If the topic of genital warts pops up in conversation amongst your peers, it can often feel awkward, due to the stigma surrounding STIs.
You’ve probably heard of human papillomavirus (HPV), maybe from sexual health classes in school or through discussions with your friends. But, did you know genital warts are caused by HPV?
According to the NHS, genital warts are amongst the most prevalent sexually transmitted infections (STIs) in the United Kingdom. The CDC has stated that HPV is so common, nearly every sexually active person will contract some form of HPV in their lifetime.
With all of that being said, if you are experiencing pain during urination or are noticing unusual penile or vaginal discharge, you should order a test kit from us to exclude the possibility of an STI.
If you have noticed any unusual genital growths, we urge you to visit your GP or local GUM clinic for a physical examination, as well as a full STI screen.
What is Human Papillomavirus (HPV)?
HPV is a group of more than 200 related viruses, making it one of the most common STIs. In addition to causing genital warts, HPV can also lead to different types of cancers (including cancers of the cervix, vagina, vulva, penis, anus, mouth, and throat).
HPV usually goes away within a couple of years, as the body fights the virus off naturally. However there are times when HPV stays in the body for many years, and it is this long term infection with HPV that can lead to the aforementioned cancers.
Although there are 14 different strains of HPV that are considered 'high-risk' for cancer development, there are two strains - HPV 16 and HPV 18 - which are largely responsible for genital warts and HPV-related cancers.
HPV can be spread by having vaginal, anal, or oral sex with someone who has the virus, even if the infected person doesn’t have any symptoms. Approximately 10% of people infected with HPV will transmit the virus, and about 10% of those exposed who contract HPV will develop genital warts.
The good news is that there is a vaccine to protect against HPV! Because there are so many different strains of HPV, the vaccine can’t protect against them all. So while the vaccines were designed to protect against the strains that are most likely to cause cancer, they ALSO protect against 90% of the HPV strains that cause genital warts! Some protection is better than no protection!
Since 2008, NHS England recommends that all girls ages 12-13 years should receive the HPV vaccine as part of their routine immunisation schedule. It wasn’t until a decade later that the policy was updated to include vaccination for boys of the same age. In 2018 the NHS also began to offer the HPV vaccine to men who have sex with men (MSM) and other LGBTQ+ individuals (aged 45 and under).
What Are Genital Warts?
Genital warts are growths on the skin that resemble the shape and structure of a skin tag - a painless, non-cancerous skin growth.
Genital warts are a recognized symptom of HPV infection and present as visible lesions on the sexual organs. These lesions can occur in various shapes and sizes, and can have a significant impact on a person’s sexual confidence.
Genital warts can be treated and removed - but there is a chance of recurrence! We’ll delve into all the details you need below.
What Are The Causes Of Genital Warts?
Genital warts are a result of HPV. HPV 6 and HPV 11 are the most common causes of genital warts and account for nearly 90% of cases.
How Do Genital Warts Spread?
Genital warts, like many other STIs, are transmitted through sexual contact, including:
● Vaginal sex
● Anal sex
● Oral sex - genital warts can be spread through oral sex, although this is less common than transmission during vaginal or anal sex.
Ejaculation doesn’t have to occur for genital warts to spread, as they are primarily transmitted through skin-to-skin contact during penetrative sex (NOTE: there is currently not enough evidence to conclusively state that genital warts can be regularly spread through other means of skin-to-skin contact e.g kissing).
Common Signs And Symptoms Of Genital Warts
Many STIs remain undiagnosed and are unintentionally transmitted due to their lack of symptoms. Genital warts are no exception, as it may be weeks or months after contracting an HPV infection before warts begin to show.
When present, genital warts can appear on sexual organs in both men and women. Genital warts are not always easily visible, particularly if they are small in size and match the colour of your skin. Genital warts can occur in clusters, or, more commonly, as a single wart.
In Men
The most common presentation of genital warts is, well, a wart, located on one’s:
● Penis
● Scrotum
● Groin
● Thighs
● Anus
In Women
In women, genital warts can present in the following regions:
● Vagina (internal or external)
● Anus
● Thighs
In addition to genital warts, individuals infected with HPV 6 and/or HPV 11 may also experience the following symptoms:
● Itching
● Redness
● Bleeding from the warts
● General discomfort around the groin area such as pain, inflammation, or chafing
When looking for genital warts, you should keep an eye out for some characteristic features, such as:
● Flat
● Dome-shaped
● Cauliflower-shaped
● Coloured with a darker pigmentation
We need to remember that genital warts can also be spread via oral sex. In such situations, warts can occur on the oral mucosa around the mouth, throat, tongue, and neck.
When Do Genital Warts Develop?
In approximately 65% of cases, genital warts develop between 3 weeks and 8 months after contact with an infected sexual partner. This is known as an incubation period, which is the time between initial exposure to an infection and development of the first symptom.
However, the HPV virus can also lay dormant for the entirety of an individual’s lifetime, meaning that some people can readily transmit the infection without ever experiencing any symptoms.
Am I At Risk Of Contracting Or Transmitting Genital Warts?
In short, if you are sexually active, yes. All sexually active individuals are capable of transmitting or contracting a variant of HPV--some which can cause genital warts--during their lifetime.
There are a variety of factors associated with an increased risk of contracting genital warts, such as:
● Those younger than 30 years - HPV testing is limited in people under the age of 30 due to the commonality of infection.
● Those who smoke - studies have shown a 23% increase in the diagnosis of genital warts in smokers.
● Those who are immunosuppressed - immunosuppressed people have weakened immune systems, making them more susceptible to infection.
