Condylomata acuminata

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Classification according to ICD-10
A63.0 Anogenital ( venereal ) warts
ICD-10 online (WHO version 2019)

For genital warts - also referred to as genital warts , Feigblattern , genital warts and genital warts known warts  - or short genital warts is a viral disease . Genital warts are small, soft pink warts that are most commonly found on the labia, penile shaft, and foreskin, but can also be found around the rectum or in the oral cavity. They are next to genital herpes and chlamydiosis one of the most common sexually transmitted diseases .

Multiple genital warts around the anus

Pathogen

90% of the genital warts are caused by low-risk types of the human papillomavirus (HPV) . The pathogens, also known as condyloma viruses, are spherical, non-enveloped, double-stranded DNA viruses (dsDNA) belonging to the Papillomaviridae , of which a total of 200 different (including approx. 40 anogenital) types are known. The anogenital HPV types are divided into low-risk types (e.g. 6 and 11) and high-risk types (e.g. 16 and 18). While a persistent infection with high-risk types (v. A. The risk of certain cancers cervical cancer , in rare cases, but also for penile cancer , anal cancer and throat mouth room and cancer) increased own changes by low-risk types degeneration potential hardly.

Transmission and dissemination

Basically, the pathogens are transmitted through contact infection or smear infection . It is theoretically possible that HP viruses can be transmitted in almost all skin-to-skin contact, but the main cause of infection is unprotected sexual intercourse. Infection by other routes, e.g. B. in the sauna, while bathing or even on the doorknob, is possible, but extremely rare.

Because of the HPV route of infection, condoms do not offer complete protection. However, a study on the protective effect of condoms against HPV has shown that consistent condom use can prevent around 70% of all HPV infections over the course of a year.

From a global perspective, the number of new infections with genital warts is increasing continuously. There are various hypotheses about the cause of this development. One of them is that the small injuries caused by intimate shaving increase the risk of genital warts and more and more people are shaving in the genital area. The main risk factors remain:

  • unprotected intercourse, especially if performed with multiple people and at a young age
  • Factors that weaken the body's immune defenses, such as: B. stress, smoking, immunosuppressants , u. a.

In addition, it is also recommended that underwear be washed with hot water, as the HP viruses are inactivated at 55 ° C.

Approximately 1% to 2% of the sexually active population have visible genital warts. In addition, approximately 5 to 10% of the population have subclinical HPV-associated lesions in the anogenital region , which cannot be seen with the naked eye and are usually undiagnosed. About 60% of the population can find antibodies against HPV in the blood, which indicate a previous infection. The risk of developing an HPV infection in the course of life is therefore estimated at between 75% and 80%.

Due to the high infectivity and spread, an HPV infection is an almost inevitable consequence of sexual contact. Five years after starting their sexual activity, approximately 70% of all women have become infected with at least one anogenital HPV type. Between 64 and 70% of the male relationship partners of women who suffer from cervical HPV disease, in turn - as several studies show - have HPV-associated lesions on the penis .

localization

A moist and warm environment favors the development of genital warts, which is why they find ideal growth conditions, especially in cracks in the genital and anal areas. Genital warts remain localized due to their type. In both sexes, genital warts are found in the anal area, less often in the rectum. In women, the labia and the vagina are affected, and less often the cervix. In men, however, the glans, the foreskin on the penis and the scrotum can be affected.

Course of the disease / symptoms

Between the infection and the first appearance of the genital warts there is an outbreak time of a few days or weeks to several months - and in very rare cases even years. However, not every infection has to lead to a wart. The HP viruses persist in the spiked and squamous cells of the epidermis . Thus, although those affected are virus carriers, the disease does not break out. In such a case, one speaks of a silent infection .

The majority of infections run without clinical symptoms and can no longer be detected after a while, even with complex methods. In around 30% of cases, genital warts that have appeared heal on their own.

