# Presentation: 479966

## Genital Human Papillomavirus (HPV) 

## Learning Objectives

- Upon completion of this content, the learner will be able to:
- Describe the epidemiology of genital HPV infection in the U.S.
- Describe the pathogenesis of genital HPV.
- Discuss the clinical manifestations of genital HPV infection.
- Identify methods used to diagnose genital warts and cervical cellular abnormalities.
- Discuss CDC-recommended treatment regimens for genital warts.
- Summarize appropriate prevention counseling messages for genital HPV infection.
- Describe public health measures for the prevention of genital HPV infection.

## Lessons

- Epidemiology of genital HPV infection in the U.S.
- Pathogenesis
- Clinical manifestations and sequelae
- Diagnosis of genital warts and cervical cellular abnormalities
- Patient management
- Patient counseling and education
- Partner management and public health measures

## Lesson I: Epidemiology of Genital HPV Infection in the U.S. 

## Introduction

- Genital HPV is one of the most common STDs.
- More than 30 HPV types can infect the genital tract.

- Epidemiology

## Introduction

- HPV types are divided into 2 groups based on their association with cervical cancer:
- Low-risk types associated with genital warts and mild Pap test abnormalities
- High-risk types associated with mild to severe Pap test abnormalities and cervical cancer
- Most genital HPV infections are transient, asymptomatic, and have no clinical consequences.

- Epidemiology

## Incidence in the U.S.

- Estimated annual incidence of sexually transmitted HPV infection is 6.2 million
- Estimated $1.6 billion spent annually in direct medical costs to treat symptoms of genital HPV infection
- Estimated 20 million people currently have a detectable genital HPV infection

- Epidemiology

## Prevalence in the U.S.

- It is estimated that at least 50% of sexually active men and women acquire genital HPV at some point in their lives.
- A recent estimate suggests 80% of women will have acquired genital HPV by the age of 50.

- Epidemiology

## Incidence and Prevalence of HPV-associated Diseases

- Genital warts
- Incidence may be as high as 100/100,000.
- An estimated 1.4 million are affected at any one time.
- Cervical cancer
- Rates of cervical cancer have fallen by approximately 75% since the introduction of Pap screening programs.
- Incidence is estimated at 8.3/100,000.

- Epidemiology

## Delay Adjusted Incidence and U.S. Death Rates of Cervical Cancer by Year of Diagnosis and Race: 1973-2001

- Epidemiology

## Transmission of Genital HPV

- Predominantly associated with sexual activity
- Can occur from asymptomatic and subclinical patients
- Infectivity after treatment of genital warts or cervical cell abnormalities is unknown

- Epidemiology

## Risk Factors for Women 

- Young age
- Sexual behavior
- Risk increases with increasing lifetime number of male sex partners
- Early age of first sexual intercourse
- Sexual behavior of male sex partners–risk increases for women whose sex partners had multiple sex partners
- Immune status–HPV more likely to be detected in immune-suppressed women

- Epidemiology

## Risk Factors for Men

- Greater lifetime number of sex partners
- Greater number of recent sex partners
- Being uncircumcised

- Epidemiology

## Lesson II: Pathogenesis

## Virology

- Double-stranded DNA virus that belongs to the Papovaviridae family
- Genital types have specific tropism (affinity) for genital skin and mucosa
- Infection generally indicated by the detection of HPV DNA or capsid protein

- Pathogenesis

## HPV Genotyping System

- Low-risk types
- Most visible warts caused by HPV types 6 and 11
- Recurrent respiratory papillomatosis associated with HPV types 6 and 11
- High-risk types
- HPV types 16 and 18 found in more than half of anogenital cancers
- Most women with high-risk HPV infection have normal Pap test results and never develop precancerous cell changes or cervical cancer

- Pathogenesis

## Pathology

- HPV infects stratified squamous epithelium and stimulates cellular proliferation.
- Affected cells display a broad spectrum of changes ranging from benign hyperplasia to dysplasia to invasive carcinoma.

- Pathogenesis

## Natural History of HPV 

- Most genital HPV infections are transient, asymptomatic, or subclinical, and have no clinical consequences in immunocompetent individuals.
- The incubation period is unclear.
- The median duration of new cervical infections is 8 months but varies by type.
- Gradual development of an effective immune response is the likely mechanism for HPV DNA clearance.

