Approximately 90% of condyloma acuminata are related to HPV types 6 and 11. These 2 types are the least likely to have a neoplastic potential. Risk for neoplastic conversion has been determined to be moderate (types 33, 35, 39, 40, 43, 45, 51-56, 58) or high (types 16, 18), with many other isolated types. The picture is complicated by proven coexistence of many of these types in the same patient (10-15% of patients), the lack of adequate information on the oncogenic potential of many other types, and ongoing identification of additional HPV-related clinical pathology.

For example, previously a part of the differential diagnosis of condyloma acuminata, bowenoid papulosis, seborrheic keratoses, and Buschke-Löwenstein tumors have been linked to HPV infections. Bowenoid papulosis consists of rough papular eruptions attributed to HPV and is considered to be a carcinoma in situ. The eruptions can be red, brown, or flesh colored. They either may regress or become invasive. Seborrheic keratoses previously were considered a benign skin manifestation. HPV has been linked to rough plaques indicative of this disease. It has both an infectious and an oncogenic potential. Finally, Buschke-Löwenstein tumor (ie, giant condyloma) is a fungating, locally invasive, low-grade cancer attributed to HPV.

Pathophysiology: Cells of the basal layer of the epidermis are invaded by HPV. These penetrate through skin and cause mucosal microabrasions. A latent viral phase begins with no signs or symptoms and can last from a month to several years. Following latency, production of viral DNA, capsids, and particles begins. Host cells become infected and develop the morphologic atypical koilocytosis of condyloma acuminata.

The most commonly affected areas are the penis, vulva, vagina, cervix, perineum, and perianal area. Uncommon mucosal lesions in the oropharynx, larynx, and trachea have been reported. HPV-6 even has been reported in other uncommon areas (eg, extremities).

Multiple simultaneous lesions are common and may involve subclinical states as well-differentiated anatomic sites. Subclinical infections have been established to carry both an infectious and oncogenic potential.

Consider sexual abuse as a possible underlying problem in pediatric patients; however, keep in mind that infection by direct manual contact or indirectly by fomites rarely may occur. Finally, passage through an infected vaginal canal at birth may cause respiratory lesions in infants.

Frequency:

In the US: Annual incidence of condyloma acuminatum is 1%. It is considered the most common sexually transmitted disease (STD). Prevalence has been reported to exceed 50%. Highest prevalence and risk is among young adults in the third decade and in older teenagers. A 4-fold or more increase in prevalence has been reported in the last 2 decades.
Internationally: International prevalence has been reported variably. Available data from England, Panama, Italy, the Netherlands, and other developed and underdeveloped countries report HPV infections to be at least as common as in the US.
Mortality/Morbidity:

Mortality is secondary to malignant transformation to carcinoma in both males and females. This oncogenic potential has been reported to triple the risk of genitourinary cancer among infected males. Fortunately, this is rare with HPV types 6 and 11, which are the most commonly isolated viruses.
HPV infection appears to be more common and worse in patients with various types of immunologic deficiencies. Recurrence rates, size, discomfort, and risk of oncologic progression are highest among those patients. Secondary infection is uncommon.
Latent illness often becomes active during pregnancy. Vulvar condyloma acuminata may interfere with parturition. Trauma then may occur, producing crusting or erythema. Bleeding has been reported in large lesions that can occur during pregnancy.