The pathogens usually form small warts in the genital region or on the anus , which tend to form beds and then form confluent (uniting) warts. Smaller foci usually show no symptoms, larger ones can cause painful tears, a feeling of tension and secondary eczema. Overall, the disease is not fatal even if left untreated, but it can have a significant negative impact on the patient's (sexual) quality of life. A possibly affected partner should definitely be examined for the HP virus and, if necessary, treated so that there is no repeated mutual infection.

Condylomata acuminata are almost always caused by low-risk types (in over 90% of cases by HPV 6 or 11) that are not considered carcinogenic . With years of illness and inadequate treatment, genital warts can still degenerate, somewhat more often in women than in men. Treatment is therefore advised. Occasionally, very large tumor accumulations also develop , which are referred to as condylomata gigantea or Buschke-Löwenstein tumors . They are characterized by destructive growth and benige degeneration. If left untreated, they can also break open and bleed profusely.

  • Genital warts in the shaved pubic area at the base of the penis, approx. 6 to 10 months after infection

  • Pronounced genital warts on the penis

  • Pronounced genital wart infestation in the vulva

Diagnosis

As a rule, due to the characteristic appearance, only a visual diagnosis is made. If the clinical picture is unclear, the attending physician has the option of further diagnostic measures.

  • Acetic acid test: three or five percent acetic acid gives the affected areas a whitish color. In this way, inconspicuous cell changes can be made visible and the spread can be better assessed if the condylomas are to be surgically removed. However, the acetic acid test is unspecific and not very sensitive; H. Discoloring areas are not necessarily HPV-associated. If suspicious areas do not change color, this does not necessarily mean that they are not condylomas. Therefore, the test can only be correctly interpreted by an experienced doctor.
  • Histological examination: A tissue sample can be examined histologically in the laboratory. Koilocytes in particular are regarded as markers for HPV-associated skin changes. However, there are also some hyper- and parakeratoses .
  • Virus detection: The detection of HPV-DNA is not part of the routine diagnosis of condylomata acuminata. Nevertheless, a swab test from a suspicious area is possible. Test methods are probe tests (widespread, inexpensive, differentiated between high and low risk) and tests using a polymerase chain reaction (expensive, very sensitive, allows the exact type of virus to be determined). In comparison, PCR is characterized by a significantly higher sensitivity and specificity.
  • HPV serology : HPV infections proceed without viraemia . Therefore the viruses cannot be detected in the blood. The detection of antibodies is reserved for scientific studies and due to the high level of contamination has no diagnostic benefit.
  • With a colposcopy , anoscopy , proctoscopy and / or urethroscopy , "internal" condylomas can be excluded. External condylomas should be removed before such examinations, otherwise there is a risk of spreading the infection through the examination itself.

Differential diagnoses

Infection with low-risk types such as HPV 6 or HPV 11 should be differentiated from infection with HPV 16 and HPV 18, since women with an infection of the latter types are at risk of developing cervical cancer. In the differential diagnosis, condylomata acuminata must be distinguished from other benign tumors (e.g. fibromas ), heterotopic sebum glands, hirsuties papillaris penis , hirsuties vulvae, hymenal remnants, premalignant and malignant changes and other infections (e.g. condylomata lata caused by syphilis). From the Middle Ages to modern times, the outdated terms genital warts and fig leaves refer to both the condylomata acuminata and hemorrhoidal nodes or hemorrhoids (grade II to III with bloody discharge) and skin tags. A histological examination and / or virus detection can be carried out to confirm the diagnosis.

Complications

Since HPV is often mentioned in connection with an increased risk of cancer, it should be noted that infection with low-risk types that cause condylomata acuminata on its own does not usually increase the risk of cancer. Since high-risk types have the same route of infection as low-risk types, a parallel infection with a high-risk type cannot be ruled out in the case of condylomata acuminata. Initial studies indicate that patients with condylomata acuminata have a comparatively high risk of being additionally infected with a high-risk type, which is why a routine HPV test for high-risk types (with a swab from the cervix) seems to be justified. If high risk types are detected, the persistence of the infection should be checked. As a rule, the immune system can successfully fight the infection, so that after two years it can no longer be detected in most women. However, if the infection with high-risk types persists, the risk of developing cervical cancer increases significantly.

