Anogenital warts guide: Key information and resources

This guide focuses on the assessment and management of external anogenital warts (AGW) caused by human papillomaviruses (HPV). HPV vaccination and HPV-related cancer screening recommendations are beyond the scope of this guide.

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Key information

Public health importance

Anogenital warts (AGW) are common and contribute to significant healthcare utilization costs and adverse psychosocial effects.

AGW are caused by human papillomaviruses (HPV), predominantly HPV types 6 and 11. In recent years, AGW occurrence has decreased markedly in countries with HPV vaccination programs.

HPV types 6 and 11 are transmitted predominantly by epithelial contact, from asymptomatic and symptomatic people. Transmission can occur during oral, vaginal and anal sex and other intimate skin-to-skin contact. Perinatal transmission rarely occurs but can lead to recurrent respiratory papillomatosis in infants and children.

The majority of AGW spontaneously regress, although recurrence is common, including after treatment. A diagnosis of AGW can have significant psychosocial consequences.

AGW may recur, proliferate, become friable and be less responsive to treatment during pregnancy. The risk of developing AGW is higher among people who are immunocompromised and people living with HIV. For these individuals, AGW may be more numerous and larger, and may be more resistant to treatment.

While HPV 6 and 11 are associated with low risk of oncogenesis, co-infection with multiple types of HPV is common. A diagnosis of AGW is an opportunity to screen for other sexually transmitted and blood-borne infections (STBBI), review HPV, hepatitis B, hepatitis A, and mpox vaccination as relevant, and offer cervical and other cancer screening in accordance with provincial and territorial guidelines.

AGW are not a nationally notifiable condition in Canada.

Screening

Screening for AGW is not recommended.

Note: Neither a diagnosis of AGW nor history of HPV vaccination modify recommendations for cervical cancer screening. Consult provincial and territorial guidelines for cervical cancer screening recommendations. Consult local practice or consensus guidelines for recommendations regarding anal cancer screening.

Diagnostic testing

AGW are usually diagnosed by visual inspection. Confirmation of diagnosis with biopsy should be considered for atypical or recalcitrant AGW. HPV testing is not recommended for people with AGW, as results would not alter clinical management or treatment.

Treatment

The goals of treating AGW are wart removal and symptom alleviation. Treatment does not eradicate HPV or prevent recurrence or transmission.

Self- and clinician-applied treatments for external AGW are available, and vary in terms of effectiveness, cost, side effect profiles and regimens. Treatment options include: cryotherapy, bi- or tri-chloroacetic acid (BCA or TCA), imiquimod, podophyllotoxin, and sinecatechins.

For urethral meatal warts, treatment options include cryotherapy and surgical removal. For vaginal, cervical and intra-anal warts, treatment options include cryotherapy, surgical removal, or BCA/TCA. Cervical and intra-anal AGW should be managed in consultation with relevant specialists.

Imiquimod and sinecatchecins have not been studied and are not approved in Canada for those younger than 18 years of age. There is a lack of safety and efficacy data for imiquimod and sinecatchecins for people who are immunocompromised.

During pregnancy, cryotherapy and TCA are preferred treatment options. Caesarian section is indicated if AGW are causing vaginal obstruction and/or may result in excessive bleeding during delivery.

For treatment of AGW in people living with HIV, consider shared management with an experienced colleague.

Follow-up

Follow up is indicated for ongoing clinician-applied treatment, and, for self-applied treatment, to provide ongoing support and monitor response to therapy.

Referral to an experienced colleague or a specialist can be considered if the area affected by AGW is extensive and/or if treatment is not effective.

Partner notification

Partner notification is not required as a public health measure for AGW. People are encouraged to discuss their diagnosis with their sexual partners so that partners can consult their healthcare provider to discuss general STBBI testing and prevention, including cancer screening. Partners should seek assessment, diagnosis and treatment if they notice any lesions during self-examination.

Resources

Awareness resources

Canada Communicable Disease Report (CCDR)

Other guidance

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