Human Papillomavirus (HPV)

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

Diagnosis

• 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

Treatment

• 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 to warts; wash off in 1–4 hours; weekly ...