Anal Condyloma: Causes, Formation, and Treatment
Condyloma treatment, the causes of genital warts, and how anal warts can be resolved—all the details you need to know are covered in our content.
The development of warts in the area around the anus, inside the anal canal, and just above the rectum—the end part of the large intestine—is known as the disease anal condyloma.
Typically, patients with genital warts also have warts in the anal area. Therefore, anogenital warts are medically referred to as condyloma acuminata. It is caused by a virus called HPV and is contagious, spreading to other parts of the body and other individuals.
Anal warts, anal condyloma, and anal verruca are alternative names for this condition.
Warts can vary in size, ranging from small to as large as a fist, and they may appear in a single location or spread across multiple areas.
This condition is most commonly observed in the transgender and gay communities, but it can occur in individuals of any gender.
Why Do Genital Warts Occur, and How Are They Formed?
The cause is the HPV virus, and transmission occurs through contact with someone who has this HPV virus. There are over 230 types of the human papillomavirus (HPV), but not all of them lead to genital warts. In most patients, sexual contact is the primary cause of the formation of genital warts, although it can occasionally be transmitted without sexual contact.
If the sexual partner has the disease and is not protected with a condom, transmission can occur. Even if the partner uses a condom, transmission can still occur if warts are present outside the area covered by the condom. The virus can be transmitted through sexual contact to the anus, penis, vagina, lips, inside the mouth, and throat.
Scientific studies have shown that transmission can also occur through shared objects outside of sexual intercourse. If an infected person touches the toilet faucet they use after relieving themselves and then touches the sink faucet, they can transmit the virus.
A study even detected the virus on the sitting part of public restroom toilets. Therefore, all toilets in our clinics are covered with individual plastic sheets and are changed after each use.
Condyloma Cauterization: What Is It, and How Is It Done?
Cauterization refers to burning, and it is performed using an electrocautery device. With the introduction of radiofrequency devices, the use of cautery has decreased because radiofrequency offers certain advantages.
When the tip of the cautery device touches the wart, the wart burns, turning into smoke and char. Since it is a painful procedure, local anesthesia is required.
The procedure is as follows:
- First, the patient undergoes a detailed examination to ensure nothing is overlooked. If there is any suspicion, an anoscope is used to examine the intestines, and all warts to be treated are identified.
- The entire application area is wiped with an antiviral solution to prevent new infections.
- All warts are anesthetized at the base with a local anesthetic, and then cautery is applied to burn the warts.
Radiofrequency Treatment for Anal Warts
Also known as radiosurgery, radiofrequency wart treatment is the latest technology developed for wart removal. Its most significant advantage is that it creates less burn around the application area. Due to the reduced lateral thermal damage, the healing time after radiofrequency treatment is faster and shorter compared to cautery.
Clinics equipped with radiofrequency technology do not perform condyloma cauterization; instead, they treat with radiofrequency.
The depth of radiofrequency penetration can be as thin as a quarter of a millimeter, ensuring more certainty about the treated layer and preventing deep burns. The use of a very fine needle also allows for controlled burns, contributing to a faster healing process.
Is There an Anal Wart Cream, and Does It Work?
Yes, there are two groups of creams with different effects:
Aldara Cream: Contains imiquimod and is recommended to support other treatments, not as a standalone treatment. It is used in conjunction with other treatments for its supportive properties during the treatment process (2).
Veregen Cream (Veregreen): Contains catechin and, like Aldara Cream, is used to support other treatments. Additionally, it can be used as a standalone treatment in early-stage cases. It is safe and successful not only in the anal area but also on the face and other body regions (3).
Aldara should be used with caution as it can cause difficult-to-repair burns in the inner skin of the anus and vagina. It is available for sale in pharmacies in Turkey.
Veregen Cream has fewer side effects, providing ease of use. However, both Veregen Cream and Veregreen Cream are not available for sale in Turkey.
HPV Symptoms:
The most significant symptom is cauliflower-like, raised, flesh-colored protrusions on the skin. These protrusions start small and can grow to the size of an orange if left untreated. Lesions are typically raised and skin-colored but can also be dark, and they may appear non-protruding on the skin.
