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Complete Summary

GUIDELINE TITLE

Anogenital warts. In: Sexually transmitted infections: UK national screening and testing guidelines.

BIBLIOGRAPHIC SOURCE(S)

  • Maw R. Anogenital warts. In: Ross J, Ison C, Carder C, Lewis D, Mercey D, Young H. Sexually transmitted infections: UK national screening and testing guidelines. London (UK): British Association for Sexual Health and HIV (BASHH); 2006 Aug. p. 97-100. [7 references]

GUIDELINE STATUS

This is the current release of the guideline.

COMPLETE SUMMARY CONTENT

 
SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 QUALIFYING STATEMENTS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Anogenital warts caused by the human papilloma virus (HPV)

GUIDELINE CATEGORY

Diagnosis
Evaluation
Risk Assessment
Screening

CLINICAL SPECIALTY

Family Practice
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology
Urology

INTENDED USERS

Advanced Practice Nurses
Clinical Laboratory Personnel
Nurses
Physician Assistants
Physicians
Public Health Departments

GUIDELINE OBJECTIVE(S)

  • To provide advice on what tests for anogenital warts are most appropriate in a United Kingdom (UK) genitourinary (GU) clinic setting (excluding human immunodeficiency virus [HIV]-infected patients)
  • To provide a basis for audit
  • To support clinics when bidding for additional resources to meet national standards

TARGET POPULATION

Individuals in the United Kingdom attending a genito-urinary medicine clinic

INTERVENTIONS AND PRACTICES CONSIDERED

  1. Visual examination of anogenital skin
  2. Speculum examination of the vagina and cervix
  3. Human papillomavirus typing (not recommended in routine clinical practice)
  4. Biopsy for histology if diagnosis is doubtful
  5. Acetic acid test with colposcope (not to be used for screening)
  6. Cervical cytology (not recommended for women under age 25)
  7. Colposcopic-directed biopsy of exophytic cervical warts
  8. Proctoscopy (not recommended except if anal irritation or bleeding)
  9. Examination of oral cavity
  10. Identification of risk groups
  11. Frequency of testing
  12. Follow-up for cure

MAJOR OUTCOMES CONSIDERED

Sensitivity and specificity of test methods

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

This guideline was obtained by searching the Medline database from 1965 until August 2002 using the MeSH headings "genital warts, anogenital warts, diagnosis, guidelines."

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Levels of Evidence

Ia: Evidence obtained from meta-analysis of randomised controlled trials

Ib: Evidence obtained from at least one randomised controlled trial

IIa: Evidence obtained from at least one well designed controlled study without randomisation

IIb: Evidence obtained from at least one other type of well designed quasi-experimental study

III: Evidence obtained from well designed non-experimental descriptive studies

IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The guidelines have been developed following the methodological framework of the Appraisal of Guidelines Research and Evaluation instrument (AGREE - adapted as described in Int J STD and AIDS 2004 15:297-305).

The extent to which the guideline represents the views of intended users has been addressed primarily by the authorship coming from the multidisciplinary membership of the Bacterial Special Interest Group (BSIG). As practising clinicians the authors were able to draw on their experience of applying the tests to symptomatic and asymptomatic patients, but it was not feasible to obtain formal input from representative patients.

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Grading of Recommendations

  1. Evidence at level Ia or Ib
  2. Evidence at level IIa, IIb, or III
  3. Evidence at level IV

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

External Peer Review
Internal Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

After drafting, other health care professionals and professional bodies in genitourinary (GU) medicine were asked to comment, the draft guidelines posted on the British Association for Sexual Health and HIV (BASHH) website for 3 months, and all comments reviewed before final publication.

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Definitions for the level of evidence (I-IV) and grade of recommendation (A-C) are provided at the end of the "Major Recommendations" field.

Recommended Tests

  • Visual examination which may be aided by a magnifying glass is the only recommended test for routine diagnosis. There is no place for human papillomavirus (HPV) typing in routine clinical practice. (Evidence Level IV, Grade of Recommendation C)
  • If there is doubt as to the diagnosis, biopsy under local anaesthetic for histology is justifiable. Biopsy is indicated if there is a concern that a lesion may be dysplastic and may need a different management strategy to genital warts. (Evidence Level IV, Grade of Recommendation C)
  • The acetic-acid test (i.e., soaking the skin under examination with 5% acetic acid and examination for "aceto-white" lesions) is occasionally justifiable for lesions that may be dysplastic or may not be warts or for targeting biopsy. This test should be aided by the use of a colposcope. There is a high false positive rate with the "aceto-white" test and it should not be used for screening purposes. (Evidence Level IIb, Grade of Recommendation B)
  • Cervical cytology test is not recommended for women under 25 years of age and is not indicated for women who have kept their normal smear intervals. (Evidence Level IV, Grade of Recommendation C)
  • Women with exophytic warts on the cervix should have colposcopic directed biopsy to exclude high grade cervical intraepithelial neoplasia (CIN) prior to treatment. (Evidence Level III, Grade of Recommendation B)

Recommended Sites for Testing

Examination of anogenital skin and speculum examination of the vagina and cervix.

