Presentation, Diagnosis & Assessment

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

Warts are the most common viral STI and patients can often be managed in a Primary Care setting without the need for onward referral to specialist services.
This guideline details how care should be provided to patients 16 years of age and older.
Patients under 13 should be referred to a paediatrician with child protection experience.
For patients aged 13 to 15 inclusive please Young people common STIs and other genital infections in 13 to 15 year olds

Presentation

  • Symptoms include noticing the presence of new lumps/growths in the anogenital area
  • Other symptoms include local irritation, bleeding or discomfort
  • More commonly warts present as soft cauliflower-like growths of varying size
  • Less commonly, the warts are flat, plaque-like or pigmented
  • On rare occasions large warts present with secondary infection and maceration
  • Rarely, warts may grow more rapidly and infiltrate local tissue or cause local erosion
  • Perianal lesions are common in both sexes and may not necessarily be associated with the practice of anal sex, due to the regional nature of infection with HPV. They are however seen more commonly in men who have sex with men (MSM). Warts inside the anal canal are usually associated with penetrative anal sex.
  • Warts can appear or increase in size during pregnancy

Diagnosis & Assessment

  • Warts are usually diagnosed by visible inspection under good illumination
  • Examination of the genitalia and perianal skin is essential to recognise the full extent of the warts
  • All patients should be offered a full sexual health screen to include HIV testing particularly if patient has extensive or non resolving warts
  • Application of 5% acetic acid to reveal subclinical or latent infection is not recommended
  • The differential diagnosis of warts includes
    • physiological features
    • dermatoses
    • other infections such as molluscum contagiosum.

If uncertain, seek the opinion of a senior doctor.

  • Occasionally magnification (eg with a colposcope) and / or biopsy (in atypical lesions) may be needed.
  • Biopsy may be advisable for lesions that do not respond to treatment
  • Speculum vaginal examination is only required if internal warts are suspected (due to vulvovaginal symptoms or warts which may extend into introitus)
  • Intravaginal and cervical warts do not require treatment unless symptomatic. Patients with cervical lesions where there is diagnostic uncertainty or clinical concern should be referred for colposcopy.
  • Ensure cervical smears are up to date. Most anogenital warts are benign and caused by HPV 6 and 11, which are of low oncogenicity. The NHS Cervical Screening Programme recommends that no changes are required to screening intervals in women with anogenital warts.
  • Proctoscopy is not routinely performed in patients with external genital warts unless there are anorectal symptoms (such as irritation, bleeding or discharge), warts at the anal margin where the upper limit cannot be visualised or other diagnostic tests are required. Intra-anal warts should only be treated if symptomatic. If uncertain, discuss with a senior doctor.
  • Meatoscopy/urethroscopy should be performed by urologists if there is difficulty in visualising the full extent of intra-meatal warts
  • Some patients present with intraepithelial neoplastic lesions in the anogenital region, either with or without coincidental benign warts. This includes intraepithelial neoplasia affecting the vulva (VIN), vagina (VaIN), perianal area (PAIN), anus (AIN) and penis (PIN). The diagnosis of intraepithelial neoplasia is made through histology. The presence of pigmentation, depigmentation, pruritus, underlying immune-deficiency, and prior history of intraepithelial neoplasia on the same or distant anogenital sites may raise suspicion of anogenital neoplasia.


The following factors should be documented.

  • Site(s) and distribution of warts (vulva, meatus, glans etc.)
  • Approximate number (single /multiple) & area of warts (especially if more than 4cm2)
  • Morphology: keratinised or non-keratinised (those on moist, soft non-hair bearing tissue tend not to have a layer of keratin)i
  • Any other notable features (e.g. pigmentation)
  • Patient factors influencing therapy (e.g. pregnancy, immunosuppression, ability to re-attend).

Editorial Information

Last reviewed: 31/05/2024

Next review date: 31/05/2028

Author(s): West of Scotland Managed Clinical Network in Sexual Health Clinical Guidelines Group .

Version: 8.1

Approved By: West of Scotland Managed Clinical Network in Sexual Health