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The Department of Health has chosen the bivalent vaccine Cervarix™ for its national vaccination programme in England. Although this will protect against human papilloma virus (HPV) 16 and 18, which cause 70% of cervical cancers, it will offer no protection against genital warts. In 2006, there were 83 745 new diagnoses of genital warts (first episode) and 44 655 recurrent episodes in patients attending departments of genitourinary medicine in England, Wales, and Scotland.1 In addition to the financial implications of treating patients with anogenital warts, estimated at £22.4 million in 2003, the psychological impact of the disease should not be underestimated.
HPV is the commonest sexually transmitted viral infection in the developed world and of the almost 200 types of HPV; about 40 infect the ano-genital tract.2 ‘Low risk’ types, such as HPV 6 and 11, cause genital warts and minor cervical cellular abnormalities (for example, borderline changes or mild dyskaryosis on cytology) whereas ‘high-risk’ types, such as HPV 16 and 18, may cause high-grade dysplasia (intraepithelial neoplasia) and cancer of the cervix, vulva, vagina, penis, and anus. Approximately 80% of sexually active individuals will at some time become infected with HPV. Most HPV infection is subclinical, producing no signs or symptoms and studies of cervical infection show that about 80% of women clear the virus within 2 years of infection.3
Approximately two-thirds of people exposed to HPV 6 or 11 will develop genital warts, most commonly within a few months of exposure, although occasionally the incubation period can be much longer. The treatment of genital warts should be determined by taking into consideration wart type (keratinised/non-keratinised), site, number and patient preference. For example, multiple non-keratinised warts may be suitable for self-applied podophyllotoxin or imiquimod (the latter is more expensive — British National Formulary prices: approximately £15 & £51 respectively), whereas larger keratinised lesions are best approached by cryotherapy or excision/diathermy (requires local anaesthetic, preferably post-application of EMLA® cream). Perianal warts are not necessarily acquired by anal intercourse and are not infrequently misdiagnosed as hemorrhoids (usually in cases where an examination has not been performed). Women with genital warts do not require more frequent cervical cytology and colposcopy is only recommended in women with abnormal cytology (as per NHS Cervical Screening Programme) or with cervical lesions of diagnostic uncertainty or clinical concern.