Factors Which Alter Tests Recommended or Sites Tested

Proctoscopy is not recommended except if the patient has symptoms such as bleeding from the anus or irritation. Warts identified in the anal canal during proctoscopy for other reasons should be discussed with the patient as to whether they wish them to be treated.

Examination of the oral cavity is indicated if the patient feels they may have warty lesions at that site.

Risk Groups

  • Gay men (no alteration to standard recommendation)
  • Sex workers (no alteration to standard recommendation)
  • Young patients (no alteration to standard recommendation)
  • Human immunodeficiency virus (HIV) positive gay men. There is a high prevalence of anal intraepithelial neoplasia (AIN) in this group and an increased incidence of anal carcinoma. It can be difficult to differentiate warty AIN from ordinary warts, and surgical biopsy is recommended in cases of doubt. A carcinoma would tend to present with a palpable lump, which to the patient might feel very similar to a wart. Patients presenting with lumps in the anal canal should be advised that further investigation may be indicated.

Other

  • Pregnant women (no alteration to standard recommendation)
  • Women with history of hysterectomy (no alteration to standard recommendation)
  • Patients who are known contacts of the infection and are not found to have any exophytic genital warts should be advised as to self examination of the genitals and advised to return for advice if they detect lesions. They should be advised that most persons developing warts as a result of recent contact do so within several months.

Recommendation for Frequency of Repeat Testing in an Asymptomatic Patient

  • As noted above, patients should self-refer if lesions appear.
  • Some patients may be reassured by a follow up examination in 3 months' time.

Recommendation for Test of Cure

Visual examination for clearance of warts is the only appropriate test of cure.

Definitions:

Levels of Evidence

Ia: Evidence obtained from meta-analysis of randomised controlled trials

Ib: Evidence obtained from at least one randomised controlled trial

IIa: Evidence obtained from at least one well designed controlled study without randomisation

IIb: Evidence obtained from at least one other type of well designed quasi-experimental study

III: Evidence obtained from well designed non-experimental descriptive studies

IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

Grading of Recommendations

  1. Evidence at level Ia or Ib
  2. Evidence at level IIa, IIb, or III
  3. Evidence at level IV

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Appropriate identification and treatment of anogenital warts

POTENTIAL HARMS

Not stated

QUALIFYING STATEMENTS

QUALIFYING STATEMENTS

Personnel involved in the management of patients in genito-urinary medicine clinics should be trained in identification of anogenital warts.

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

IMPLEMENTATION TOOLS

Audit Criteria/Indicators

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Getting Better
Living with Illness

IOM DOMAIN

Effectiveness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • Maw R. Anogenital warts. In: Ross J, Ison C, Carder C, Lewis D, Mercey D, Young H. Sexually transmitted infections: UK national screening and testing guidelines. London (UK): British Association for Sexual Health and HIV (BASHH); 2006 Aug. p. 97-100. [7 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2006 Aug

GUIDELINE DEVELOPER(S)

British Association for Sexual Health and HIV - Medical Specialty Society

SOURCE(S) OF FUNDING

No specific or external funding was sought or provided in the development of this guideline.

GUIDELINE COMMITTEE

Screening Guidelines Steering Committee
Clinical Effectiveness Group (CEG)

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Author: Dr. Raymond Maw on behalf of the HPV Special Interest Group of British Association for Sexual Health and HIV (BASHH)

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on June 26, 2008. The information was verified by the guideline developer on October 20, 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developers and/or BMJ Publishing Group's copyright restrictions. Reproduction and use of this guideline is permitted provided that (a) the original content is not changed or edited; and, (b) any content derived from the original guideline is acknowledged as that of the author(s) and responsible organizations.

Readers wishing to download and reproduce material for purposes other than personal study or education should contact BMJPG to seek permission first. Contact: BMJ Publishing Group, BMA House, Tavistock Square, WC1H 9JR, UK.

DISCLAIMER

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