Genital Warts

Genital warts remain one of the most common conditions treated in GUM clinics with over 130,000 cases treated a year in the UK in 2015.

Genital warts are caused by the Human Papilloma Virus (HPV). There are approximately 120 types of HPV, of which about 40 infect the genital tract. Types 6 and 11 are responsible for 90% of genital warts cases.

Most people who have been exposed to HPV do not get any warts. There is a good chance that you and your partner have already shared the virus with each other and like most people who carry the virus without getting any symptoms, your partner has not developed any warts.

In the unlikely event that your partner does get warts in the future, it does not mean that they have necessarily contracted this virus from you. It’s possible that they may have been exposed to the virus even before starting your relationship but have never developed warts until now.

Management Guidelines

i

Further Readings

At a glance

Symptoms
Skin lesions and lumps around the genitalia (and sometimes anus).

See specific symptoms >

Causes
Genital warts are an STI, caused by transmission of HPV.

Learn more about causes >

Prevalence
20-24 year olds account for 35.3% of new diagnosis.

More statistics coming soon.

Diagnosis & Treatment
Diagnosis of genital warts is often by a physical examination from a specialist.

Learn more >

Symptoms

What are the symptoms of genital warts?

Genital warts produce painless skin lesions or lumps in the genitalia and sometimes around the anus. Genital warts may be so small and flat that they can’t be seen with the naked eye. Sometimes, however, genital warts may multiply into large clusters.

They can be itchy or sore when they are growing fast, and occasionally may bleed.

Genital warts in men:

Men can experience genital warts in the following areas:

  • Pubic area
  • Penis
  • Meatus (i.e. in the opening of the water pipe)
  • Scrotum
  • Perineum (i.e. the area between the external genitals and the anus)
  • Anus
  • Peri-anal area

A note on meatal warts:

  1. Warts can also be found in the opening of the water pipe which can present blood in the urine or deviation in the direction of the flow of urine.
  2. Sometimes meatal warts are missed unless the clinician specifically examines you for it.
  3. Wart creams should not be used for treatment of meatal warts as they can severely inflame the area, making passing urine painful and difficult.

Genital warts in women:

Women can experience genital warts in the following areas:

  • Pubic area
  • Vulval area
  • Vaginal walls
  • Cervix
  • Perineum (i.e. the area between the external genitals and the anus)
  • Anus
  • Peri-anal area

Genital Warts during pregnancy

The genital warts of a pregnant patient does not normally present a risk to the baby. We meet many patients who have anxiety about potentially passing the virus to their newborn.

This anxiety about warts is often compounded by a sense of embarrassment at the prospect of delivering in front of midwives and doctors. We urge our patients not to dwell too much on such anxieties, and to ask us questions so that we may ease your concerns.

Effect on relationships

The effects of genital warts on one’s relationship can be significant – affecting men and women alike. This may involve:

  • Low self-esteem
  • Anxiety about transmitting it to partner
  • Breakdown of relationships
  • Abstinence from intimacy

Why do I have anal warts when I’ve never had anal sex?

Many people are perplexed to learn that they have anal warts even if they have not engaged in anal sex. This is because the HPV has a tendency to infect both anal and genital areas irrespective of its site of initial contact. Therefore, having anal warts does not mean that one has necessarily had anal sex.

Can genital warts be painful?

Genital warts may cause discomfort and/or irritation. This can be due to inflammation produced by rubbing against clothing, or the rapid increase in size outstripping its blood supply.

Genital warts, especially those with a narrower base, can twist on its base cutting off its blood supply and can become painful and discoloured.

Occasionally, the warts can also be a site for another infection which may be responsible for the pain. Commonly encountered infections causing pain include:

  • Anaerobic infections
  • Herpes outbreak
  • General bacterial infections

It is important to diagnose and treat these underlying infections before treatment for genital warts is considered.

Lastly, one may find themselves with some discomfort as a consequence of Cryotherapy or Wart Creams as a treatment of genital warts.