- Pathogenesis

## Natural History of HPV (continued)

**Persistent infection** is infection that is not cleared by the immune system and is characterized by persistently detectable HPV DNA.
- HPV infection that persists is the most important factor for precancerous cervical cell changes and cervical cancer.
- Most women with persistent HPV infection do not develop cervical cancer precursors or cervical cancer.

- Pathogenesis

## Lesson III: Clinical Manifestations and Sequelae

## Clinical Manifestations and Sequelae

- In most cases, genital HPV infection is transient and has no clinical manifestations or sequelae.
- Clinical manifestations of genital HPV infection include:
- Genital warts
- Cervical cell abnormalities
- Anogenital squamous cell cancers
- Recurrent respiratory papillomatosis
- Most common clinically significant HPV infection manifestations:
- Genital warts
- Cervical cell abnormalities

- Clinical Manifestations

## Genital Warts: Appearance

- Condylomata acuminata
- Cauliflower-like appearance
- Skin-colored, pink, or hyperpigmented
- May be keratotic on skin; generally non-keratinized on mucosal surfaces
- Smooth papules
- Usually dome-shaped and skin-colored
- Flat papules
- Macular to slightly raised
- Flesh-colored, with smooth surface
- More commonly found on internal structures (i.e., cervix), but also occur on external genitalia
- Keratotic warts
- Thick horny layer that can resemble common warts or seborrheic keratosis

- Clinical Manifestations

## Genital Warts: Location

- Warts commonly occur in areas of coital friction.
- Perianal warts do not necessarily imply anal intercourse.
- May be secondary to autoinoculation, sexual activity other than intercourse, or spread from nearby genital wart site.
- Intra-anal warts are seen predominantly in patients who have had receptive anal intercourse.
- Patients with visible warts can be simultaneously infected with multiple HPV types.

- Clinical Manifestations

## Genital Warts: Symptoms

- Genital warts usually cause no symptoms other than the warts themselves.
- Vulvar warts--dyspareunia, pruritis, burning discomfort
- Penile warts--occasional itching
- Urethral meatal warts--occasional hematuria or impairment of urinary stream
- Vaginal warts--usually asymptomatic; occasional discharge/bleeding, obstruction of birth canal (secondary to increased wart growth during pregnancy)
- Perianal warts--usually asymptomatic; pain, bleeding on defecation, itching
- Most patients have fewer than 10 genital warts, with total wart area of 0.5-1.0 cm2.

- Clinical Manifestations

## Genital Warts: Duration

- May regress spontaneously or persist with or without proliferation.
- Frequency of spontaneous regression is unclear.
- Persistence of infection occurs, but frequency and duration are unknown.
- Recurrences after treatment are common.

- Clinical Manifestations

## Genital Warts and High-Risk HPV

- High-risk HPV types occasionally found in visible genital warts
- Associated with external genital (i.e., vulvar, penile, and anal) squamous intraepithelial lesions

- Clinical Manifestations

## Genital Warts in Preadolescent Children

- May be due to sexual abuse and should prompt an evaluation for such
- May also result from vertical transmission, and transmission of non-genital HPV types to genital surface, and possibly fomite transmission (although fomite transmission has never been documented)

- Clinical Manifestations

## Perianal Warts

- Clinical Manifestations

*Source*: Seattle STD/HIV Prevention Training Center at the University of Washington/ UW HSCER Slide Bank

## Vulvar Warts

- Clinical Manifestations

*Source:  *Reprinted with permission of Gordon D. Davis, MD.

## Penile Warts

- Clinical Manifestations

*Source*: Cincinnati STD/HIV Prevention Training Center

## Intrameatal Wart

- Clinical Manifestations

*Source*: Cincinnati STD/HIV Prevention Training Center

## Cervical Cell Abnormalities

- Usually subclinical
- Detected by Pap test, colposcopy, or biopsy
- Usually caused by high-risk HPV types
- Most of the time high-risk HPV types do not cause any abnormalities.
- Most women infected with high-risk HPV types have normal Pap test results.
- Often regress spontaneously without treatment

- Clinical Manifestations

## Classification of Cervical Cell Abnormalities 

- _2001 Bethesda System_
- Atypical squamous cells (ASC) are cells that do not appear to be completely normal.
- ASC–US—_a_typical _s_quamous _c_ells of _u_ndetermined _s_ignificance. Sometimes the changes are related to HPV infection. ASC–US changes are usually mild abnormalities.
- ASC–H—_a_typical _s_quamous _c_ells cannot exclude a _high_-grade squamous intraepithelial lesion.  ASC–H changes are more likely to be precancerous abnormalities.

