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Definition

Anal warts, also known as condyloma acuminata, are small warts that can occur in the rectum.

Description

Initially appear as tiny blemishes that can be as small as the head of a pin or grow into larger cauliflower-like protuberances. They can be yellow, pink, or light brown in color, and only rarely are painful or uncomfortable. In fact, infected individuals often are unaware that they exist. Most cases are caused by sexual transmission.

Most individuals have between one to 10 genital warts thtat range in size from roughly 0.5-1.9 cm². Some will complain of painless bumps or itching, but often, these warts can remain completely unnoticed.

Causes and symptoms

Condyloma acuminatum is one of the most common sexually transmitted disease (STD) in the United States. Young adults aged 17 to 33 years are at greatest risk. Risk factors include smoking, using oral contraceptives, having multiple sexual partners, and an early coital age. In addition, individuals who have a history of immunosuppression or anal intercourse are also at risk.

Roughly 90% of all anal warts are caused by the human papilloma virus (HPV) types 6 and 11, which are the least likely of over 60 types of HPV to become cancerous. Anal warts are usually transmitted through direct sexual contact with someone who is infected with condyloma acuminata anywhere in the genital area, including the penis and vagina. Studies have shown that roughly 75% of those who engage in sexual contact with someone infected with condyloma acuminata will develop these warts within three months.

Treatment

According to guidelines from the Centers for Disease Control (CDC), the treatment of all genital warts, including anal warts, should be conducted according to the methods preferred by the patient, the medications or procedures most readily available, and the experience of the patient's physician in removing anal warts.

Treatment options include electrical cautery, surgical removal, or both. Warts that appear inside the anal canal will almost always be treated with cauterization or surgical removal. Surgical removal, also known as excision, has the highest success rates and lowest recurrence rates. Indeed, studies have shown that initial cure rates range from 63-91%.

Unfortunately, most cases require numerous treatments because the virus that causes the warts can live in the surrounding tissue. The area may seem normal and wart-free for six months or longer before another wart develops.

Laser surgery is another possibility, but requires local, general, or spinal anesthesia, depending on the number warts and where they are.

Electrocoagulation, a technique that uses electrical energy to destroy the warts, is usually the most painful of the procedures done to eliminate condyloma acuminata of the anus, and is usually reserved for larger warts. It is done with local anesthesia, and may cause discharge or bleeding from the anus.

Follow-up visits to the physician are necessary to make sure that the warts have not recurred. It is recommended that these patients see their physicians every three to six months for up to 1.5 years, which is how long the incubation period is for the HPV virus.

Carbon dioxide laser treatment and electrodesiccation are other options, but these are usually reserved for extensive warts or those that continue to recur despite numerous treatments. However, because HPV virus can be transmitted via the smoke caused by these procedures, they are usually reserved for the worst infections.

For small warts that affect only the skin around the anus, several medications are available, which can be applied directly to the surface of the warts by a physician or by the patients themselves.

Such medications include podophyllum resin (Podocon-25, Pod-Ben-25), a substance made from the cytotoxic extracts of several plants. This agent offers a cure rate of 20-50% when used alone, and is applied by the physician weekly and then washed off 6 hours later by the patient.

Podofilox (Condylox) is another agent, and is available for patients to use at home. It can be applied twice daily for up to 4 weeks. Podofilox offers a slightly higher cure rate than podophyllin, and can also be used to prevent warts.

Trichloroacetic and bichloroacetic acids are available in several concentrations up to 80% for the treatment of condyloma acuminata. These acids work to cauterize the skin, and are quite caustic. Nevertheless, they cause less irritation and overall body effects than the other agents mentioned above. Recurrence, however, is higher with these acids.

Bleomycin (Blenoxane) is another treatment option, but it has several drawbacks. First, it must be administered by a physician into each lesion via injection, but is can have a host of side effects, and patients must be followed carefully by their physician.

Imiquimod 5% cream is also available for patients to apply themselves. It is to be applied three times weekly, for up to 16 weeks, and has been shown to clear warts within eight to 10 weeks.

Finally, the interferon drugs, which are naturally occurring proteins that have antiviral and antitumor effects, are available. These include interferon alfa 2a and 2b (Roferon, Intron A), which are to be injected into each lesion twice a week for up to eight weeks.

Prognosis

Once a diagnosis of anal warts has been made, further outbreaks can be controlled or sometimes prevented with proper care. Unfortunately, many cases of anal warts either fail to respond to treatment or recur. Patients have to undergo roughly six to nine treatments over several months to assure that the warts are completely eradicated.

Recurrence rates have been estimated to be over 50% after one year and may be due to the long incubation of HPV (up to 1.5 years), deep lesions, undetected lesions, virus present in surrounding skin that is not treated.

Prevention

Sexual abstinence and monogamous relationships can be the most effective form of prevention, and condoms may also decrease the chances of transmission of condyloma acuminata. Abstinence from sexual relations with people who have anal or genital warts can prevent infection. Unfortunately, since many people may not be aware that they have this condition, this is not always possible.

Individuals infected with anal warts should have follow-up checkups every few weeks after their initial treatment, after which self-exams can be done.

Sexual partners of people who have anal warts should also be examined, as a precautionary preventive measure.

Finally, 5-flourouracil (Adrucil, Efudex, Fluoroplex) may be useful to prevent recurrence once the warts have been removed. Treatment must, however, be initiated within 1 month of wart removal.

Key Terms

Electrocoagulation

a technique using electrical energy to destroy the warts. Usually done for warts within the anus with a local anesthesia, electrocoagulation is most painful form of therapy, and can cause both bleeding and discharge from the anus.

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