Genital warts female are benign tumors of the female genitals associated with infection with a tumor–borne virus. The disease may be asymptomatic or manifest exophytic growths in the vulva, vagina, cervix. Visible neoplasms are usually accompanied by bleeding and itching. The diagnosis is established based on the results of a clinical examination, colposcopy, cytological and DNA analysis. The treatment is complex, includes immunotherapy, the use of cytostatic drugs, methods of destructive influence.
A63 Other sexually transmitted diseases not classified elsewhere
Genital warts female (genital papillomavirus infection, anogenital or venereal warts) are epithelial fibrous growths localized on the surface or in the thickness of the mucous membranes of the genitals. The disease is registered at any age from infancy to old age. The peak incidence occurs during the period of maximum sexual activity (18-30 years), the incidence of warts among patients of the specified age range is 45-81%. The pathogen of pathology has oncogenic potential, which is due to the increased likelihood of epithelial malignant tumors of the genitals in patients suffering from condylomatosis.
Genital warts female have an infectious etiology. The causative agents of the disease are various types of human papillomavirus (HPV). Condylomatosis refers to anthroponotic infections (it spreads only among people), infection occurs by contact. Papillomavirus is highly contagious, 60% of women develop an infection after the first contact with an infectious agent. There are two ways to transfer:
- Sexual. Transmission of the virus through sexual contact is the main route of infection. The probability of infection is significantly increased by the following features of sexual behavior: early (up to 17 years old) initiation of sexual activity, the practice of unprotected sexual contacts, frequent change of sexual partners.
- Contact and household. Caused by non-compliance with the rules of personal hygiene (using other people’s personal belongings). The virus is transmitted through infected underwear, bath accessories. With this method of infection, the anogenital zone is mainly affected. Household infection in adults is registered much less often than sexual.
After the virus enters the body, the disease does not always develop. The main predisposing condition for infection is a decrease in immune activity. Susceptibility to the virus is increased in pregnant women, in children (up to 10-12 years old) and senile age, in heavy smokers. Local (inflammatory gynecological diseases, bacterial vaginosis, dystrophic changes in the mucous membrane of the genitals) and general somatic (diabetes mellitus, obesity, hypovitaminosis A, C, B9) pathologies significantly increase the risk of infection.
HPV refers to DNA-containing tumor-bearing (capable of causing the development of tumors) human viruses. Papillomavirus infects basal epithelial cells and has a productive and (or) transformative effect on them. If the DNA of the virus has not integrated into the DNA of the host cell, the infection develops according to a productive type: after infection, the cells begin to divide intensively, resulting in the growth of so–called productive condylomas – benign neoplasms visible to the naked eye. The risk of their malignancy is quite low.
Transforming infection is more characterized by qualitative changes in the affected cells, leading to a violation of differentiation. Microscopic unproductive warts are formed, carrying an increased risk of cancer transformation. The form of infection largely depends on the type of HPV. The viruses of high oncogenic risk, in most cases leading to a transforming infection, include the types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68. HPV of low oncogenic risk, among which types 6 and 11 are most common, more often entail the development of productive forms.
The disease can have two ways of development, usually depending on the immune status of the patient. In the presence of transient immune disorders, virus elimination and spontaneous recovery occur after 3-9 months. Spontaneous regression of formations is noted. If the reaction of the immune system remains weak, a persistent infection is detected with the likely further formation of precancerous epithelial changes, and later – carcinoma.
Genital warts female are classified according to various criteria. According to the clinical course, clinical, subclinical, latent forms of infection are distinguished. Taking into account the localization of pathological changes, there is condylomatosis of the cervix, vulva, vagina (often there is a lesion with growths of different areas). According to clinical signs and appearance , genital warts can be divided into two types:
- Exophytic. It is the prevailing form of the disease. Well-visualized growths of various shapes (pointed, papillary, papular) towering above the mucous membrane are found. Outgrowths rarely malignate (with the exception of the giant Bushke-Levenstein condyloma), the area of the external genitals is more often affected.