Larger condylomas (especially condylomata gigantea) can obstruct the birth canal, which can make birth by caesarean section appear necessary. In general, a caesarean section can reduce the risk of HPV transmission to the child, but it cannot reliably prevent it.

In rare cases, laryngeal papillomatosis can occur after low-risk types are passed on to the newborn during childbirth .

treatment

Medical interventions

In addition to surgical removal , wart removal with laser , electrocoagulation , cauterization (burns with cautery ) or cryotherapy (icing) is possible. During freezing, liquid nitrogen or other freezing sprays are used to try to remove the warts.

Swelling and scarring may appear after removal. If condylomas are also to be treated on the anus, there is a risk that the sphincter muscle will be injured so that it can either no longer close or it loses its stretching function, with the possible consequence of incontinence .

Medication

  • In the case of cauterization due to chemical burns , treatment is carried out with a wide variety of agents such as salicylic acid lotions , trichloroacetic acid , monochloroacetic acid or silver nitrate . Many common "limited virucidal" disinfectants are not suitable for disinfection because HPV is an unenveloped virus.
  • For external cytostatic treatment, drugs such as podophyllotoxin or 5-fluorouracil are applied. Treatment with podophyllin is now considered obsolete due to increased toxicity and the suspicion of carcinogenic effects. As a substitute for this, there is now the main active ingredient podophyllotoxin, which is isolated from podophyllin and is much more tolerable, in the form of an ointment (Wartec) or a solution (Condylox) for home use.
  • Experimentally, isotretinoin has been shown to be effective in cases of genital warts that could not be treated by other therapies. However, due to the severe side effects of isotretinoin, this therapy is rarely performed. There are few studies of isotretinoin's use on genital warts, and this therapy is off-label .
  • Strengthening the immune defense to fight the wart-causing viruses with drugs such as interferon , sinecatechins (green tea extracts) (Veregen, VeregenRX) and imiquimod (Aldara) provokes a localized inflammation, stimulates the local production of antibodies and leads to an increased production of interferons, which have a tumor-inhibiting effect. On average, consistent therapy with imiquimod ointment is successful in every second patient. After successful therapy with imiquimod, the recurrence rate should be lower than with the other available forms of therapy. Therefore, the cream is sometimes also prescribed for postoperative prevention of recurrences. Polyphenon E ointment (Veregen), similar to imiquimod, has an immunomodulating effect and achieved similar success rates with a low rate of relapse in approval studies.

All of the treatment methods mentioned can be associated with more or less painful irritations due to the exposed position of the affected parts of the body. In addition, the therapy is often lengthy and requires a high level of discipline from the patient. The existence of a ping pong effect is controversial. However, consistent condom use seems to support the healing process. At this point, however, it should be pointed out again that condoms generally significantly reduce the risk of infection by HPV, but do not guarantee complete protection.

Immunosuppression

This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.
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People who are being treated with drugs that are supposed to suppress the immune system ( immunosuppression ), such as cancer or lupus erythematosus , are also susceptible to such an infection .

