Genital warts and herpes are unpleasant viral sexually transmitted infections for which treatment is unsatisfactory. The infections can only be suppressed, not cured. Once infected, people may transmit the virus to others, even when they themselves are asymptomatic, and we do not know whether they remain infectious forever. Using condoms reduces the risk but does not always prevent infections.
Women with first attacks of either genital warts or herpes need screening for coexistent infections, especially chlamydia, and contact tracing. Therefore, in many cases the best option may be referral to the local genitourinary clinic.
Genital warts are common, usually sexually transmitted, and difficult to treat. They are caused by human papilloma virus, and although most are benign, some types are associated with cervical cancer.
Symptoms and signs
Genital warts are often asymptomatic, but may be associated with itching or discharge. They are usually noticed on the vulva or introitus. They may enlarge during pregnancy.
This is clinical. However, subclinical human papilloma virus infection is much commoner than clinical warts and is often diagnosed on a cervical smear or colposcopy. No treatment is required for subclinical infection but visible cervical warts are an indication for cytology and colposcopy.
As with commmon warts, this is laborious and not very effective. Patients find the fact that treatment is so inadequate very difficult to deal with. The aim is merely to remove obvious lesions as no therapy has been shown to eradicate the virus. Treatment is more effective for warts that are small and have been present for less than a year. Provided the patient is not pregnant, podophyllotoxin 0.15% cream may be used for external warts. Treatment consists of twice daily application for 3 days followed by 4 days rest for 4 cycles. It can be used for home treatment but should be discontinued if there are side effects such as soreness or irritation. It is teratogenic.
If treatment is ineffective after 4 weeks, or the patient is pregnant and the warts are causing problems, patients may be referred to a genitourinary clinic for cryotherapy or electrocautery. Recurrence rates are at least 25% after 3 months. Warts may regress or reappear spontaneously and condoms should be used until at least 3 months after apparent cure.
Imiquimod 5% cream may be used for treatment failures but is not approved for use in pregnancy or internally. It is an immune response modifier. Cream is applied to lesions three times weekly and washed off 6 – 10 hours for up to 16 weeks. It costs ВЈ55 for a 4 week course and is normally prescribed by a genitourinary physician.
The NHS Cervical Screening Programme policy recommends that no changes are required to screening intervals in women with anogenital warts. However, this may change when we can routinely type human papilloma virus. Partner notification and screening for coexistent infections are recommended.
This is discussed in the “10-minute consultation” at the end of the post.
These are much more user friendly than in the past. It is very helpful if there are good relations between general practitioners and local genitourinary physicians. A patient is much more likely to attend if the general practitioner gives her a clinic leaflet and letter and reassures her that the doctors are sympathetic and understanding.
Genitourinary clinics have positive advantages. Treatment is free and confidential. There are experienced health advisors with time for counselling and contact tracing (see below). The clinics will also screen for other sexually transmitted infections, including human immunodeficiency virus if requested. Also the tests used may be more sensitive or investigations more extensive than those available in most general practices. Finally, they can review compliance with treatment and perform a test of cure if required.
Contact tracing/partner notification
For each infected woman (index case) there are at least two people affected – her sexual contact and the person who infected her contact. Often it is more complicated. Thus, contact tracing requires time and sensitivity. In genitourinary clinics it is done with the assistance of health advisers. After discussion, the patient telephones or visits the partner and urges him to attend a genitourinary clinic for examination and treatment. The partner is given a contact slip, which includes the original patient’s note number and a code for the diagnosis. When he goes to a genitourinary clinic for treatment, he hands in the contact slip which is then returned to the clinic of origin so that accurate contact tracing records can be kept. Health advisers prefer not to inform contacts themselves unless the patient is unable to do so. Confidentiality is paramount and no information will be given to anyone outside the clinic, including partners or other doctors, without the patient’s permission.
In general practice, if a woman with a sexually transmitted infection is reluctant to attend a genitourinary clinic for contact tracing, she could be given a letter similar to a contact slip to give to her partner for him to take to a genitourinary clinic. The letter could state the woman’s diagnosis and treatment given. If the partner hands this in at a clinic and gives consent for information to be released to the general practitioner, the clinic will reply with details of his diagnosis and treatment. Both partners should be advised not to have sexual intercourse until they have completed their courses of treatment.