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Anogenital warts

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Updated 2024 EAU guidelines for the management of anogenital warts.

Background

Overview

Definition
Anogenital warts, also known as condylomata acuminata, are a STI caused by certain strains of the HPV, primarily HPV genotypes 6 and 11.
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Pathophysiology
The pathophysiology of anogenital warts involves the transmission of HPV through sexual contact, leading to the infection of squamous epithelial cells in the anogenital region. The virus causes these cells to proliferate excessively, resulting in the formation of warts.
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Epidemiology
The incidence of anogenital warts is estimated at 160-289 per 100,000 person-years worldwide.
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Disease course
Clinically, anogenital warts present as growths on the skin or mucous membranes of the anogenital area. They can vary in size and shape, ranging from flat to raised, small to large, and singular to multiple. Some warts may be asymptomatic, while others can cause symptoms such as itching, discomfort, or bleeding.
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Prognosis and risk of recurrence
The prognosis of anogenital warts is generally good as they are usually benign. However, they can recur after treatment, and certain high-risk HPV strains can lead to malignancies, such as SCC.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of anogenital warts are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024), the Center for Disease Control (CDC 2021,2019), the International Union Against Sexually Transmitted Infections (IUSTI 2020), the American College of Obstetricians and Gynecologists (ACOG 2017), and the American Society of Colon ...
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Diagnostic investigations

Physical examination: as per CDC 2021 guidelines, consider performing inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy in patients with external anal warts, as they might also have intra-anal warts.
E
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  • Screening for STIs

  • Screening for cervical cancer

  • Assessment of sexual partners

Diagnostic procedures

Biopsy: as per CDC 2021 guidelines, perform a biopsy in female patients with exophytic cervical warts to exclude high-grade squamous intraepithelial lesion before initiating treatment.
E

Medical management

Imiquimod: as per EAU 2024 guidelines, offer self-administered imiquimod 5% cream, applied to all external warts overnight thrice weekly for 16 weeks, for the treatment of anogenital warts.
A

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  • Podophyllotoxin

  • Sinecatechins

  • Trichloracetic acid

  • 5-FU

  • Management of internal involvement (intra-anal)

  • Management of internal involvement (urethral)

  • Management of internal involvement (vaginal)

  • Management of internal involvement (cervical)

Nonpharmacologic interventions

Smoking cessation: as per IUSTI 2020 guidelines, advise smoking cessation for general health benefit, recognizing that there is no evidence that smoking cessation improves outcomes of wart treatment.
B

Therapeutic procedures

Intralesional interferon injection: as per IUSTI 2020 guidelines, consider offering intralesional interferon injections in patients with refractory anogenital warts.
B

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  • Cryotherapy

  • Photodynamic therapy

Perioperative care

Considerations for ambulatory anorectal surgery: as per ASCRS 2015 guidelines, recognize that anorectal surgery May be safely and cost-effectively performed in an ambulatory surgery center.
B
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Surgical interventions

Surgical excision: as per EAU 2024 guidelines, offer surgical management (excision, electrosurgery, electrocautery, or laser therapy) of anogenital warts based on an informed discussion with the patient.
A

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  • Male circumcision

Specific circumstances

Pregnant patients: as per IUSTI 2020 guidelines, avoid using topical treatments during pregnancy. Offer ablation using cryotherapy, trichloracetic acid, or any surgical modality in pregnant patients. Cooperate with the obstetrician.
D
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Patient education

Patient education
As per IUSTI 2020 guidelines:
Provide patients with a detailed explanation of their condition, including advice about onward transmission,
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and offer them clear and accurate written information.
B
Advise on condom use when either partner has genital warts until resolution of lesions,
A
while informing them that condoms offer only partial protection against onward transmission.
B

Preventative measures

HPV vaccination: as per EAU 2024 guidelines, offer HPV vaccination in men after surgical removal of high-grade AIN.
B
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Follow-up and surveillance

Follow-up: as per IUSTI 2020 guidelines, obtain follow-up at regular intervals, such as every 4 weeks, until warts have resolved, and switch treatments in case of an inadequate response.
B