Treatment methods with no proven effect

In addition to the treatment methods recognized by conventional medicine, alternative drugs are also offered. In particular, thuja or tea tree oil is said to have positive effects. Several herbal ointments and solutions are also offered on the Internet, the effectiveness of which has never been proven in scientific studies.

outlook

  • Several therapeutic vaccinations against HPV are in early clinical trials. The therapy of dysplasias caused by high-risk types is the focus of interest. However, research is also being carried out into therapeutic vaccines against low-risk types that cause condylomata acuminata. In contrast to the only available vaccine against genital warts ( Gardasil ) that the L1 capsid - proteins containing HPV types 6, 11 (Low Risk) and 16, 18 (High Risk) and only prophylactic protects containing therapeutic vaccines mostly the tumor- expressed proteins E1, E2, E6 or E7 and therefore stimulate the immune system to reject already infected cells. The only exception is the experimental therapeutic vaccination against genital warts, which is being researched in Australia and the People's Republic of China (see next point).
  • A phase 2 clinical study at the University of Queensland (Australia) in collaboration with the Wenzhou Medical College (China) was intended to clarify whether immunization with L1 VLPs without adjuvant has a therapeutic effect on HPV infections. In a pilot study from 1999, immunization with L1 VLPs resulted in complete regression of the warts in approx. 75% of the study participants within 20 weeks. From this, the scientists concluded that the protein L1 may also be suitable for therapeutic vaccination. The aluminum adjuvant used in Gardasil® seems to prevent the cytotoxic effects necessary for a therapeutic effect . The study was due to end in April 2008, with results expected to be released towards the end of the same year. A market launch was estimated and would be expected in 2012 at the earliest if the study results were positive. In 2018, therapeutic vaccinations were still in development.
  • In 2010, a phase III study on the efficacy of low-dose cyclophosphamide (7 days 50 mg / d) was terminated after laser therapy. There was a complete remission and no recurrence.

prevention

The most effective ways of preventing infection are abstinence and vaccination . Safer sex does not offer complete protection, but it does significantly reduce the risk of infection. The prophylactic HPV vaccine Gardasil against HPV types 6, 11, 16 and 18 - approved by the American Medicines Agency (FDA) in the USA in June 2006, by the European Medicines Agency in the EU in September 2006 - protects according to the existing ones 100% examinations before infection with the named virus types. Boys 9 to 15 years of age developed immunity after vaccination . The quadrivalent vaccine was judged to be effective in a study of 4,065 boys and men aged 16 to 26 years. A worldwide clinical study for the prevention of venereal diseases, especially genital warts, is ongoing for homosexual men, as well as studies with the HPV vaccine. The aim is a vaccination to prevent anal and penile cancer , the development of which is also associated with infections caused by HPV. Because of the transmission route, homosexual men are at increased risk of developing anal cancer .

All HPV vaccines are preventive; an existing HPV infection cannot be treated or even eliminated. The initial vaccination should therefore be completed before the first sexual intercourse, as the vaccination does not seem to have any effect on existing infections. As with all new drugs and procedures, a final assessment of the efficacy and tolerability is not possible, but side effects do not seem to play a role so far. It is unclear how long such vaccination protection will last. So far, a basic vaccination with three vaccinations at intervals of zero, two and four to six months has been recommended, there are no guidelines for vaccination booster, since long-term studies on the course of the protective effect over the entire life span are inevitably lacking. Since the vaccination is not effective against all HPV types, vaccinated women should definitely use the preventive medical check-ups against cervical cancer (from the age of 20).

In 2011, the first data were published after the introduction of a comprehensive vaccination program with a quadrivalent vaccine. The program was established in Australia in 2007. The vaccination rate there is 80 to 90 percent. Just three years after the start of the vaccination campaign, the cancer precursors requiring treatment in girls under 18 years of age have fallen by 59 percent.

