CAMAGÜEY.- Condyloma acuminatum, also called genital wart, is an exophytic neoformation (abnormal growth that protrudes from the surface of a tissue), generally multiple, pink or white-greyish in color, on the surface of which filiform projections (appearance of elongated thread) or papillomatous can be seen. They are usually located in the anogenital region and are usually asymptomatic, although they sometimes present with pain or itching.

Its size is very variable. They generally grow rapidly until they acquire considerable dimensions and the typical "cauliflower appearance", although on occasions the size of the lesion stabilizes or decreases until it disappears completely.

Thus began our dialogue with Dr. Marvelis Rodríguez González, 1st Degree specialist in Comprehensive General Medicine (MGI) and 3rd year Resident in Dermatology, from the Amalia Simoni Clinical Surgical Hospital, in the city of Camagüey, who responded to:

— How is it acquired or transmitted?

— Sexual contact is the most common way of transmission, although sometimes it can occur in another way, as in the case of newborns having contact with the infected mother at the time of delivery, and infection by fomites (objects inert substances that can be contaminated with body fluids, previously damaged epithelium, blood). In the case of children, although the virus can be transmitted non-sexually (it can simply be the transmission of warts on the hands), the presence of genital warts should raise suspicions of sexual abuse and be carefully evaluated.

— Does it appear suddenly or does it have an incubation period?

— It has an incubation period of six weeks to two years, with an average figure of two to three months. The moment of greatest contagion is at six months because the concentration of viral particles is higher. Spontaneous regression can occur in 33% depending on the host.

— Is it a common disease?

— Among sexually transmitted diseases, it is one of the most frequent among young people and adults of sexually active age. The infection mainly affects men who have sex with men (MSM) and heterosexual women, aged approximately 20 to 29 years.

— What causes this ailment?

— It is caused by the human papilloma virus (HPV). The most common etiologic agents are HPV types 6 and 11, which are associated with benign lesions. Types 16, 18, 31, and 33 are associated with the development of cervical carcinoma. Currently, more than 130 HPV subtypes have been detected; there is a preferential association between certain genotypes, their morphological appearance and their particular anatomical location. Some of these HPV subtypes have oncogenic potential.

— Can you name some risk factors?

— Genital warts include multiple sexual partners, frequency of sexual intercourse, contact with a new partner, multiparous, condom misuse, due to other Sexually Transmitted Infections (STIs), having a sexual partner with external genital warts, in turn, the number of external genital warts of the sexual partner, early initiation of sexual relations, smoking and country of origin, because it is considered that the prevalence is higher in the poorest.

- How does it manifest itself?

— The clinical form of the infection is variable, even in 30% of cases the lesions can resolve spontaneously, it is possible that they remain unchanged or increase in number and size. They are usually located in the areas that suffer the greatest trauma during intercourse. Generally the reason for consultation is the appearance of skin lesions that the person notices during personal hygiene.

"The basic lesion of condyloma acuminatum is the vegetation. These lesions have different sizes, sometimes they are observed with the naked eye as white or whitish-grayish millimeter plaques, and less frequently as friable hyperpigmented macules or papules to the touch, which cause Mild symptomatology "Later, the lesions usually grow radially and tend to coalesce to form plaques and spread superficially depending on factors of the host and the environment in which it develops, such as mucosal humidity, temperature, and viral load. The anogenital tract is the main reservoir of HPV, and they are more common in the anal area due to the moisture and squamous epithelium present in this region."

— Is it located the same in men as in women?

— In men, condyloma acuminatum is commonly located in lesions on the penis, predominantly on the prepuce and balanopreputial area; in women it is associated with lesions in the vagina, vulva, urethra and cervix.

In the mucosa of the cervix and vagina they rarely cause pain, burning, itching, dyspareunia, leucorrhoea, or bleeding during intercourse. In the vulvar area, the condyloma may present itching, burning, pain, or even bleeding. When they are located in the urethral meatus (more frequently in men, between four and eight percent) it can cause obstruction and secondary dysuria. "In the anus there are slight symptoms in patients with a greater number of lesions such as pruritus, humidity in the area or they may even present difficulties with hygiene or defecation when the lesions are large. In extragenital areas -such as the mouth, the conjunctiva or the nasal cavity – the symptoms depend on the size of the lesion".

- Does it present complications?

— Generally, patients have altered psychological status and come to the clinic with concern, shame, and both self-esteem and sexual problems.

"In advanced stages, the lesions can progress to invasive cervical cancer in women; and anal squamous cell cancer (especially anal intraepithelial neoplasia in MSM and HIV-positive patients) and penile cancer in men. Suspicious signs of malignancy are bleeding, ulceration, irregular pigmentation and palpation of dermal infiltration".

— How is the diagnosis achieved?

— The diagnosis is made by physical examination and clinical characteristics in the medical consultation. Doing it in a timely manner allows us to carry out an immediate and effective treatment that reduces complications, the transmission capacity to sexual partners and reduces morbidity and mortality.

"In women, the perianal area should always be explored and a speculum placed to check the vagina and cervix, as well as indicate organic cytology. The performance of colposcopy and anoscopy will be assessed individually.

"Biopsy is not necessary for the diagnosis of typical anogenital condyloma. It is required to rule out pre-invasive and invasive lesions and can be useful in differential diagnosis.

"In men, remove the foreskin to fully assess the glans penis and examine the testicles. Assess penoscopy. Inquire about urethrorrhagia (emission of blood through the urethral meatus, regardless of urination), dysuria, or bloody discharge from the urethra to suspect the infection of the same (more frequent in men than in women).

"Those that are located in the anus may be due to anal intercourse or by the spread of vulvar secretions (in the case of women).

"Current sexual partners and, if possible, those of the last six months, should be evaluated for the presence of lesions, sex education, and for counseling on sexually transmitted diseases and their prevention."

- Can it be avoided?

— The condom only partially protects, both from primary infection and from re-exposure, since it does not protect the perineum, pubis, female external genitalia, or the base of the penis or the scrotum. Condom use or sexual abstinence is recommended until the lesions are resolved.

— What do you recommend from an educational point of view?

— Education and counseling are important aspects in the management of patients with condyloma acuminatum or genital warts. Attempts should be made to cover the following key messages: a) genital HPV infection is a common viral infection in sexually active adult individuals; b) it is transmitted sexually, but the incubation periods are variable and it is generally difficult to determine the source of infection; c) the evolution is generally benign and recurrence within the first months after treatment is common; d) the possibility of transmission to future partners and the duration of infectivity (ability of the infectious agent to invade and multiply in the host's tissues) after treatment are unknown.

"The use of latex condoms and the informative dialogue about other STIs should be encouraged and tried as much as possible. The information is essential for the proper management of patients and should contain value judgments, offering support and focusing on the nature of the disease, expectations about therapy, and a balanced perspective on issues involving sexuality.

— Is condyloma acuminata curable?

— There is no treatment for human papillomavirus (HPV), we limit ourselves to treating the skin lesions it produces and helping the patient's immune system to prevent transmission. It is said that spontaneous regression of lesions can occur in 33%, depending on the host.

— Advice for those with symptoms?

— Condyloma represents the most common sexually transmitted disease in our environment, especially in young people and adults of sexually active age, and can be associated with other STIs; so it is very important that in the event of any symptoms, go to the dermatologist in your health area to receive the appropriate treatment, as well as education and counseling.

Translated by Linet Acuña Quilez