Genital warts can also occur in the mouth or throat of a person following oral sexual contact.

Will my genital warts go away?

Many patients report that the warts have resolved spontaneously without any treatment. Studies show that up to 50% of warts resolve on their own within 24 months of their occurrence.

However, it is hard to predict who will benefit from such spontaneous clearance, and many people do not like the idea of having on-going warts due to cosmetic and confidence reasons.

In the event that your warts don’t go away by themselves, or you’d prefer not to wait, effective genital wart treatment options are available. To learn more about the various treatment options we provide, please click here.

When do genital warts start to appear?

Genital warts usually appear between 3 weeks to 8 months after exposure to HPV/genital warts. However, it is entirely possible to develop genital warts after this time if the virus becomes active from its dormancy. This means that genital warts may appear on someone after years of being exposed to HPV.

Complications

In most people, genital warts do not lead to any medical complications.

However, the following complications may sometimes arise:

1) Squamous Cell Carcinoma: Sometimes High Risk HPV may be present in the warts and this can lead to development of cellular abnormalities which may lead to the development of cancer (squamous cell carcinoma). This is why sometimes a screen for High Risk HPV and a biopsy is recommended to rule out underlying problems.

High risk HPV (HR-HPV) causes abnormalities on the cells of genital tissue, and these abnormalities are described by the site of their occurrence, namely PeIN (Penile intra-epithelial neoplasia), VIN (Vulval intraepithelial neoplasia), CIN (Cervical intraepithelial neoplasia) and AIN (anal intra-epithelial neoplasia).

2) Infection on the surface/base of the warts: Warts can sometimes get infected with secondary bacterial or fungal infections.

3) Bleeding: Warts have got very rich blood supply, and tend to bleed heavily after being cut off accidentally (shaving, avulsion by trauma) or attempts to cut them off in desperation.

4) Difficulty in maintaining hygiene: Larger warts can have cauliflower like surface, and make it very difficult to maintain hygiene, especially those near the anal area.

5) Buschke Lowenstein Tumors: Sometimes genital warts can be large enough to affect day to day activities. Buschke Lowenstein Tumors are very large warts which are treated surgically.

6) Affect vaginal delivery in pregnant women: Sometimes genital warts can be large enough to interfere with a vaginal delivery. Fortunately, such warts are very rare in the UK.

7) Blood in urine dipstick: Meatal warts especially in men (i.e. genital warts at the opening of the water pipe/urethra) can lead to blood in a urine dipstick. If meatal warts as the underlying cause is not identified, this may result in unnecessary anxiety about cancer and lead to unnecessary urological investigations.

8) Laryngeal Papillomatosis in children: Warts in the larynx can occur in children before 5 years of age and can produce hoarseness of voice, noisy breathing and difficulty in breathing in more severe cases. This is normally caused by Low Risk HPV Types 6 and 11. Research has shown that HPV DNA is detected in nasopharyngeal secretions of almost 1 in 2 of  newborns after a vaginal delivery if their mothers had HPV in their cervical cells. However, laryngeal papillomas are relatively rare.

9) Laryngeal Papillomatosis in adults: The papilloma in the Larynx (or voice box), can lead to hoarseness of voice. They are caused by low risk HPV types 6 and 11. They are rare in the UK. Laryngeal papillomas behave in a lot more benign manner compared to children.

10) Concurrent skin conditions: Sometimes warts are present on the skin surface with another skin condition like lichen sclerosus. Treatment of this skin condition requires application of very strong steroid cream, which nourishes warts, and makes them worse. On the other hand, local creams used to treat warts can irritate the skin and make lichen sclerosus much worse. Clinical judgement is helpful in such instances in deciding how to manage such co-existing skin conditions.

Images

Here are images of some severe cases of genital warts (before receiving treatment from us).

Please be advised that the images are highly graphic in nature.


Causes

What causes genital warts?