Web links

Commons : Images about Genital Warts  - Collection of images, videos and audio files

Individual evidence

  1. ↑ Cloe Borton, Laurence Knott: Human Papillomavirus and Genital Warts , July 19, 2013; Retrieved April 24, 2015
  2. ↑ What are genital warts and how common are they? , Sexskrankheiten.de - the information portal for sexually transmitted diseases; Retrieved April 18, 2015
  3. ↑ a b c Dr. med. Harald Bresser: Condylomas, genital warts, HP viruses: diagnosis, cause, treatment of genital warts
  4. ^ Condom Use and the Risk of Genital Human Papillomavirus Infection in Young Women. (PDF) In: The new england journal of medicine. June 22, 2006, (English).
  5. ↑ a b c Anal genital warts . ( Memento of the original from April 5, 2015 in the Internet Archive ; PDF) Info: The archive link was inserted automatically and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. Guidelines of the German Society for Coloproctology; Retrieved April 22, 2015 @1@ 2Template: Webachiv / IABot / www.awmf.org
  6. ↑ Intimate shaving favors genital warts. (No longer available online.) In: www.schleswig-holstein.de. The Prime Minister of Schleswig-Holstein - State Chancellery, archived from the original on May 3, 2015 ; accessed on July 13, 2017 .
  7. ↑ What are genital warts? What causes genital warts? medicalnewstoday.com; Retrieved April 22, 2015
  8. ↑ Susanne Krüger Kjær, Trung Nam Tran, Par Sparen, Laufey Tryggvadottir, Christian Munk, Erik Dasbach, Kai-Li Liaw, Jan Nygård, Mari Nygård: The Burden of Genital Warts: A Study of Nearly 70,000 Women from the General Female Population in the 4 Nordic Countries. In: The Journal of Infectious Diseases. 196, 2007, p. 1447, doi: 10.1086 / 522863 .
  9. ↑ arhp.org
  10. ↑ a b Human papilloma viruses and cancer: Answers to frequently asked questions - Paths of infection: How are the viruses transmitted? , Cancer Information Service of the German Cancer Research Center (DKFZ), Heidelberg. February 17, 2014. Last accessed September 4, 2014.
  11. ↑ digene.de (PDF)
  12. ↑ Frequently asked questions about human papillomavirus (HPV) and cervical cancer . cervical cancer consortium europe
  13. ↑ Renate Huch, Klaus D. Jürgens (ed.): Mensch, Körper, Illness . 6th edition. Elsevier / Urban & Fischer, Munich 2011, ISBN 978-3-437-26792-5 , pp. 138, 409.
  14. ↑ Dr. med. Nonnenmacher: Genital warts (HPV). March 19, 2014; Retrieved April 24, 2015
  15. ↑ Risk factors for infection with HPV and the development of genital warts. geschlechtskrankheiten.de; Retrieved April 22, 2015
  16. ^ A b Volker Schumpelick, Niels Bleese, Ulrich Mommsen et al .: Kurzlehrbuch Chirurgie p. 364, 8th edition, Georg Thieme Verlag, Stuttgart New York, ISBN 978-3-13-127128-0
  17. ^ Condylomata . ( Memento of the original from December 20, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. University of Munich, patient information. @1@ 2Template: Webachiv / IABot / www.klinikum.uni-muenchen.de
  18. ↑ a b c HPV-associated lesions of the external genital region and the anus - genital warts and precancerous stages of the vulva, penis, and peri- and intra-anal skin . (PDF) AWMF Guideline 082-008, accessed on August 14, 2019
  19. ^ Histology and cytology of benign and malignant changes in the vulva . ( Memento of the original from March 21, 2005 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF) aixcyto.de @1@ 2Template: Webachiv / IABot / www.aixcyto.de
  20. ↑ Papillomavirus (HPV) diagnostics . labor-bo.de
  21. ^ Max Höfler: German book of names of diseases. Munich 1899, p. 781.
  22. ↑ Jürgen Martin: The 'Ulmer Wundarznei'. Introduction - Text - Glossary on a monument to German specialist prose from the 15th century. Königshausen & Neumann, Würzburg 1991 (= Würzburg medical-historical research. Volume 52), ISBN 3-88479-801-4 (also medical dissertation Würzburg 1990), p. 185.
