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Human Papillomavirus (HPV)

Human Papillomavirus (HPV). Genital Warts. Human Papillomavirus (commonly called Genital Warts). Human Papillomavirus (HPV) is a virus that can cause various disease states including “genital” or “venereal” warts

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Human Papillomavirus (HPV)

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  1. Human Papillomavirus (HPV) Genital Warts

  2. Human Papillomavirus(commonly called Genital Warts) • Human Papillomavirus (HPV) is a virus that can cause various disease states including “genital” or “venereal” warts • Papillomaviruses are a complex group of DNA tumor viruses. They can cause benign growths (papillomas), cancers, or more commonly, transient infections • HPV infection is causally associated with cervical cancer ; other genital cancers including anal, penile, vulvar, and vaginal cancers may have HPV as co-factor

  3. HPV Prevalence • Most common STD • Yearly incidence of 6.2 million • 20 million currently infected • 80 million infected at least once between the ages of 15-49 • An estimated 9.2 million sexually active adolescents and young adults 15-24 years of age are infected with genital HPV • An estimated 5%-30% of people infected with genital HPV are infected with multiple types of the virus • 316,000 initial visits to physicians’ offices (2004)-genital wart diagnosis

  4. GENITAL HPV INFECTION1% 1.4 MILLION VISIBLE WARTS4% 5 MILLION Subclinical (Colposcopy)10% 14 MILLION Subclinical (DNA testing)60% 81 MILLION Prior infection (+ antibodies)25% 34 MILLION No prior/current infection

  5. Epidemiology of HPV and Cervical Cancer • Over 99% of cervical cancers have HPV DNA detected within the tumor • 70% of cervical cancer is caused by one of two types of HPV, 16 or 18 • The quadrivalent HPV vaccine protects against Types 6, 11, 16 and 18

  6. Risk Factors for Acquiring a Genital HPV Infection • Young age (less than 25 years) • Multiple sex partners • Early age at first intercourse (16 years or younger) • Male partner has (or has had) multiple sex partners

  7. HPV Transmission • Direct skin-to-skin contact • Usually, but not always sexual contact • Infected birth canal • Fomites (very rare) Friction and abrasion are key factors. Difficult to determine how and where infection occurred due to poor standardized tests and variable latency periods.

  8. What about oral sex? • It can occur in the mouth, throat or respiratory tract • It is relatively uncommon • It appears to be an inefficient mode for transmission

  9. HPV Incubation • Average incubation is 3 weeks to 1 year • Possibly years before appearance of warts or cervical abnormalities • Some will be transient and may never be detected

  10. Common Symptoms of Genital Warts in Males & Females • The symptoms may include single or multiple fleshy growths around the penis, scrotum, groin, vulva, vagina, anus, and/or urethra • They may also include: itching, bleeding, or burning, and pain • The symptoms may recur from time to time

  11. Genital Warts in a Male Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides Source: Cincinnati STD/HIV Prevention Training Center

  12. HPV Penile Warts Source: Cincinnati STD/HIV Prevention Training Center

  13. Pearly Penile Papules

  14. Intra-meatal Wart of the Penis(and Gonorrhea) Source: Florida STD/HIV Prevention Training Center

  15. Circumcision and HPV • Risk for penile cancer • May influence the risk of HPV acquisition, transmission and cervical cancer

  16. Female Genital Warts Source: CDC/NCHSTP/Division of STD, STD Clinical Slides

  17. HPV Warts on the Thigh Source: Cincinnati STD/HIV Prevention Training Center

  18. Perianal Warts Source: Cincinnati STD/HIV Prevention Training Center

  19. Complications of Genital Warts(if untreated) • It may destroy body tissue around the genitals and anus • For pregnant women • Delivery complications or need for C-section • Juvenile Onset Recurrent Respiratory Papillomatosis (JO-RRP)

  20. Testing & Treatment for Genital Warts • Can be detected in a clinical exam; • Can be treated by removing the warts; • The virus cannot be removed, so the warts may grow back.

  21. HPV Diagnostic Techniques • History • Visual exam • Pap smears • DNA testing

  22. Papillomavirus Treatment • Primary goal for treatment of visible warts is the removal of symptomatic warts • Therapy may reduce but probably does not eradicate infectivity • Difficult to determine if treatment reduces transmission • No laboratory marker of infectivity • Variable results utilizing viral DNA

  23. HPV Treatment Options • Chemical agents • Cryotherapy • Electrosurgery • Surgical excision • Laser surgery • Imiquimod (Aldara) • Defer treatment • Natural therapies

  24. Papillomavirus • Surgical removal • Patient-applied Podofilox (Condylox) 0.5% solution or gel Apply 2x/day for 3 days, followed by 4 days of no therapy. Repeat as needed, up to 4x or Imiquimod (Aldara) 5% cream Apply 1x/day @ bedtime 3x/week for up to 16 weeks • Provider-administered Cryotherapy (liquid nitrogen) *repeat every 1-2 weeks or Podophyllin resin 10-25% *thoroughly wash off in 1-4 hrs or Trichloroacetic or Bichloroacetic acid 80-90% *can be repeated weekly

  25. Papillomavirus Vaginal warts Cryotherapy or TCA/BCA 80-90% Urethral meatal warts Cryotherapy or podophyllin 10-25% Anal warts Cryotherapy or TCA/BCA 80-90%

  26. Papillomavirus • Therapy choice needs to be guided by preference of patient, experience of provider, and patient resources (time and/or money) • No evidence exists to indicate that any one regimen is superior • An acceptable alternative may be to do nothing but watch and wait; possible regression/uncertain transmission

  27. Case Study Amy was diagnosed with genital warts and successfully treated with liquid nitrogen therapy three years ago. The genital warts have never returned after therapy. Amy has met someone new and she wants to begin a sexual relationship. She wants to know if she needs to disclose her prior infection to her new partner. What would you tell Amy?