These manifestations are similar in moist and closed areas such as the mouth, inner vagina, where they may resemble white ulcers. In the intestines, they may appear like decayed tissue and can be confused with hemorrhoids.
Due to small traumas during scratching or sitting, these growths can become detached, leading to bleeding.
They can cause a foul odor due to moisture and inflammation.
Moisture may also lead to itching in the anal and genital areas.
How Is the HPV Vaccine Administered and Who Should Receive It?
All wart vaccines are administered into the muscle, preferably into the shoulder muscle of the non-dominant arm. Routine vaccination is not available in Turkey, and individuals purchase and receive vaccinations on their own. There are two vaccines named Cervarix and Gardasil. Cervarix is not sold in Turkey. Gardasil has two forms, one effective against 4 types and the other against 9 types.
- Gardasil 4 vaccine is effective against types 6, 11, 16, 18.
- Gardasil 9 vaccine provides protection against types 6, 11, 16, 18, 31, 33, 45, 52, 58.
In Turkey, only Gardasil 4, effective against 4 types, was available, and as of early 2023, Gardasil 9 has also been imported and distributed to pharmacies.
The administration of the Gardasil vaccine depends on the situation. The World Health Organization (WHO) recommends it for women over 9 years old, under 24 years old, and who have never engaged in sexual intercourse. The primary goal is to prevent 99% of cervical cancers in women, which are primarily caused by HPV. The aim of vaccination is to prevent cervical cancer in women.
In addition to routine vaccination, it is recommended in the following situations:
- Immunocompromised individuals (e.g., organ transplant recipients)
- Presence of diseases that suppress the immune system, such as AIDS
- Individuals engaged in high-risk sexual behaviors, such as sex workers and those with multiple partners
- Individuals with multiple sexual partners, including those in the transgender and gay communities
Scientific studies have shown that administering the vaccine to individuals with HPV undergoing treatment strengthens immunity and increases treatment success.
Studies also suggest the possibility of treating HPV with the Gardasil vaccine (4).
How Is the HPV Test Conducted?
There are two different testing methods:
Detection of the presence of condyloma under a microscope. This can be done in two ways:
- In both men and women, a sample is taken from the detected wart and examined by a pathologist to diagnose the disease.
- In women, a smear test (pap smear) is taken from the cervix, and similarly, it is diagnosed under a microscope by a pathologist.
Testing the genetic structure of existing warts through genetic analysis for type determination.
The information provided by these two tests is different. Pathological examination determines the presence of the disease, while type determination identifies the presence and type of the virus.
Pathological examination does not determine the type. If type determination is needed, it is unnecessary to undergo a pathological examination. The cost of type determination is 4-5 times higher than the cost of pathological examination.
Why is HPV Positive but Warts are Absent?
Some types of condyloma may not cause protruding warts, while others may. Types 16, 18, and 31 may not cause warts in many individuals. The absence of warts does not indicate the absence of the disease, and more importantly, it does not indicate that a woman does not have cervical cancer. Types 16 and 18 rarely cause protruding lesions.
Is Having Warts in the Genital Area Risky?
Yes, there are thousands of scientific studies that suggest a very high risk, especially for women. The risk is so significant that the only known cause of cervical cancers is HPV, i.e., genital warts. Most importantly, types 16 and 18 are responsible for 70% of all genital warts. Other high-risk groups are responsible for 90% of total genital warts. Gardasil 9 prevents 90% of cervical cancers when administered.
Are Genital Warts Contagious, and How Does Transmission Occur?
Yes, they are contagious and are transmitted through direct contact, primarily through sexual intercourse. There is some information suggesting that a small portion of transmissions occurs indirectly through the use of shared items.
Transmission can also occur through direct touching of the body, hands, and facial areas, such as through handshakes or kissing.
While treating anogenital warts, there is a concern that the treating team may transmit the virus to the upper respiratory tract, leading to the possibility of developing nasopharyngeal cancer.
How Is Genital Wart Treatment Performed?