Genital warts are caused by the Human Papilloma Virus (or HPV). There are more than 100 types of HPV and types 6 & 11 are accountable for more than 90% of genital warts. The transmission of HPV, and the development of genital warts, occurs as a result of the following:

  • Having unprotected vaginal, anal or oral sex with someone with HPV infection (with or without warts)
  • Very close contact with partners’ genitals
  • (Rare) During childbirth from infected mother

You can’t get genital warts from kissing, hugging, sharing baths or towels, from swimming pools, toilet seats or from sharing cups, plates or cutlery.

It has been observed that effective HPV vaccination to teenage school girls in the UK has resulted in the dramatic reduction in the prevalence of genital warts. As a result, it is expected that a greater number of new diagnoses of genital warts would be due to HPV types other than 6 & 11.

    Can I get genital warts even if I wear a condom?

    Often people who have always been meticulous in protecting themselves with condoms are distraught when they learn that they have genital warts. This is because the virus is shed from a much wider genital area than a condom can cover.

      Can you tell who gave me genital warts?

      Often people seek an explanation as to when they first got exposed to the virus and from which partner. It is very difficult to pin-point the exact moment when you come in contact with HPV because the virus has a habit of laying dormant without causing any symptoms but being contagious at the same time.

      Furthermore, most people will have developed genital warts after being with someone who did not have them. This can make it even harder to determine who gave you the infection.

      What factors can increase the likelihood of getting warts?

      • You come into contact with someone with genital warts present
      • You have sex with someone of the same gender
      • Increased number of sexual partners
      • Unprotected vaginal or anal sex
      • Weaker immune system

      In rare cases, one might:

      • Develop warts in the mouth, throat or on the lips from oral sex
      • Pass warts on the hands to the genitalia
      • If you’re pregnant and have genital warts at the time, it’s possible to pass the virus to the baby at birth in rare cases

      What are the factors that can lead to more severe warts?

      1) Immunosuppressive drugs: Drugs to suppress the immune system are used in patients with kidney transplant and conditions such as psoriasis, rheumatoid arthritis and lupus. Such drugs make immune responses to fight the HPV infection, and can result in patients developing extensive warts, or warts resistant to commonly used drugs.

      2) Steroids: Steroids have a well-established effect of suppressing the immune system, especially when taken orally, but can also produce a similar effect when used topically on the genital skin, with risk of activating the otherwise latent HPV infection, producing warts. Sometimes patients with genital eczema and psoriasis report developing warts, or substantial worsening of their warts, after starting to use steroids.

      3) Diabetes: Poorly controlled diabetes, especially type 1 diabetes mellitus, is associated with more severe cases of genital warts, poor response to treatment and higher chances of recurrence.

      4) Smoking: More severe cases of genital warts have been noted amongst heavy smokers and it is a standard practice to advise patients to stop or reduce smoking to reduce the chances of warts coming back after treatment.

      How can I prevent getting genital warts?

      • A full course of HPV vaccination
      • Having protected vaginal, oral and anal sex with new partner(s)
      • Using a condom, femidom and/or dental dam with a new partner
      • Recommend your partner to get treated for genital warts

       

      Diagnosis

      It is extremely important to get the diagnosis of genital warts right. The wrong diagnosis can result in unnecessary treatment, undue anxiety and avoidable stress in life and relationships.

      As specialists in the field of sexual health, we often see cases where a lesion in the genital area has been wrongly diagnosed as genital warts, with a devastating impact on the patient’s life.

      How are genital warts diagnosed?

      Many patients present themselves having self-diagnosed with genital warts. Often they’re right, but not always. If the lesions are small and unusual in appearance, it may be difficult to differentiate them from other skin conditions that mimic genital warts.

      Genital warts are commonly diagnosed by a physical examination from an experienced professional. Occasionally, the use of a magnifying glass, dermatoscope or colposcope helps in this diagnosis.

      In cases where it is difficult to diagnose genital warts, we use the aid of two diagnostic tools:

        • Cryotherapy: A cold spray of liquid nitrogen is applied directly to the lesion, and brings up its finer details.
        • Dilute acid: We apply the acidic solution directly onto the lesions, and it makes them more prominent and easier to see. This in turn makes them easier to diagnose.