  23. ^ Statement of the German Society for Cytology (DGZ) on the primary screening for human papilloma viruses ( Memento of the original of July 9, 2007 in the Internet Archive ) Info: The archive link was inserted automatically and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 120 kB) @1@ 2Template: Webachiv / IABot / www.dgz.de
  24. ↑ Pregnancy and HPV ( Memento of the original from October 4, 2012 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Health Department Baden-Württemberg @1@ 2Template: Webachiv / IABot / www.gesundheitsamt-bw.de
  25. ↑ Replacement for podophyllin-containing formulations . dermotopics.de, edition 2/2001, Gesellschaft für Dermopharmazie e. V.
  26. ↑ S. Georgala, AC Katoulis, C. Georgala, E. Bozi, A. Mortakis: Oral isotretinoin in the treatment of recalcitrant condylomata acuminata of the cervix: a randomized placebo-controlled trial . In: Sexually Transmitted Infections . 80, No. 3, November 2004, pp. 216-218. doi : 10.1136 / sti.2003.006841 .
  27. ↑ Virendra N. Sehgal, Govind Srivastava, Kabir Sardana: Isotretinoin - unapproved indications / uses and dosage: a physician's reference . In: International Journal of Dermatology . 45, No. 6, May 2006, pp. 772-777. doi : 10.1111 / j.1365-4632.2006.02830.x .
  28. ↑ Veregen®: local ointment made from green tea extract against genital warts (Condylomata acuminata) ( Memento of the original from July 4, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. at Medknowledge, 2010 @1@ 2Template: Webachiv / IABot / www.medknowledge.de
  29. ↑ Warts vaccine: one of many in pipeline . The University of Queensland Australia (English)
  30. ↑ LF Zhang, et al .: HPV6b virus like particles are potent immunogens without adjuvant in man. In: Vaccine. Volume 18, Numbers 11-12, January 2000, pp. 1051-1058, PMID 10590325 .
  31. ↑ Website of the International RRP ISA Center ( Memento of the original from March 12, 2008 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / rrpwebsite.org
  32. ↑ Protection at a price . australiandoctor.com.au, October 26, 2006 (English).
  33. ↑ Hancock, Hellner, Dorrell: Therapeutic HPV vaccines . In: Best Pract Res Clin Obstet Gynaecol , 2018 Feb; 47, pp. 59-72, doi: 10.1016 / j.bpobgyn.2017.09.008 , PMID 29108943
  34. ↑ CD4 + FOXP3 + regulatory T cell depletion by low-dose cyclophosphamide prevents recurrence in patients with large condylomata acuminata after laser therapy . PMID 20338811
  35. ↑ Cervical cancer: condoms prevent HPV infections . ( Memento of the original from September 3, 2007 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. ärzteblatt-studieren.de, June 22, 2006 @1@ 2Template: Webachiv / IABot / www.aerzteblatt-studieren.de
  36. ^ Anna R. Giuliano et al .: Efficacy of Quadrivalent HPV Vaccine against HPV Infection and Disease in Males. In: N Engl J Med , No. 364, 2011, pp. 401-411, doi: 10.1056 / NEJMoa0909537 .
  37. ↑ HPV vaccination without therapeutic effect . ( Memento of the original from January 23, 2008 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. ärzteblatt.de, August 15, 2007. @1@ 2Template: Webachiv / IABot / www.aerzteblatt.de
  38. ↑ Early regression of cervical lesions after HPV vaccination.  ( Page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice. In: Deutsches Ärzteblatt. News of June 20, 2011.@1@ 2Template: Toter Link / www.aerzteblatt.de  
  39. ↑ Julia ML Brotherton, Masha Fridman, Cathryn L May, Genevieve Chappell, A Marion Saville, Dorota M Gertig: Early effect of the HPV vaccination program on cervical abnormalities in Victoria, Australia: an ecological study. In: The Lancet , No. 377, 2011, pp. 2085-2092, doi: 10.1016 / S0140-6736 (11) 60551-5 .