● Those who are pregnant - have a risk of transmitting genital warts to their newborns during birth; furthermore, genital warts can grow larger during pregnancy, causing more painful urination and more bleeding during delivery.
● Those who have unprotected sex
Long-Term Complications
Long-term complications of genital warts are dependent upon the underlying HPV strain. For example, HPV 16 and 18 are associated with 70% of cervical cancers. These HPV strains can also cause precancerous dysplasia of the vulva, penile cancer and anal cancer. HPV 6 and HPV 11 (the main strains that cause genital warts) have even been shown to have a low-risk association with a type of skin cancer (a melanoma called verrucous carcinoma)!
Diagnosing Genital Warts
The majority of genital wart diagnoses are made visually, and should be done by a medical professional. However in some cases, a small biopsy (a medical procedure that involves taking a tissue sample) is carried out to confirm the nature of the wart. Biopsies are usually taken when the warts are unresponsive to treatment, a sudden regrowth occurs, or an unusual pigmentation is observed.
If you begin to experience any symptoms relating to pain during urination, penile or vaginal discharge, or pain during intercourse, we recommend that you take an STI test to help rule out any underlying STIs.
For Women
The NHS runs a cervical cancer screening program for women in the UK, which involves a pap smear swab test every 3 - 5 years, from the ages of 25 until 65. The pap smear test looks for evidence of HPV and/or early changes in cells that can lead to cervical cancer.
In women, genital warts can also occur inside of the vagina, so a pelvic exam may be also required during screening to identify warts which may not be visible externally.
Treatment
Genital warts come and go. Sometimes lesions can disappear by themselves, and other times you may require medications or minor procedures to help alleviate the pain and discomfort.
Genital warts cannot be treated using over-the-counter medication. Instead, your doctor may need to prescribe the following medications to help treat your symptoms:
● Imiquimod
● Podophyllin and podofilox
● Trichloroacetic acid
These are creams or liquids which you apply to warts a few times a week. Over the course of a few weeks, you should begin to notice a considerable reduction in the number and size of the warts.
However, if topical treatment has been ineffective, minor procedures can be carried out to help remove warts, such as:
● Freezing
● Laser
● Excision (with a local anaesthetic)
● Injection with the drug interferon
● Electrocautery (using heat and electrical current to remove genital warts)
Finally, we need to reiterate that while most HPV infections clear up on their own, some can stay in the body for years. There is currently no cure for HPV, but with prompt diagnosis and adequate symptom control, people with genital warts can lead healthy, fulfilling lives.
If you know you are infected with HPV, no matter how dormant the virus may be, we recommend that you have an open discussion with your doctor and any new sexual partner(s) to discuss safe sex methods.
The CDC recommends regular STI testing at least once a year and before any new sexual partners to help reduce transmission of STIs. Why not opt for one of our testing kits for a more discreet diagnosis?
Prevention
Genital warts are contracted through sexual contact with an individual infected with HPV. This means that various barrier methods (although not 100% effective) can be used to help reduce your risk of contracting or transmitting genital warts. Such barrier methods include:
● Condoms
● Dental dams - a flexible piece of latex used during oral sex to prevent direct mouth-to-genital contact
● Diaphragm - a small dome that blocks the cervix and prevents sperm from entering the womb
The NHS has a cervical screening program for people aged 25 - 64 years, who are registered as female with their GP, to help identify the presence of HPV strains associated with cervical cancer. Trans men are not automatically enrolled onto the service, but can still receive regular screening if they have a cervix.
Vaccination
As part of the NHS vaccination program, all children between the ages of 12-13 years are offered the HPV vaccine. By protecting against HPV strains 16 and 18, this vaccine helps prevent cervical cancers, cancers of the mouth, throat and genitals, as well as prevent genital warts.
The vaccine Gardasil-9, is a 9-valent vaccine that protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.
As of April 2018, men who have sex with men (MSM) are also eligible for free HPV vaccination on the NHS.
Both doses of the vaccine are required for efficacy. The HPV vaccine is offered by the NHS up until the age of 25 years. Anyone between the ages of 26 - 45 is advised to arrange a consultation with their doctor to determine if they would benefit from receiving the vaccine.
As we get older, the vaccine becomes less efficient, meaning that further boosters are needed to maintain efficacy. This is because the HPV vaccines are meant to be prophylactic, and are therefore most effective when given pre-exposure. Individuals over the age of 25 are more likely to have been exposed to HPV.
Conclusion
Genital warts are extremely common. Owing to the risk of cancer associated with various HPV strains, a vaccination program has been rolled out to help reduce any risk of transmission.
Genital warts can reoccur once treated, as there is no cure for HPV. Treatment is recommended to help alleviate the pain and discomfort associated with genital warts, and help to prevent warts from developing into more chronic health complications.
If you believe that you have genital warts, we recommend that you attend your local GUM clinic for prompt diagnosis and treatment. However, if you do not have any visible lesions but are suffering from other signs or symptoms of an STI (such as discomfort when peeing or any unusual itching or discharge), then consider ordering a discreet STI test and book an appointment with your GP to help discuss your treatment options.
Lastly, we believe that having an open discussion with any new sexual partner(s) can help break down the stigma surrounding STIs, lead to safer sexual practices, and prevent unintended STI transmissions.
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Hassan Thwaini is a qualified Clinical Pharmacist who has completed his Master's degree at the University of Sunderland. Since then he has not only pursued community and clinical pharmacy, but has expanded to aid in humanitarian work across the less fortunate areas of the globe. Hassan is currently working as a medical writer and has successfully been published within various nutritional websites, produced unique content for his university board, and carried out research for renowned surgeons.