      Whilst there are HPV tests available, they are designed to look for the HPV DNA itself (i.e. the virus that causes genital warts) rather than the genital warts themselves. 

      Histopathological examination of a biopsy specimen from the suspected lesion is rarely needed to confirm the diagnosis. Such an examination also serves to rule out or detect underlying precancerous or cancerous changes in the suspected wart. Namely, examination of tissue from lesions around the anus, vulva and areas over the penile foreskin may result in the detection of precancerous abnormalities in the lesions, described as AIN (Anal Intra-epithelial Neoplasia), VIN (Vulval Intra-epithelial Neoplasia) and PeIN (Penile Intra-epithelial Neoplasia). 

      What factors can help a correct diagnosis?

      Based on our experience of managing warts of all kinds, shapes, size, duration etc, we have come up with the following rules to guide a diagnosis.

      Listening to the patient provides vital clues that can guide the diagnosis in a certain way and also help answer your questions. Patients can sometimes identify when the lesions first appeared, while there are others whose attention was first drawn to these lumps following a specific life event (e.g. change in partner).

      An unhurried & well illuminated examination gives our eyes time to adjust and time to ensure no detail is missed. A proper clinical examination may reveal lesions which were not initially noticed by the patients.

      High quality pictures taken by the patient of their lesions over a length of time can provide further information from which to make a diagnosis and answer questions.

      A serial examination allows us to reassess the skin lesions and monitor for any changes as there are cases where one can be unsure whether the lesions are warts or not. If the lesions have worsened or improved, it makes the diagnosis easier for the doctor. If they remain unchanged, then this is a case for further observation in a few months time, or we can take a piece of tissue and send it for biopsy.

      Can you tell who gave me genital warts?

      Often people seek an explanation as to when they first got exposed to the virus and from which partner. It is very difficult to pin-point the exact moment when you come in contact with HPV because the virus has a habit of laying dormant without causing any symptoms but being contagious at the same time.

      Furthermore, most people will have developed genital warts after being with someone who did not have them. This can make it even harder to determine who gave you the infection.

      Can another infection be mistaken as genital warts?

      In trying to diagnose genital warts, there are other kinds of lesions we have to make sure it is not. These may include:

      • Molluscum Contagiosum
      • Skin tags
      • Seborrhoeic Keratosis
      • Lichen Sclerosus
      • Chronic herpetic lesions in those with underlying immunosuppression
      • Blocked sebaceous glands 
      • Localised cysts
      • Scarring

      Sometimes patients may have lesions due to more than one cause. This can result in a multiple diagnosis, examples including:

      • Skin tags and genital warts
      • Molluscum Contagiosum and genital warts
      • Lichen Sclerosus and genital warts

      Is there any other way to diagnose genital warts?

      If there is a diagnostic uncertainty, concern about precancerous or cancerous changes in the skin then a lab biopsy may be recommended. This is where a skin lesion is taken under local anaesthetic and sent to a research lab for analysis. Results can take between 14-21 days.

      This is an invasive procedure, apart from being expensive, and is not routinely recommended.

      What does it mean for me and my partner?

      Most people who have been exposed to HPV do not get any warts. There is a good chance that you and your partner have already shared the virus with each other and like most people who carry the virus you may not have any symptoms.

      In the event that your partner does get warts in the future, it does not mean that they have necessarily contracted this virus from you. It is important to remember that you may have been exposed to the virus even before starting your relationship and have never developed warts before.

      Do I have to tell my partner I have genital warts?

      Your partner does not need to get tested for HPV or receive any treatment if they have no signs or symptoms of genital warts. This is where HPV and genital warts are managed very differently from other classical STIs like Chlamydia, Gonorrhoea and Syphilis.

      Therefore, it’s not necessary for you to tell your partner that you have been diagnosed with genital warts. However, your relationship may be such that you may feel it is necessary to share your diagnosis with your partner to help with your inner well-being.