- Clinical Manifestations

## Classification of Cervical Cell Abnormalities (continued)

- Low-grade squamous intraepithelial lesion (LSIL)--generally a transient infection with a high-risk HPV type
- High-grade squamous intraepithelial lesion (HSIL)--generally a persistent infection with a high-risk HPV type with a higher risk for progression to cervical cancer

- Clinical Manifestations

## Anogenital Squamous Cell Cancers

- HPV infection is causally associated with cervical cancer and probably other anogenital squamous cell cancers (e.g., anal, penile, vulvar, vaginal).
- Over 99% of cervical cancers have HPV DNA detected within the tumor.
- Persistent infection with a high-risk HPV type is necessary but not sufficient for the development of cervical cancer.

- Clinical Manifestations

## Recurrent Respiratory Papillomatosis 

- HPV infections in infants and children may present as laryngeal papillomatosis, also known as juvenile onset recurrent respiratory papillomatosis (JORRP).
- Respiratory papillomatosis is a rare condition, usually associated with HPV types 6 and 11.

- Clinical Manifestations

## Lesson IV: Diagnosis of Genital Warts and Cervical Cellular Abnormalities

## Diagnosis of Genital Warts

- Diagnosis is usually made by visual inspection with bright light.
- Diagnosis can be confirmed by biopsy when:
- Diagnosis is uncertain
- Patient is immunocompromised
- Warts are pigmented, indurated, or fixed
- Lesions do not respond or worsen with standard treatment
- There is persistent ulceration or bleeding

- Diagnosis

## Diagnosis of Genital Warts (continued)

- Use of type-specific HPV DNA tests for routine diagnosis and management of genital warts is not recommended.
- Acetic acid evaluation (acetowhitening) of external genitalia is not recommended.
- External genital warts are not an indication for cervical colposcopy or increased frequency of Pap test screening (assuming patient is receiving screening at intervals recommended by her health care provider).

- Diagnosis

## Differential Diagnosis of Genital Warts 

- Other infections
- Condylomata lata--tend to be smoother, moist, more rounded, and darkfield-positive for *Treponema pallidum*
- Molluscum contagiosum--papules with central dimple, caused by a pox virus; rarely involves mucosal surfaces

- Diagnosis

## Differential Diagnosis of Genital Warts (continued)

- Acquired dermatologic conditions
- Seborrheic keratosis
- Lichen planus
- Fibroepithelial polyp, adenoma
- Melanocytic nevus
- Neoplastic lesions
- Normal anatomic variants
- “Pink pearly penile papules”
- Vestibular papillae (micropapillomatosis labialis)
- Skin tags (acrochordons)

- Diagnosis

## Diagnosis of Cervical Cell Abnormalities 

- Cytology (Pap test)
- Useful screening test to detect cervical dysplasia (not HPV per se)
- Provides indirect evidence of HPV because it detects squamous epithelial cell changes that are almost always due to HPV

- Diagnosis

## Diagnosis of Cervical Cell Abnormalities (continued)

- Nucleic acid testing
- FDA-approved for two optional uses:
- To triage women with atypical cells of undetermined significance (ASC-US) Pap test results
- As an adjunct to the Pap test to screen for cervical cancer in women 30 years or older.
- Use of HPV DNA testing for women with SIL Pap test results is unnecessary because the vast majority of women with SIL are infected with HPV.

- Diagnosis

## Diagnosis of Cervical Cell Abnormalities (continued)

- Indication for colposcopy is guided by physical exam or Pap test findings with or without HPV DNA test findings.
- Indications for cervical biopsy include:
- Visible exophytic lesions on the cervix
- Pap test with HSIL
- Pap test with ASC-H or LSIL with colposcopic abnormalities

- Diagnosis

## Lesson V: Patient Management

## General Treatment of Genital Warts 

- Primary goal is removal of symptomatic warts.
- If left untreated, genital warts may regress spontaneously or persist with or without proliferation.
- In most patients, treatment can induce wart-free periods.
- Currently available therapies may reduce, but probably do not eradicate infectivity.
- Effect of current treatment on future transmission is unclear.

- Management

## General Treatment of Genital Warts (continued)

- No evidence that presence of genital warts or their treatment is associated with development of cervical cancer.
- Some patients may choose to forgo treatment and await spontaneous resolution.
- Consider screening persons with newly diagnosed genital warts for other STD (e.g., chlamydia, gonorrhea, HIV, syphilis).

