Approach

Diagnosis of genital warts is made based on the clinical presentation of lesions located on the genital area, perianal region, or adjacent areas such as the mons pubis, with a tendency for genital wart formation to occur on areas of high friction.[3][17][38][39] Biopsy is generally not performed for the diagnosis of genital warts.

Clinical presentation

Genital warts are usually 1 to 3 mm, discrete, sessile, smooth-surfaced exophytic papillomas or they may coalesce into larger plaques. These plaques may be extensive, with expansion into the urethra, or into the anal or vaginal canals.[3][Figure caption and citation for the preceding image starts]: Venereal warts in the anal region of the perineumCDC/Dr Wiesner [Citation ends].com.bmj.content.model.Caption@e6ebc55 Color varies from flesh-colored to whitish to hyperpigmented. Maceration may occur, particularly in moist areas lacking the thick horny cell layer found in cutaneous warts.[5][Figure caption and citation for the preceding image starts]: Wart on shaft of penisFrom Dr Tyring's personal collection; used with permission [Citation ends].com.bmj.content.model.Caption@468ea02c[Figure caption and citation for the preceding image starts]: Close-up of penile wartFrom Dr Tyring's personal collection; used with permission [Citation ends].com.bmj.content.model.Caption@4a984f12 External genital warts may be diagnosed using direct visual inspection aided by bright light and magnification.[3] Lesions are generally asymptomatic, but may be painful, friable, or pruritic.[5][6]​​​ Bleeding may occur due to local trauma or maceration of the area. Urinary symptoms such as terminal hematuria or abnormal stream of urine may be present.

Investigations

A biopsy may be indicated if the genital warts appear fixed to underlying structures or are refractory to standard therapy.[40] Additional indications for biopsy include ulceration of the lesions or an individual wart larger than 1 cm.[6]​ Should a biopsy be indicated, the following histologic features are seen: epidermal hyperplasia, parakeratosis, koilocytosis, and papillomatosis.[17] Compared with common warts, the papillomatosis seen in genital warts tends to be more rounded. Not all of these histologic features are necessarily seen in every genital wart. Should the biopsy be definitive for condyloma, do not perform immunohistochemistry (IHC) or in situ hybridization (ISH) for HPV.[41]​​[42]​ Do not perform low-risk HPV testing (testing for strains of HPV that cause genital warts or minor cell changes on the cervix) because there is no change in management indicated when low-risk HPV is identified​.[43][44]​ In patients with recurrent perianal warts, evaluation for intra-anal warts by anoscopy is recommended.[6]​ Urinary symptoms such as terminal hematuria or abnormal stream of urine should prompt a referral for urethroscopy to evaluate the distal urethra and meatus.​[6]

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