Anal warts

Anal warts or condyloma acuminata (CA) are lesions occurring around the ano-genital area.

They are caused by human papilloma virus (HPV). Many genotypes of the virus are responsible. The common ones are HPV type 6, 11, 16 and 18. The latter two show a higher incidence of dysplasia or neoplasia in the lesion. These may lead to squamous cell carcinoma. These lesions are generally sexually transmitted and are very common in human immunodeficiency virus (HIV)-positive patients. Interestingly, these lesions show a higher incidence and prevalence among smokers.

CA clinically present as lumps around and inside the anal canal, around the vulva and the perineum [Figure 1]. The lesions may be verrucous, papillomatous or flat. They may also present with itching and pain. The diagnosis is mostly clinical. Rarely, one may have to ask for a polymerase chain reaction for HPV to confirm the diagnosis.

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Figure 1:

Warts seen in the anal region.

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The differential diagnosis includes normal variants like penile papules, infective lesions like syphilis and neoplastic lesions like Bowen’ disease.

Various treatment options are available:^[1,2]

1. Physical ablation

   1. Cryotherapy

   2. Nd-Yag Laser

   3. Electrocautery

   4. Scalpel excision.

2. Pharmacological ablation

   1. Trichloroacetic acid

   2. Podophyllin.

3. Immunotherapy - Imiquimod.

The choice of treatment depends on the number and size of lesions, whether they are perianal or intra-anal and the choice of the patient.

Some lesions are known to undergo spontaneous regression in 6–12 months.

In general, large and multiple lesions and lesions that are intra-anal are treated by physically ablative measures. Electrocautery is commonly used. Imiquimod cream or pharmacological ablation is used for smaller lesions.

Combination of electrocautery and pharmacological methods works better than monotherapy.

Recurrences are common. It is about 10% at 1 year and 50% at 10 years.

In view of the possibility of dysplasia and neoplasia, particularly in HIV patients, excised lesions should be sent for histopathology. The patients must be warned about recurrence. They should be informed about sexual transmission and advised about use of condoms. They should be kept under surveillance forever, looking for recurrence and possible neoplasm.