• Genital warts are caused by human papillomavirus (HPV)
• There are more than 100 types of HPV, with over 40 types which can infect the anogenital and oropharyngeal mucosa. HPV can be divided into low-risk and high-risk types, based on their association with the development of malignancy
• 90% of genital warts are caused by HPV 6 or 11. These are low-risk types of HPV, which are generally not associated with malignancy
• HPV is almost universal among sexually active populations. It can be regarded as an inevitable consequence of being a sexually active adult
• Transmission is from skin-to-skin contact, and can occur through penetrative and non-penetrative sex, as well as sexual activity through fingers or sex toys from genital areas infected with HPV
• Most anogenital HPV infections are asymptomatic. Most HPV infection is transient and often becomes undetectable within 12 months. HPV infection may become latent, and reactivate after several years, or infection may persist. Because HPV infection may remain latent for some time, developing warts during a long-term relationship does not necessarily imply the presence of other sexual contacts
• Immunity from natural infection is poor. Previous infection does not necessarily create long-term immune memory, so may not prevent future infection with the same HPV type. Vaccination provides effective long-term protection against HPV acquisition
• Gardasil 9 vaccination is funded for people aged 9-26 years, and protects against the types of HPV that cause most genital warts, as well as 7 types of oncogenic HPV
• Vaccination has reduced the prevalence of genital warts in younger age groups, and is recommended for those who are eligible, even if already sexually active

• Genital warts are clinically diagnosed, based on characteristic appearance. Consider biopsy if lesions are atypical
• HPV DNA testing is currently available only as an adjunct to cervical cytology. HPV DNA testing has no clinical utility in sexually transmitted infection (STI) screening
• A complete sexual health check may be appropriate, depending on sexual history

• The goal of treatment is to eliminate warts that cause physical or psychological symptoms
• The elimination of external visible warts may not decrease infectivity since the warts may not represent the entire viral burden. For this reason recurrence is common, especially in the first 3 months

Special situations

• Consideration should be given for a change in treatment modality or onward referral if there is no significant response within 4-6 weeks
• A continuing lack of response to therapy might indicate other pathology and a referral for assessment should be considered in such cases
• Saltwater baths can sooth and heal the genital skin during treatment
• Avoid shaving or waxing as this may spread the warts
• There is no need to alter sexual activity with a regular partner, as sharing of HPV would have occurred long before the clinical appearance of the lesions
• Consistent condom use has been shown to reduce the risk of HPV acquisition and genital warts by 30-60%, and is recommended if new sexual contact

• Not indicated

Referral to or discussion with a sexual health specialist is recommended for:

• Lack of response to therapy
• If diagnosis is not clear, and second opinion required
• Immunocompromised patients with genital warts
• Urethral warts
• Cervical warts which are still present after 6 months
• Intra-anal warts

• 100% of patients aged under 27 years are offered Gardasil vaccination
• 100% of patients diagnosed are offered treatment