- Endophytic. The formations are located in the thickness of the epithelium, usually do not rise above the surface, are invisible without the use of instrumental methods. There are flat and inverting (penetrating deep into the stroma, cervical glands), condylomas. Endophytic forms are more often combined with dysplasia, cancer, and are observed mostly in the cervical and vaginal areas.
In addition to these types, some clinicians distinguish condylomatous vaginitis and cervicitis. These forms are characterized by focal without clear boundaries or diffuse epithelial lesion of the entire anatomical zone (vulva, vagina or cervix). Sometimes they can be determined without special visualization tools as small spiny outgrowths against the background of edematous mucosa along its entire surface.
Genital warts female manifests in 3 weeks-six months (on average 3 months later) after contact with the virus. Subjective manifestations are noted only in exophytic forms, endophytic formations are characterized by a subclinical course (without visible manifestations). Single papillomas (condylomas) of the cervix and vagina are almost asymptomatic, the only sign may be spotting during sexual intercourse due to damage to neoplasms. With multiple growths, serous-mucous or purulent whites, dyspareunia may be observed.
Exophytic condylomatosis of the vulva is accompanied by the growth of specific formations that a woman can detect on her own. The favorite areas of the lesion are the areas of the labia minora and their frenulum, the mouth of the urethra, the vestibule of the vagina. Often pathological changes are localized in the perianal zone, the perineum. At first, separate small formations in the form of papillae appear, which do not differ in color from the normal mucous membrane. Over time, the sprawl increases, acquires a diverse appearance.
Pointed warts look like papillary outgrowths with a thin stem or a wide base, represented by single nodes or colonies like cauliflower. Papillary warts are similar to skin vulgar warts. At the slightest injury, the formations begin to bleed. In the future, their surface becomes bright red, itching, pain, unpleasant-smelling vestibular whites are added. When the mouth of the urethra is affected, there are signs of urethritis – pain in the discharge of urine, frequent urges.
Regressing condylomas gradually fade, their size decreases until complete disappearance, concomitant discomfort disappears. Recovery or temporary remission occurs. Persistent papillomavirus infection, which can last for years, is characterized by alternating periods of remission and exacerbation (often the process triggers hypothermia, concomitant infection, psychoemotional stress). The latent form of the disease is not accompanied by any subjective manifestations, nor histo- and cytomorphological changes.
The most threatening complication of genital warts female is gynecological cancer, which develops in 10% of patients with endophytic condylomas after two years from the moment of diagnosis and in 5% against the background of exophytic formations that have existed for at least five years. Most often it is cervical carcinoma, less often – squamous cell carcinoma of the vulva, vagina. Due to injury to exophytic growths, the addition of bacterial infection, an inflammatory process often occurs in patients (vulvitis, colpitis, cervicitis). Giant condyloma can provoke the destruction of surrounding tissues.
A dangerous consequence of untreated papillomavirus infection in pregnant women is infection of the fetus during childbirth through the natural genital tract, followed by the development of laryngeal papillomatosis in the child. This disease is life-threatening, entails developmental disorders of the infant, because due to the age-related narrowness of the respiratory tract, pathological growths can block a significant part of the tracheal lumen and, as a result, lead to respiratory failure, asphyxia.
Diagnosis of large exophytic condylomas of the anogenital region is usually not difficult, since pathological changes are easily visualized during a gynecological examination. The possible presence of flat cervical or vaginal condylomas can be suspected on the basis of anamnestic data, according to the available condylomas of the vulva. To clarify the diagnosis, it is necessary to conduct the following studies:
- Endoscopy. Colposcopy with staining allows detecting endophytic and individual exophytic condylomas of small size, suggesting epithelial dysplasia. The signs of flat condylomas include a pattern in the form of “mosaic and punctuation”, spiny epithelial outgrowths, atypical vessels, pointed condylomas are indicated by finger-shaped outgrowths with an expanded vascular loop.