In males, bleeding has been reported due to flat warts of the penile urethral meatus, usually associated with HPV-16. Lesions may lead to disfigurement of area(s) involved. Finally, acute urethral obstruction in women also may occur.
Sex:

Both sexes are susceptible to infection.
Overt disease may be more common in men (reported in 75% of patients); however, infection may be more prevalent in women.
Age:

Prevalence is greatest in persons aged 17-33 years, with incidence peaking in persons aged 20-24 years.
CLINICAL Section 3 of 11
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History:

Smoking, oral contraceptives, multiple sexual partners, and early coital age are risk factors for acquiring condyloma acuminata.
Generally, two thirds of individuals who have sexual contact with a partner with condyloma acuminata develop lesions within 3 months.
The chief complaint usually is one of painless bumps, pruritus, or discharge.
Involvement of more than 1 area is common.
History of multiple lesions, rather than 1 isolated wart, is common.
Oral, laryngeal, or tracheal mucosal lesions (rare) presumably are transferred by oral-genital contact.
History of anal intercourse in both males and females warrants a thorough search for perianal lesions.
Rarely, urethral bleeding or urinary obstruction may be the presenting complaint when the wart involves the meatus.
The patient's history may indicate presence of previous or other current STDs.
Coital bleeding may occur. Vaginal bleeding during pregnancy may be due to condyloma eruptions.
Latent illness may become active, particularly with pregnancy and immunosuppression.
Lesions may regress spontaneously, remain the same, or progress.
Pruritus may be present.
Discharge may be a complaint.
Physical:

Single or multiple papular eruptions may be observed.
Eruptions may appear pearly, filiform, fungating, cauliflower, or plaquelike.
They can be quite smooth (particularly on penile shaft), verrucous, or lobulated.
Eruptions may seem harmless or may have a disturbing appearance.
Carefully search for simultaneously involved multiple sites.
Eruptions' color may be the same as the skin, or they may exhibit erythema or hyperpigmentation. Check for irregularity in shape, form, or color suggestive of melanoma or malignancy.
Propensity has been established for penile glans and shaft in men and for vulvovaginal and cervical areas in women.
In contrast to early reports, presence of external condyloma acuminata in both men and women warrants a thorough search for cervical or urethral lesions.
Such internal lesions have been found in more than one half of females with external lesions.
One report indicates that infected males have a 20% chance of having subclinical urethral lesions.
More than 50% of female patients with external lesions have been found to have negative Papanicolaou (Pap) tests but tested positive for HPV infection using in situ hybridization.
Urethral meatus and mucosal lesions can occur.
Some are subclinical.
Hair or the inner aspect of uncircumcised foreskin hides some lesions.
Search for evidence of other STDs (eg, ulcerations, adenopathy, vesicles, discharge).
Look for perianal lesions, particularly in patients with history or risk of immunosuppression or anal intercourse.
Causes:

Several of the epidermotropic HPVs cause condyloma acuminata.
HPV types 6 and 11 most commonly are isolated, but many of the more than 60 types of HPV potentially cause condyloma.
Male sexual partners of women with cervical intraepithelial neoplasia often have infections with the same viral type.
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Lab Studies:

As indicated by history and examination, test for other STDs, such as HIV, gonorrhea, chlamydia, and syphilis.
Although not ED tests, the following are listed strictly for educational purposes and to assist readers in understanding and managing potential complications:
Pap smear: This test is used to look for papillomatosis, acanthosis, koilocytic abnormality, and mild nuclear abnormality.
Filter hybridization (Southern blot and slot blot hybridization), in situ hybridization, and polymerase chain reaction (PCR): These tests may be used for diagnosis and HPV typing.
Hybrid capture
Other Tests:

Acetowhitening
Subclinical lesions can be visualized by wrapping penis with gauze soaked with 5% acetic acid for 5 minutes.
Using a 10-X hand lens or colposcope, warts appear as tiny white papules.
A shiny white appearance of skin represents foci of epithelial hyperplasia (subclinical infection).
Procedures:

Although not ED procedures, the following are listed strictly for educational purposes and to assist readers in understanding and managing potential presenting complications:
Colposcopy (stereoscopic microscopy): This is very useful to identify (mostly) cervical lesions, which are identified better using acetic acid.

Biopsy: Biopsy is indicated for lesions that are atypical, recurrent after initial success, or resistant to treatment or in patients with a high risk for neoplasia or immunosuppression.
Anoscopy
Antroscopy

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