The methods used for genital wart treatment are as follows:
Genital Wart Medication: In the early stages, genital warts can be treated using Veregen Cream. Veregen is sold in the United States, and an equivalent product, Veregreen Cream, is available in Europe. However, patients often seek medical attention at more advanced stages due to embarrassment.The decision on whether to use medication for treatment should be made by the examining doctor, and patients should not insist on medication; otherwise, the disease may progress.Aside from Veregen, another medication called Aldara is available. However, due to its significant burning sensation during use, patients may have difficulty adhering to the treatment.
Wart Cauterization: During the examination, all warts are carefully observed, and if possible, they are counted to ensure none are missed. Subsequently, the area is locally anesthetized, and preferably, using radiofrequency, all warts are vaporized in the same session.The procedure can be performed by burning with cautery or using laser treatment. Among these methods, radiofrequency is the most successful.
Wart Surgery: Surgical removal by cutting, a widely practiced method in the past, has largely been replaced by radiofrequency and other methods. Surgical cutting causes broader and deeper wounds, leading to prolonged healing. Particularly in anal warts, surgery may cause anal stenosis, which is a challenging side effect to treat.HPV surgery is mostly used in the treatment of giant condyloma acuminata, known as Buschke-Lowenstein disease.
How to Care for Wounds After Wart Treatment?
Depending on the size, number, and extent of genital warts, wounds of varying sizes may form. Since the resulting wounds are open, there is a 100% chance of microbial contamination. Especially in the anal region, infection is inevitable due to fecal contamination. However, if the correct wound ointment is used, this infection can be avoided. Additionally, the use of a cream that accelerates wound healing shortens the recovery time.
The most commonly prescribed medication after wart treatment is Kutalin Cream.
Kutalin Cream, with its chlorhexidine digluconate content, kills 99.9% of microbes in the applied area. Moreover, thanks to its ingredients such as dexpanthenol, triticum vulgare, hamamelis virginiana, and zinc oxide, it accelerates wound healing, allowing the skin to close earlier.
The antiviral effect of chlorhexidine digluconate in Kutalin Cream prevents the development and growth of small warts that are not visible to the naked eye during treatment. This effect makes it recommended not only after anal and genital warts but also after the treatment of all warts seen anywhere on the body (7).
References
1- Gupta, P. J. (2004). Radio surgery: a new tool in proctology practice. Bratislavske lekarske listy, 105(7/8), 270-276.
2- Wiley, D. J., Douglas, J., Beutner, K., Cox, T., Fife, K., Moscicki, A. B., & Fukumoto, L. (2002). External genital warts: diagnosis, treatment, and prevention. Clinical Infectious Diseases, 35(Supplement_2), S210-S224.
3- Clouth, A., & Schöfer, H. (2015). Treatment of recalcitrant facial verrucae vulgares with sinecatechins (greentea catechins) ointment. Journal of the European Academy of Dermatology and Venereology, 29(1), 178-179.
4- Lee, H. J., Kim, J. K., Kim, D. H., & Yoon, M. S. (2011). Condyloma accuminatum treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, 18). Journal of the American Academy of Dermatology, 64(6), e130-e132.
5- Paraskevas, K. I., Kyriakos, E., Poulios, E. E., Stathopoulos, V., Tzovaras, A. A., & Briana, D. D. (2007). Surgical management of giant condyloma acuminatum (Buschke-Loewenstein tumor) of the perianal region. Dermatologic Surgery, 33(5), 638-644.
6- Ramani, N., & Mathew, S. (2012). Comparative evaluation of antimicrobial efficacy of chlorhexidine digluconate and propolis when used as an intracanal medicament: ex vivo study. Journal of International Oral Health, 4(2), 17.
7- Mendoza, J. P. I. M., Ubillús, B. P. T., Bolívar, G. T. S., Palacios, R. D. P. C., Lopez, P. S. G. H., Rodríguez, D. A. P., & Koecklin, K. H. U. (2022). Antiviral effect of mouthwashes against SARS-COV-2: A systematic review. The Saudi dental journal.
