Sexual Health

Anogenital Warts

Anogenital warts are usually benign HPV-related epithelial lesions, most often associated with low-risk types 6 and 11; diagnose them clinically, biopsy atypical or treatment-resistant lesions, and choose observation, topical treatment or ablation by site, morphology, pregnancy status and patient preference.

In a nutshell

Anogenital warts are usually benign HPV-related lesions, most often associated with types 6 and 11, and are diagnosed clinically. Biopsy atypical, uncertain or treatment-resistant lesions. Observation is acceptable; otherwise choose imiquimod or podophyllotoxin for suitable external warts and cryotherapy or other ablation for keratinised, extensive, internal or resistant disease. Pregnancy changes treatment choice, and HPV vaccination is preventive rather than therapeutic.

Classic presentation

A sexually active adult has painless flesh-coloured papilliform or keratotic lesions on the genital or perianal skin, with no systemic illness and a typical appearance on careful examination.

Key points

Around 90% of anogenital warts are associated with low-risk HPV types 6 and 11; typical warts are benign but atypical lesions may contain dysplasia or malignancy.
Diagnosis is clinical after examining the whole external anogenital area and urethral meatus; biopsy bleeding, ulcerated, indurated, fixed, uncertain or non-responding lesions.
Observation is acceptable for small or asymptomatic lesions; there is no single best treatment and recurrence is common.
Imiquimod or podophyllotoxin suit selected external warts; cryotherapy or specialist ablation suits keratinised, extensive, internal or resistant disease.
Avoid self-applied topical agents in pregnancy or breastfeeding; use appropriate ablative options if treatment is necessary and do not perform caesarean birth solely to prevent HPV transmission.
HPV vaccination prevents new vaccine-type infection but does not treat established warts; eligible people should still follow routine cervical screening.

First-line investigation

Clinical inspection of the entire external anogenital area and urethral meatus, with internal examination, biopsy and sexual-health tests selected by symptoms, appearance and risk.

Management

Confirm typical disease and identify red flags

Examine the whole external area and meatus; biopsy atypical or uncertain lesions and refer internal, cervical, anal or potentially malignant disease appropriately.¹

Explain and offer observation or treatment

Explain spontaneous regression, recurrence and treatment limits; observation is acceptable, while selected external warts may be treated with imiquimod or podophyllotoxin.^1,5

Ablate resistant or site-inappropriate disease

Use cryotherapy, trichloroacetic acid, electrosurgery, excision or laser when lesions are keratinised, extensive, internal or resistant, with specialist site-specific care.¹

Modify pregnancy, immunosuppression and safeguarding pathways

Avoid self-applied topical agents in pregnancy or breastfeeding, use safe ablative options when needed, biopsy atypical disease in immunosuppression and follow NICE safeguarding guidance for children and young people.^1,4,5

Prevent, reassure and review selectively

Offer eligible HPV vaccination, continue cervical screening, explain condom limitations and lack of routine partner notification, and review persistent or incompletely responding lesions.^1,2,3

Exam traps

Typical warts are benign, but bleeding, ulceration, induration, fixation, rapid growth, uncertainty or treatment failure should prompt biopsy rather than repeated empirical treatment.
HPV 6 and 11 cause most typical warts, but oncogenic HPV can coexist; do not equate a wart with a premalignant lesion or ignore atypical features.
Pregnancy and breastfeeding change treatment: do not use self-applied topical agents routinely; use specialist-approved ablative options when treatment is necessary.
HPV vaccination prevents infection and future disease but is not a treatment for existing warts, and vaccinated people still attend cervical screening.
Routine partner notification is not required, and the long variable latency means warts cannot date or prove a specific sexual contact.
Anogenital warts in a child or young person require safeguarding-sensitive assessment without assuming a single transmission route.

Illustrations

Sensitive clinical image, hidden — Small anogenital condylomaClinical photograph of a small raised papilliform condyloma on scrotal skin, illustrating a subtle presentation of anogenital warts.Bikepunk2, Wikimedia Commons · CC0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.