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
- Evidence at level Ia or Ib
- Evidence at level IIa, IIb, or III
- Evidence at level IV