  28. HPV is INCURABLE Warts can and often do recur after treatment. Virus can remain in surrounding tissue after warts have been destroyed.

  29. Perinatal complications

  30. HPV and Pregnancy • No link with premature labor, miscarriage, or other complications • Low rate of transmission to baby • Range is generally from 0.4 to 1.1 cases/100,000 births • C-section is not recommended in most instances

  31. Treatment Regimens

  32. PapillomavirusTreatment in Pregnancy • Imiquimod, podophyllin, and podofilox should not be used in pregnancy • Many specialists advocate wart removal due to possible proliferation and friability • HPV types 6 and 11 can cause respiratory papillomatosis in infants and children • Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction or if vaginal delivery would result in excessive bleeding

  33. HPV in Neonates • Those who develop warts will usually do so within several weeks • First-born child • Juvenile onset recurrent respiratory papillomatosis (JO-RRP) • rare -- 1 per 100,000 births • types 6 and 11 • occurs up to age four

  34. HPV and Cervical Cancer

  35. HPV Linked to Cancer • Cervical Cancer • 10,000 new cases diagnosed/year in the US • 3,000 deaths/year in the US • 400,000-500,000 new cases internationally • 300,000 deaths/year internationally, especially in developing countries • Single most important factor for cervical cancer • Virtually all squamous cell cervical cancer contain one of 18 types of HPV • The type of HPV that causes visible warts are not linked to cervical cancer • Associated with cancer of the penis, anus, vagina and vulva.

  36. HPV DNA Classification • Low Risk HPV Types: 6,11,40,42,43,44, 54, 61, 72, 73, 81 • types 6 and 11 responsible for 95% of visible warts • High-Risk HPV Types: 31,33,35,39,45, 51, 52, 56, 58, 59, 68,82 High cancer risk: 16 • Most common-50% of cervical cancer High cancer risk: 18 • 10-12% of cervical cancer *Risk not well established yet: 26, 53, 66, 73

  37. Can a person be re-infected with HPV? • There appears to be humoral and probably cellular immunity that develops to a specific type of HPV after a person has been infected with it and “has cleared” it. • The risk for re-infection with that specific type of HPV appears to be rare. • However, a person can be infected with more than one type of HPV

  38. HPV and Cervical Cancer • Infection is generally indicated by the detection of HPV DNA • Routine Pap smear screening ensures early detection (and treatment) of pre-cancerous lesions • Only a small percentage of women infected with genital HPV develop persistent infections • Only women who develop persistentinfections are at risk for developing high-grade pre-cancerous changes / cervical cancer • Most women with persistent HPV infection do NOT develop precancerous changes/cervical cancer • The most critical factor for developing cervical cancer is not having routine pap smears

  39. Active/passive Cigarette Smoking Chronic inflammation associated with other STDs Long term use of oral contraceptives High number of live births* Weakened immune system Multiple sex partners Sex at an early age Nutritional deficiencies Mother who took DES Lack of circumcision of male partner(s) Cofactors for Cervical Cancer LACK OF SCREENING IS THE MOST IMPORTANT FACTOR

  40. Pap Smears • What is it? • How is it done? • When should I get the first one? • How often do I need one? • Do I still need to get one if I’ve been vaccinated?

  41. Preparing for a Pap Smear • Schedule a day when you won’t be having your period • Do not douche 48 hours before the test • Avoid sexual intercourse 48 hours before the test • Do not use tampons, vaginal creams, foams, films or other jellies for 48 hours before the test

  42. Pap Smears2001 Bethesda System • Specimen type • Coventional vs Liquid sample • Specimen adequacy • Satisfactory or unsatisfactory for evaluation • General categorization • Negative for Intraepithelial lesion/malignancy • Epithelial cell abnormality (squamous or glandluar) • Other things observed (ex. Endometrial cells)

  43. Pap Smears2001 Bethesda System • Epithelial cell abnormalities • Squamous • Atypical squamous cell of undetermined significance(ASC-US) • Cannot exclude HSIL (ASC-H) • Low-grade squamous intraepithelial lesion (LSIL) • Includes HPV/mild dysplasia/CIN 1 • High-grade squamous intraepithelial lesion (HSIL) • Includes moderate, severe dysplasia, CIS/CIN 2 and 3 • Squamous cell carcinoma

  44. Pap Smears2001 Bethesda System • Epithelial cell abnormalities (continued) • Glandular cells • Atypical • Endocervical (Not otherwise specified, or favor neoplastic) • Glandular (not otherwise specified or favor neoplastic) • Endometrial • Endocervical carcinoma in situ • Adenocarcinoma • Endocervical • Endometrial • Extrauterine • Not otherwise specified

  45. Pap Smear Terms • Cervical Dysplasia • Abnormal cell changes • Precancerous cell changes • CIN (Cervical Intraepithelial Neoplasia) • SIL (Squamous Intraepithelial Lesions) • “Warts” on the cervix

  46. Interpreting Pap smears Interpretation of Pap smears can be difficult: • Abnormalities may not be picked up by the spatula or brush • Abnormalities may be difficult to see

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