- DNA analysis. The positive result of the PCR study confirms that the lesion is caused by papillomavirus. With the help of RT-PCR, the type of HPV is determined. This makes it possible to choose an adequate treatment and make a prognosis. Molecular analysis is the only method of diagnosing latent infection.
- Microscopic analysis. Cytological examination of the smear allows to diagnose the clinical and subclinical forms of genital warts, to identify precancerous changes. The basis for the diagnosis of papillomavirus infection is the detection of coilocytosis and dyskeratosis in a smear taken from the affected area.
Condylomas should be differentiated with precancerous (dysplasia), intraepithelial and invasive cancer of the genital organs (including non-viral etiology). For this purpose, in doubtful cases, an additional targeted biopsy of the affected area is prescribed, followed by a histological examination of the material, consulting an oncogynecologist.
Currently, there is no effective specific treatment for condylomas. In endophytic papillomas, not complicated by severe dysplasia, a wait-and-see tactic is used with regular gynecological supervision. Exophytic formations are usually removed because they are easily injured, cause physical and psychological discomfort. Immunological therapy is used in conjunction with various destructive methods to reduce the likelihood of relapse. Medical treatment of condylomas includes the following methods:
- Non-surgical destruction. To destroy pathological formations by non-physical methods, applications of cytotoxic agents (podophyllin, colchamine, 5-fluorouracil), medicines based on acid solutions (trichloroacetic, acetylsalicylic, lactic, oxalic, nitric) are applied to the area of the condyloma. Therapy with antitumor drugs is sometimes carried out to increase the therapeutic effect after surgical ablation.
- Nonspecific antiviral therapy. Antiviral drugs inhibit virus replication, slow down cell proliferation, and can be used as monotherapy or as an adjunct to ablative methods. For the treatment of warts, alpha- and beta-interferons are used in the form of applications, local and intraocular injections, as well as systemically.
- Immunomodulatory therapy. Immunomodulators correct the activity of a person’s own immune system – stimulate the synthesis of interferons and immune cells, increase their activity. Inosinplex and others are used in the therapy of condylomatosis. Medications are prescribed for adjuvant and neoadjuvant therapy before or after surgical treatment. There are oral and rectal injectable forms of release of these drugs.
Surgical treatment of complicated forms of genital warts female (with signs of severe dysplasia, intraepithelial cancer) should be carried out by an oncogynecologist. Uncomplicated warts are treated by an operating gynecologist. Before using ablation methods, it is necessary to exclude the malignant nature of the neoplasm. The following surgical methods are used in the treatment of condylomatosis:
- Ablative. Destruction of papillomatous growths is carried out in the case of uncomplicated condylomas, in the presence of mild or moderate dysplasia. Laser vaporization, cryodestruction, and radiofrequency ablation are performed to remove pathological growths. Radio frequency and laser methods are the most gentle, but the least accessible.
- Excisional. With cervical condyloma, combined with moderate or severe dysplasia, noninvasive cancer is most often performed organ–preserving surgery – cone excision. Resection can be performed with inverting and giant condylomas of the vulva. The scope of the operation varies from a wide excision of the affected area to a simple vulvectomy.
Prognosis and prevention
The prognosis depends on the patient’s immune status. In 80%, spontaneous recovery occurs within 1-2 years, sometimes the disease is difficult to treat, relapses. The most effective method of primary prevention of warts in women in modern gynecology is active immunization with Gardasil or Cervarix vaccines for girls and young women aged 9-26 years. Other measures include the exclusion of promiscuous unprotected sexual contacts and the use of other people’s intimate hygiene items, the treatment of pathologies that weaken the immune system.
For timely detection of the disease and its complications (precancerous, cancer), patients at high risk and with a persistent course of infection need regular (at least once every one to three years) gynecological examination with mandatory colposcopy and cytological smear analysis. Delivery of pregnant women with HPV infections is carried out by caesarean section in order to prevent infection of the child.