Completely excise; APR +/- reconstruction if necessary / severe / recurrent
- oral retinoids or imiquimod for smaller lesions.
No proven role for adjuvant therapy

Complications
If fistulating:
* test for HIV and biopsy at EUA in OR
Fistulotomy and fulguration of condylomas if superficial
Else long term draining seton and frequent wart destruction.
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MANIFESTATIONS

Symptoms
Warty growth.
- fleshy, exophytic, or sessile verrucous growths of various size
- "flat", "dome" "keratotic" or "cauliflower" types
- latter most common, often on partly-keratinized squamous epithelium; anoderm.
- gray, pink or skin coloured
- small (<1mm) to large (several cm)
- few or innumerable; single, clusters, plaques or pedunculated.
May be on perianal skin, in anal canal (only at or below dentate line)
- and on penis, vulva, vagina, cervix, and occasionlly, groin
Generally only bothersome growths
- but commonly psychological distress
Other Sx
Pruritus ani
Bleeding
Pain
Discharge / wetness / difficulty with hygeine
Consider for SCC complications.
- rapid growth, change, ulceration, pain, fixity and blue-black discoloration should be red flags.

Signs
Anoscopy to see intra-anal-canal extent
Strong focused lighting.

Common Differentials
Molluscum contagiosum
Seborrheoic keratosis
Secondary syphilis (condylomata lata)
Enlarged anal papillae.
SCC, BCC
Dysplastic nevus
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INVESTIGATIONS

Pathology
Histology confirmative; need a biopsy.
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MANAGEMENT

Often disappointing
Many Rx proposed, few ideal.
Goal is destruction and removal of all gross warts with preservation of intervening anoderm
- but cannot eradicate virus, so recurrence is a stubborn problem.
- particularly when immunosuppressed, e.g. HIV
- perhaps up to 50% of immunocompetent pts can be cured

Excision / Cautery
Perhaps the most effective treatment / lowest recurrence
Under GA; can see full extent.
Legs up in lithotomy
No antibiotics or bowel prep.
Retract gluteal folds with 3 inch tape.
Apply acetic acid 3-4% on a cotton tip applicator through anoscope for 1-2m to improve visualization.
Excise or cauterize.
- not too extensively or can get anal stenosis.
- use pointed scissors for focused removal of discrete lesions
--> then fulgarate base with diathermy.
- smaller multiple lesions can be fulgurated directly, then eschar wiped off and base diathermied to ensure destruction of upper dermis tissue.
- intra-anal lesions excised and fulgarated.
Avoid nuisance bleeding from deep excision over haemorrhoidal plexus.
Send tissue and document their site of excision clearly for each in case SCC.
*Avoid large open wounds in HIV pts; more conservative approach.
*Avoid anal stenosis if normal anoderm insufficiently preserved.
--> else may need dermal advancement flaps

Post-operative management
Tepid water baths and showers tds and after each BM
Pain meds, stool softeners, dry gauze dressings.
Review <2w and every 4w until healed.
Follow 3 monthly, for 1y then 6 monthly, then yearly.
- treat early recurrence with topical Rx

Laser therapy?
No. no proven role.

Topical Therapy
Best indicated for small, scattered warts or as an adjunct to prevent recurrence.

Podophyllin
Antimitotic plant resin cytotoxic to condylomata
Irritative to normal skin.
Use limited to minimal disease / extra-anal warts
Apply via cotton-tip applicator in thin layer to wart, then air dry.
- 1 drop at a time, drying between drops until covered; max 0.5mL per session.
- wash area 2-4h later and avoid sex for 24h
Do not repeat
- local complications
- potential systemic toxicity
Cheap but often ineffective.
Do not use in pregnancy - cytotoxic
Must biopsy before use; may produce dysplastic change.

Podofilox (condylox)

"5% podophyllin" as a solution or gel
Standardized gel prep for perianal disease
Patient-directed therapy.
Use for 3 consecutive days, then not for 4; repeat for 4 weeks to limited areas <0.5g / treatment.
If incomplete response, try something else.

Cryotherapy.
Liquid nitrogen and cotton wool applicator
Used in anal canal through anoscope
70% go away.
1/3 of these later relapse.

Trichloroacetic acid (TCA)
Easiest topical agent.
End of a toothpick-sized wooden applicator is dipped in acid and dabbed onto warts; chemical cauterization.
Acid turns tissue white;
Destroys perianal and intra-anal warts
Side effects are burning, pruritis and tenderness.

Imiquimod 5%
Immune response modifier; ?induces macrophages to produce cytokines
Apply thin layer at night, three times per week, wash in mornings, for 16 weeks.
Action is via the toll-like-receptor 7
Adjunctive use after other therapy may reduce recurrence

5-Fluorouracil Cream
Patient applies it at home od or 2-3x/week for up to 16 weeks.
Not recommended for routine use; mutagenic.
Warn pt - causes some perianal skin inflammation.
Not for use in anal canal.
Should use gloves and apply after washing and drying
Relative efficacy unclear.

Recommendation
1. EUA, gauge extent.
2. Excise / cauterize with extensive biopsies if large, atypical or recalcitrant
- or if small and scattered, topic Rx with imiquimod or podofilox for 8-12w then re-examine.
3. Small recurrences treated with TCA
4. If frequent or persistent, or if immunocompromised, add in imiquimod post-op.
- some use this for 6/52 after all excisions.

5. Don't forget contact tracing and warning of sex partners.


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