- Management

## Treatment Regimens

- Patient-applied and provider-administered therapies are available.
- Providers should be knowledgeable about and have available at least 1 patient-applied and 1 provider-administered treatment.
- Choice of treatment should be guided by:
- The preference of the patient
- The available resources
- The experience of the healthcare provider

- Management

## Treatment Regimens (continued)

- Factors influencing treatment selection:
- Wart size
- Number of warts
- Anatomic site of wart
- Wart morphology
- Patient preference
- Cost of treatment
- Convenience
- Adverse effects

- Management

## Treatment Response

- Affected by:
- Number, size, duration, and location of warts, and immune status
- In general, warts located on moist surfaces and in intertriginous areas respond better to topical treatment than do warts on drier surfaces.
- Many patients require a course of therapy rather than a single treatment.
- Evaluate the risk-benefit ratio of treatment throughout the course of therapy to avoid over-treatment.
- No evidence that any specific treatment is superior to any of the others.
- The use of locally developed and monitored treatment algorithms has been associated with improved clinical outcomes.

- Management

## Recurrence

- Up to 2/3 of patients will experience recurrences of warts within 6-12 weeks of therapy; after 6 months most patients have clearance.
- If persistent after 3 months, or if there is poor response to treatment, consider biopsy to exclude a premalignant or neoplastic condition, especially in an immunocompromised person.
- Treatment modality should be changed if patient has not improved substantially after 3 provider-administered treatments or if warts do not completely clear after 6 treatments.

- Management

## Complications

- Complications rarely occur if treatments for warts are employed properly.
- Depressed or hypertrophic scars are uncommon but can occur, especially if the patient has had insufficient time to heal between treatments.
- Rarely, treatment can result in disabling chronic pain syndromes (e.g., vulvodynia or hyperesthesia of the treatment site).
- Patients should be warned that persistent hypopigmentation or hyperpigmentation are common with ablative modalities.

- Management

## CDC-Recommended Regimens For External Genital Warts (Patient-Applied) 

- Podofilox 0.5% solution or gel (CondyloxTM)
- Patients should apply solution with cotton swab or gel with a finger to visible warts twice a day for 3 days, followed by 4 days of no therapy.
- Cycle may be repeated as needed up to 4 cycles.
- OR
- Imiquimod 5% cream (AldaraTM)
- Patients should apply cream once daily at bedtime, 3 times a week for up to 16 weeks.
- Treatment area should be washed with soap and water 6-10 hours after application.

- Management

## CDC-Recommended Regimens For External Genital Warts (Provider-Administered)

- Cryotherapy with liquid nitrogen or cryoprobe
- Repeat applications every 1-2 weeks, OR
- Podophyllin resin 10%-25% in compound tincture of benzoin
- Apply a small amount to each wart and allow to air dry
- Treatment may be repeated weekly if needed, OR
- Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80%-90%
- Apply small amount only to warts and allow to dry
- Treatment may be repeated weekly if needed, OR
- Surgical removal--tangential scissor excision, tangential shave excision, curettage, or electrosurgery

- Management

## CDC-Recommended Alternative Regimens 

- Intralesional interferon
- OR
- Laser surgery

- Management

## Treatment of Exophytic Cervical Warts

- High-grade squamous intraepithelial lesions (SIL) must be excluded before treatment is initiated.
- Management should include consultation with a specialist.

- Management

## CDC-Recommended Regimens for Vaginal Warts 

- Cryotherapy with liquid nitrogen
- The use of a cryoprobe in the vagina is not recommended because of risk for vaginal perforation and fistula formation.
- OR
- TCA or BCA 80%-90% applied to warts
- Apply small amount only to warts and allow to dry (white “frosting” develops).
- Treatment may be repeated weekly if needed.

- Management

## CDC-Recommended Regimens for Urethral Meatus Warts 

- Cryotherapy with liquid nitrogen
- OR
- Podophyllin 10%-25% in compound tincture of benzoin
- Treatment area must be dry before contact with normal mucosa.
- Treatment may be repeated weekly, if needed.

