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9. Genito-urinary diseases
Veneral warts
Venereal w arts are benig n tum ours of th e skin or m ucous m em branes d ue to certain
papillom a v iruses (HP V ).
Clinical features
– Venereal w arts are soft, raised , painless g rowth s, som etim es clustered (cauliflower-
like appearance) or m acules (flat warts), wh ich are m ore d ifficult to d iscern. W arts
can be external (v ulv a, penis, scrotum , perineum , anus) and /or internal (v ag ina,
cerv ix, ureth ra, rectum ; oral cav ity in HIV infected patients).
– In w om en, th e presence of external warts is an ind ication for a speculum exam ination
to exclud e v ag inal or cerv ical warts. S peculum exam m ay rev eal a friable, fung ating
tum our on th e cerv ix, sug g estiv e of cancer associated with papillom a v1 irus .
Treatment
Ch oice of treatm ent d epend s on th e size and location of th e w arts. T reatm ent m ay be 9
less effectiv e, and relapses m ore frequent, in HIV infected patients.
External warts < 3 cm and vaginal warts
podophyllotoxin 0.5% 2 solution m ay be self-applied by th e patient, but in th e ev ent of
v ag inal warts, th e treatm ent m ust be applied by m ed ical staff.
E xplain th e proced ure to th e patient: apply th e solution to th e warts using an applicator
or cotton bud , sparing th e surround ing h ealth y skin, allow to air d ry.
O n v ag inal w arts, th e solution sh ould be allow ed to d ry before th e speculum is
with d rawn.
Apply th e solution twice d aily, 3 consecutiv e d ays per week, for up to 4 weeks.
P od oph yllum preparations are contra-ind icated in preg nan3t or breastfeed ing wom en.
T h ey sh ould not be applied on cerv ical, intra-ureth ral, rectal, oral or extensiv e warts.
Im proper use m ay result in painful ulceration.
External warts > 3 cm; cervical, intra-urethral, rectal and oral warts; warts in pregnant
or breastfeeding women
S urg ical excision or cryoth erapy or electrocoag ulation.
1 Certain types of HPV may cause cancer. Presence of genital warts in women is an indication to screen for
pre-cancerous lesions of the cervix, if feasible in the context (visual inspection with acetic acid, or cervical
smear, or other available techniques), and to treat any lesions identified (cryotherapy, conisation, etc., according
to diagnosis).
2 Podophyllum 10%, 15% or 25% resin is another preparation which is much more caustic, and should be applied
only by medical staff. Protect the surrounding skin (vaseline or zinc oxide ointment) before applying the resin.
Wash off with soap and water after 1 to 4 hours. Apply once weekly for 4 weeks.
3 Treatment of warts is not an emergency and may be deferred if alternatives to podophyllum preparations are not
available. Genital warts are not an indication for caesarean section: it is uncommon for warts to interfere with
delivery, and the risk of mother-to-child transmission is very low.
243
Veneral warts
Venereal w arts are benig n tum ours of th e skin or m ucous m em branes d ue to certain
papillom a v iruses (HP V ).
Clinical features
– Venereal w arts are soft, raised , painless g rowth s, som etim es clustered (cauliflower-
like appearance) or m acules (flat warts), wh ich are m ore d ifficult to d iscern. W arts
can be external (v ulv a, penis, scrotum , perineum , anus) and /or internal (v ag ina,
cerv ix, ureth ra, rectum ; oral cav ity in HIV infected patients).
– In w om en, th e presence of external warts is an ind ication for a speculum exam ination
to exclud e v ag inal or cerv ical warts. S peculum exam m ay rev eal a friable, fung ating
tum our on th e cerv ix, sug g estiv e of cancer associated with papillom a v1 irus .
Treatment
Ch oice of treatm ent d epend s on th e size and location of th e w arts. T reatm ent m ay be 9
less effectiv e, and relapses m ore frequent, in HIV infected patients.
External warts < 3 cm and vaginal warts
podophyllotoxin 0.5% 2 solution m ay be self-applied by th e patient, but in th e ev ent of
v ag inal warts, th e treatm ent m ust be applied by m ed ical staff.
E xplain th e proced ure to th e patient: apply th e solution to th e warts using an applicator
or cotton bud , sparing th e surround ing h ealth y skin, allow to air d ry.
O n v ag inal w arts, th e solution sh ould be allow ed to d ry before th e speculum is
with d rawn.
Apply th e solution twice d aily, 3 consecutiv e d ays per week, for up to 4 weeks.
P od oph yllum preparations are contra-ind icated in preg nan3t or breastfeed ing wom en.
T h ey sh ould not be applied on cerv ical, intra-ureth ral, rectal, oral or extensiv e warts.
Im proper use m ay result in painful ulceration.
External warts > 3 cm; cervical, intra-urethral, rectal and oral warts; warts in pregnant
or breastfeeding women
S urg ical excision or cryoth erapy or electrocoag ulation.
1 Certain types of HPV may cause cancer. Presence of genital warts in women is an indication to screen for
pre-cancerous lesions of the cervix, if feasible in the context (visual inspection with acetic acid, or cervical
smear, or other available techniques), and to treat any lesions identified (cryotherapy, conisation, etc., according
to diagnosis).
2 Podophyllum 10%, 15% or 25% resin is another preparation which is much more caustic, and should be applied
only by medical staff. Protect the surrounding skin (vaseline or zinc oxide ointment) before applying the resin.
Wash off with soap and water after 1 to 4 hours. Apply once weekly for 4 weeks.
3 Treatment of warts is not an emergency and may be deferred if alternatives to podophyllum preparations are not
available. Genital warts are not an indication for caesarean section: it is uncommon for warts to interfere with
delivery, and the risk of mother-to-child transmission is very low.
243
