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Key Features

Essentials of Diagnosis

  • Transmitted sexually

  • Most frequent cause of an abnormal Papanicolaou (Pap) smear

  • There are almost 100 serotypes of HPV

    • Types 6 and 11 cause approximately 90% of genital warts

    • Types 16 and 18 cause more than 70% of cervical dysplasia and cervical cancer

  • Infection is more common in persons with multiple partners and in those who initiate sexual intercourse at an early age

General Considerations

  • An estimated 20 million people in the United States are infected each year with HPV, including approximately more than 9 million sexually active adolescents and young adults 15–24 years of age

  • An estimated 32–50% of adolescent females having sexual intercourse in the United States have HPV infections, though only 1% may have visible lesions

  • Thirty to 60% of males whose partners have HPV have evidence of condylomata on examination

  • Pap smears should be obtained starting at age 21 and then every 3 years

  • More frequent and earlier evaluations are recommended if there are additional risk factors, such as coinfection with HIV

Clinical Findings

Symptoms and Signs

  • In males, lesions

    • Are found on the shaft or corona of the penis

    • May develop in the urethra or rectum

    • Do not produce discomfort

    • May be single or found in clusters

  • In females, lesions

    • Develop on any genital mucosal surface, either internally or externally

    • Perianal lesions often develop

Differential Diagnosis

  • Normal anatomic structures (pearly penile papules, vestibular papillae, and sebaceous glands)

  • Molluscum contagiosum

  • Seborrheic keratosis

  • Syphilis


  • Acetowhitening is used to indicate the extent of cervical infection

  • Pap smears detect cervical abnormalities

    • Changes range from atypical squamous cells of undetermined significance (ASCUS) to low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL)

    • LSIL encompasses cellular changes associated with HPV and mild dysplasia

    • HSIL includes moderate dysplasia, severe dysplasia, and carcinoma in situ

    • If results show signs of inflammation only, and concomitant infection such as vaginitis or cervicitis is present, the smear should be repeated after the inflammation has cleared

  • Colposcopy

    • Recommended if the grade of the atypical squamous cells remains uncertain or HSIL is detected on Pap smear

    • Not needed if LSIL is detected, but a repeat Pap smear should be done in 1 year


  • Warts may resolve or remain unchanged if left untreated or they may increase in size or number

  • External lesions can be treated topically

    • Patient applied

      • Podofilox, 0.5% solution or gel; apply twice a day for 3 days

      • Imiquimod 5% cream, applied 3 times a week overnight (maximum of 16 weeks)

      • Imiquimod 3.75% cream, applied daily at bedtime (maximum of 16 weeks)

      • Sinecatechins 15% ointment, applied 3 times daily (maximum of 16 weeks)

      • Podophyllin, 25% in benzoin tincture applied directly ...

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