- Management

## CDC-Recommended Regimens for Anal Warts

- Cryotherapy with liquid nitrogen
- OR
- TCA or BCA 80%-90% applied to warts
- Apply small amount only to warts and allow to dry (white “frosting” develops)
- Treatment may be repeated weekly if needed
- OR
- Surgical removal

- Management

## CDC-Recommended Regimens for Oral Warts 

- Cryotherapy with liquid nitrogen
- OR
- Surgical removal

- Management

## Management of Genital Warts in Pregnancy 

- Genital warts can proliferate and become more friable during pregnancy.
- Cytotoxic agents (podophyllin, podofilox, imiquimod) should not be used.
- Cryotherapy, TCA, BCA, and surgical removal may be used.
- Prevention value of cesarean delivery is unknown, thus C-section should not be performed solely to prevent transmission to neonate.

- Management

## Management of Genital Warts in Immunodeficient Patients

- More frequent, more pronounced clinical manifestations and occurrence of atypical lesions
- More resistant to conventional therapy
- More common recurrence of lesions after treatment
- Role of warts (or irritated treatment sites) in HIV transmission is unknown.
- Treatment unlikely to be effective due to high recurrence rate; therefore, treat only if the patient is symptomatic.
- Because HSIL and invasive cancer can occur in wart-like lesions, especially in the perianal area, lesions which are hyperpigmented or which persist despite treatment should be evaluated by biopsy.

- Management

## Pap Test Screening in Immunodeficient Patients 

- Immunodeficiency appears to accelerate intraepithelial neoplasia and invasive cancer.
- Provide cervical Pap test screening every 6 months for 1 year, then annually for all HIV-infected women with or without genital warts.
- Anal pap tests and anoscopy:  value in absence of symptoms not established, but is under investigation

- Management

## Genital Wart Follow-Up 

- Counsel patients to:
- Watch for recurrences
- Get regular Pap screening at intervals as recommended for women WITHOUT genital warts
- After visible warts have cleared, follow-up evaluation not mandatory, but provides opportunity to:
- Monitor or treat complications of therapy
- Document the absence of warts
- Reinforce patient education and counseling messages
- Offer patients concerned about recurrences a follow-up evaluation 3 months after treatment.

- Management

## Treatment of Cervical Cellular Abnormalities 

- For more information on managing women with cervical cell abnormalities, refer to:
- CDC National Breast and Cervical Cancer Early Detection Program _[http://](http://www.cdc.gov/cancer/nbccedp/index.htm)__[www.cdc.gov/cancer/nbccedp/index.htm](http://www.cdc.gov/cancer/nbccedp/index.htm)_
- 2001 Consensus Guidelines for the Management of Women with Cervical Cytologic Abnormalities _[http://](http://www.asccp.org/consensus/cytological.shtml)__[www.asccp.org/consensus/cytological.shtml](http://www.asccp.org/consensus/cytological.shtml)_

- Management

## Lesson VI: Patient Counseling and Education

## The Nature of HPV Infection

- Genital HPV infection is common in sexually active adults.
- Incubation period is variable, and it is often difficult to determine the source of infection.
- Natural history of HPV infection is usually benign:
- Low-risk genital HPV types are associated with mild Pap test abnormalities and genital warts.
- High-risk types are associated with mild to severe Pap test abnormalities and, rarely, cancers of the cervix, vulva, anus, and penis.
- Most women infected with high-risk HPV types have no Pap test abnormalities and do not develop cervical cancer.
- Genital warts have a high recurrence rate after treatment.

- Patient Counseling and Education

## Transmission Issues

- Determining source of infection is usually difficult.
- Recurrences usually are not re-infection.
- Transmission risk to current and future partners is unclear.
- Abstinence and long-term mutual monogamy with an uninfected partner are the most effective options to prevent transmission.
- Likelihood of transmission and duration of infectivity with or without treatment are unknown.
- Value of disclosing a past diagnosis of genital HPV infection to future partners is unclear, although candid discussions about past STD should be encouraged.

- Patient Counseling and Education

## Risk Reduction

- Assess patient’s behavior-change potential.
- Develop individualized risk-reduction plans with the patient for lasting results.
- Discuss prevention strategies such as abstinence, mutual monogamy with an uninfected partner, condoms, limiting number of sex partners, etc.
- While the effect of condoms in preventing HPV infection is unknown, condom use has been associated with lower rates of genital warts and cervical cancer, both HPV-associated diseases.
- HPV infections can occur in male and female genital areas that are not covered by a latex condom, as well as in areas that are covered.

