Wart a problem!

Since the launch of the HPV vaccination programme in Malaysia, a lot of attention has been given to one of the major diseases that HPV is linked to: cervical cancer.

Last year, the free vaccination programme for human papillomavirus (HPV) for women and girls was rolled out nationwide.

HPV is a sexually-transmitted virus that can cause symptoms in the anogenital tract (anus and genital tract), including cancer. HPV infection is a complex issue, as there are many different types of HPV, each affecting a different part of the body.

Since the launch of the HPV vaccination programme in Malaysia, a lot of attention has been given to one of the major diseases that HPV is linked to: cervical cancer.

However, HPV infection can also cause genital warts. This is what I will be focusing on in this article.

An introduction to HPV

To say that there are many types of HPV is an understatement - there are more than 100 types of the virus that can infect both men and women.

Out of these, more than 40 types specifically infect the anal and genital tract (from these, a further subgroup is responsible for precancerous changes in the uterine and cervix, causing uterine and cervical cancer).

The most common types of HPV that infect the anogenital tract are HPV-6, -11, -16 and -18. These can be further narrowed down to HPV-6 and -11 as the two most common "low-risk" types, as they are associated with genital warts and precancerous cells in the cervix.

On the other hand, HPV-16 and -18 are the "high-risk" types as they are found in the majority of cervical, uterine and anal cancers.

Many people are unaware of this - and usually do not believe me when I tell them - but HPV infection is remarkably common and, for the most part, harmless.

In the US, statistics show that at least 75 per cent of the reproductive-age population has been infected with HPV at some point in their lives. Over six million people are newly infected with HPV every year in the US, with half of them falling between the ages of 15 and 25.

Most people who have been infected with HPV do not develop warts or cancer, or even any symptoms of HPV infection. This is why many people are not even aware that they have or had the virus, although they can potentially pass on the virus to their sexual partners through sexual contact.

One can also live with the HPV virus in the body for many years, without any symptoms occurring, until much later.

The what of warts

Genital warts may look like flesh-coloured spots that are raised or flat, or growths that resemble the top of a cauliflower (think of the wrinkly texture).

In women, the warts may be found inside or outside the vagina or anus, or on areas of skin near these body parts. They may also grow on the cervix, which is the top end of the vagina that joins with the lower part of the uterus inside the body.

In men, the warts are commonly found on the penis, testicles, groin area, thighs, as well as inside or around the anus.

It may be commonly perceived that genital warts are generally very large and obvious, but this is not true. Some may be so tiny that you cannot spot them.

A word about non-genital warts: HPV infection can also cause warts to develop on the lips, mouth, tongue and throat.

Along with the warts themselves, other symptoms may occur, including increased dampness in the genital area near the warts, unusual vaginal discharge or bleeding (during or after sex) and itching/burning/tenderness in the genital area. However, these symptoms are rare and may not necessarily occur in every case.

Diagnosing genital warts

There is no actual test for warts itself, as they are usually diagnosed through physical examination. For warts that cannot be seen with the naked eye, the doctor may use colposcopy to magnify the view of the cervix and vagina.

However, there are ways to test for the presence of HPV in the body. The most common test is the Pap smear, which identifies abnormal or precancerous cells in the cervix caused by HPV infection, although it does not actually identify the virus itself.

To know whether you have been infected by the high-risk types of HPV, you may need a HPV DNA test, which can look for the presence of HPV-16 or -18. The DNA test is carried out if Pap smear screening shows that precancerous cells have developed.


If the warts are obvious, your doctor may prescribe treatment immediately without further testing.

While genital warts can be treated and removed, there is, unfortunately, no treatment for the HPV virus itself. This means that even though you treat the warts this time around, they may recur later.

You are also still able to spread the virus to your sexual partners even if your warts have been removed.

Your doctor may prescribe a 0.5 per cent solution or gel of podofilox, which is to be applied to the warts twice per day for three days, followed by four days without treatment.

This routine is to be continued for up to three to four weeks, or until the lesions are gone.

Another form of treatment is a 5 per cent cream of imiquimod, which stimulates the body's immune response. This cream is to be applied to the warts three times a week before going to bed, and washed off upon waking up the next morning.

This routine is continued for up to 16 weeks or until the warts are gone.

Some treatments have to be administered by the doctor. One of them is a 10-25 per cent solution of podophyllin resin, applied on the warts and then washed off several hours later.

This is done every week until the warts are gone.

Another treatment you can get at the clinic is an 80-90 per cent solution of trichloroacetic acid (TCA) or bichloracetic acid (BCA), applied weekly on the warts.

Apart from topical treatments, some people may require injections, either of 5-flurouracil epinephrine gel or interferon alpha. These injections also require several weeks of visits to the clinic.

If these non-invasive therapies do not work, laser surgery or surgical excision of the warts may be necessary.

Preventing genital warts

The burden of HPV infection usually lies on the woman, as men carrying the HPV virus never develop problems or symptoms. However, men can pass on the virus to their partners. Therefore, the most effective way of preventing HPV infection and warts is by having safe sex.

Obviously, abstaining from sexual contact altogether is the most foolproof way of avoiding genital warts. Recognising that this is not possible for most people, other measures that women can take are to have as few sexual partners as possible.

Using condoms can reduce the risk of HPV transmission, though it will not eliminate it completely. This is because HPV is transmitted through skin contact, not through bodily fluids.

Finally, there is the HPV vaccination, which I mentioned at the beginning of this article. There are two types of vaccines in the market - one of them protects against HPV-6, -11, -16 and -18, while the other only protects against the two high-risk types, HPV-16 and -18.

These vaccines can be given to girls and boys, and can greatly reduce the risk of developing warts and cervical cancer, as they protect against the HPV types that are most commonly implicated in tese conditions.

The vaccinations are most effective if administered before a girl or woman becomes sexually active.

Many women find it difficult to address the issue of genital warts, but I urge them to be open with their partner and doctor if they develop the symptoms.

Women who have genital warts also need to be aware that regular Pap smears are very important to screen for cervical cancer and precancerous changes.

Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician & gynaecologist (FRCOG, UK). For further information, visit www.primanora.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.