      Concluding Remarks

      Many patients are worried about how their diagnosis affects their future, in terms of relationships and children. We find that such embarrassment and worries often forms as a result of the stigma surrounding diagnosis like genital warts. In our experience, this stigma creates a barrier for patients when seeking treatment, as we often meet patients who have waited years to seek medical advice out of fear of being judged.

      It is our hope that by keeping people informed about their diagnosis, they will feel no hesitation when seeking help.

      Treatment

      We understand the frustration, anxiety and stress that genital warts can cause in your life. This may especially be the case if you have tried other treatments before.

      At Clarewell Clinics, we pride ourselves on being able to provide a same day genital wart removal for most of our patients and have the skillset to treat complex warts (e.g. anal/peri-anal).

      Please read through the information presented below about our services and if you have any questions, please don’t hesitate to get in touch.

      Recurrence

      It is fairly common for genital warts to recur in patients despite treatment, and at Clarewell Clinics, we consider this as an important factor for patients to understand before opting for any treatment. 

      Why do genital warts recur?

      Genital warts can recur after treatment because the treatment only eradicates the symptoms of HPV, but not the HPV infection itself.

      There is no cure for the HPV infection, you will still have the infection in your body despite any treatment you may have had for genital warts. The main way of clearing the infection is via a natural process, although it can be a chronic and long lasting infection for others. 

      How likely is it that warts will recur after treatment?

      Although warts are very common and treated widely,  accurate statistics do not exist to make precise predictions. Therefore, it’s difficult to predict the likelihood of warts recurring after the treatment in an individual patient.

      However, the presence of underlying health conditions including diabetes, use of immunosuppressive drugs and the use of steroids can increase the likelihood of warts coming back after treatment.

      The recurrence rate of warts for various treatments, based on available evidence are as follows:

      TreatmentRecurrence Rate (%)Time Frame (weeks)
      Podophyllotoxin solution13-1008-21
      Podophyllotoxin cream6-558-12
      Imiquimod Cream6-2610-24
      Cryotherapy21-424-12
      Electrosurgery (Hyfrecation)2212

      In practice, recurrence rates are lower than quoted above. The warts can come back after successful treatment, months or even years later. More often than not, recurrence of warts is likely to be due to activation of existing HPV type, rather than getting exposed to a new HPV type.

      Warts may respond well to a treatment and may appear to have gone away, whilst in truth they may be still there but barely visible to be easily noticed. Such warty lesions may regrow again with passage of time.

      It can be very disheartening when one notices the return of genital warts. It is sometimes the case that patients think the warts have gone away, and have come back, but in reality the warts had not gone away. They had just become much smaller after treatment, and have regrown since.

      Is there any way to prevent genital warts from recurring?

      There is no validated way to prevent genital warts from recurring. General advice to reduce the chances of warts coming back include:

      • Stopping smoking
      • Avoid shaving areas affected by genital warts
      • Tighter control of diabetes (in those with diabetes)
      • Treatment of HIV /AIDS (in those with underlying infection)

      In rare cases, agents to boost immune system to fight HPV more effectively can be used. Immunovir (Inosine Pranobex) is one such medication. Although there are some case reports of warts responding to HPV vaccine, there is no evidence to suggest that administration of the vaccine will reduce the recurrence of genital warts. However it’s possible that the vaccine will still protect the individual from HPV types to which they have not yet been exposed. 

      Page reviewed by Dr. Manoj Malu (Clinical Director)

      Last reviewed date: 8 July 2020
      Next review due: 8 July 2023

      Whilst this content is written and reviewed by sexual health specialists, it is for general guidance only. It is not intended to replace the advice of your clinician.

      If you think you may have Genital Warts

      We highly recommend seeing a sexual health clinician to receive an accurate diagnosis and a thorough discussion about what it means for you (and your partner), any tests you may need and the right treatment option for you.

      Book an appointment >