- Patient Counseling and Education

## Resources 

- National HPV and Cervical Cancer Prevention Resource Center, created by the American Social Health Association
- 	_[http://](http://www.ashastd.org/hpvccrc/)__[www.ashastd.org/hpvccrc](http://www.ashastd.org/hpvccrc/)__[/](http://www.ashastd.org/hpvccrc/)_
- CDC Cervical Cancer Screening Fact Sheet _[http://](http://www.cdc.gov/cancer/cervical/pdf/cc_basic.pdf)__[www.cdc.gov/cancer/nbccedp/cc_basic.htm](http://www.cdc.gov/cancer/cervical/pdf/cc_basic.pdf)_
- National Cancer Institute Cervical Cancer Screening Information For Patients _[http://www.nci.nih.gov/cancerinfo/pdq/screening/cervical/patient/](http://www.nci.nih.gov/cancerinfo/pdq/screening/cervical/patient/)_
- American Society of Colposcopy and Cervical Cancer Pathology _[http://](http://www.asccp.org/pdfs/patient_edu/women_should_know.pdf)__[www.asccp.org/pdfs/patient_edu/women_should_know.pdf](http://www.asccp.org/pdfs/patient_edu/women_should_know.pdf)_

- Patient Counseling and Education

## Partner Management and Public Health Measures

## Partner Management for Patients with Genital Warts

- Sex partner examination is not necessary for management of genital warts because no data indicate that reinfection plays a role in recurrences.
- Providing treatment solely for the purpose of preventing future transmission cannot be recommended because the value of treatment in reducing infectivity is not known.
- The counseling of sex partners provides an opportunity for these partners to:
- Learn about the implications of having a partner who has genital warts and about the potential for future disease transmission.
- Receive STD and Pap screening if necessary.

- Prevention

## Cervical Cancer Screening

- The key strategy to prevent cervical cancer is regular cervical cancer screening (Pap test screening) for all sexually active women.
- New technologies, including liquid-based cytology and testing for high-risk HPV types, may offer potential advantages over conventional Pap testing.
- Several organizations provide guidelines for cervical cancer screening, including:
- The American Cancer Society
- The American College of Obstetricians and Gynecologists
- The U.S. Preventive Services Task Force

- Prevention

## Reporting Requirements

- Genital HPV infection is not a reportable infection in any state.
- Genital warts are reportable in some states.
- Check with state or local health department for reporting requirements in your area.

- Prevention

## HPV Vaccines 

- Several potential approaches are under investigation.
- The most promising is the use of virus-like particles (VLPs), which preserve native conformations of viral proteins without presence of viral DNA.

- Prevention

## Case Study

## History

**Anne Drew:** 34-year-old woman who wants to get "checked out" because Jonathan, her sex partner, has small solid "bumps" on the skin on the shaft of his penis
- Jonathan told her that he was diagnosed and treated for genital warts about a year ago, and his health care provider told him they could recur.
- No history of abnormal Pap smears and no history of STDs
- Last Pap smear performed 4 months ago
- Sexually active with men only since age 16; has had a total of 7 sex partners over her lifetime
- Currently sexually active with 1 partner for the last 8 months
- Uses oral contraceptives for birth control

- Case Study

## Question

- What should be included in Ms. Drew’s evaluation?

- Case Study

## Physical Examination

- Vital signs: blood pressure 96/74, pulse 78, respiration 13, temperature 37.1° C
- Cooperative, good historian
- Chest, heart, musculoskeletal, and abdominal exams within normal limits
- Pelvic exam is normal
- Visual inspection of the genitalia reveals multiple small (<0.5 cm), flesh-colored, papular lesions in the perineal area

- Case Study

## Questions

- 2. What is the differential diagnosis for the papular genital lesions?
- 3. What is the **most likely** diagnosis based on history and physical examination?
- 4. Which laboratory tests should be ordered or performed?

- Case Study

## Patient Management

- The following genital warts management options are discussed with Ms. Drew:
- Patient-applied therapy
- Podofilox 0.5% solution or gel (CondyloxTM)
- Imiquimod 5% cream (AldaraTM)
- Provider-administered therapy
- Cryotherapy with liquid nitrogen or cryoprobe
- Podophyllin resin 10%-25% in compound tincture of benzoin
- Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80%-90%
- Surgical removal
- No intervention

- Case Study

## Questions

- What is the effect of treatment on future transmission?  What is the possibility of recurrence after treatment?
- What are appropriate counseling messages for Ms. Drew about genital warts and HPV infection?
- What condition could cause a substantial increase in the number and size of Ms. Drew’s genital warts?

- Case Study