Coupon Accepted Successfully!


Genital Warts

As in herpes, only a minority of human papillomavirus (HPV) infections appear to result in noticeable lesions. Anogenital warts, also known as condylomata acuminata, are benign growths that are most commonly associated with HPV types 6 or 11.

These warts typically present as soft, flesh-colored papules that may progress to a cauliflower like mass. Multiple clustered lesions are typically present, yet a solitary wart may occasionally occur.

The most common locations in men are the glans, edge of the corona, prepuce, shaft, frenulum, and scrotum. Sites of predilection in women include the labia, perineum, clitoris, and fourchette.

The majority of patients who present with genital warts also have subclinical HPV infection, often including many other HPV types. Therefore all affected women should be screened for cervical intraepithelial neoplasia.

Untreated, condylomata acuminata may spontaneously regress, enlarge, or remain unchanged. Rarely the warts themselves may undergo malignant transformation with time.

Table 1: Epithelial Anchorage for Various HPV Type



HPV Types Detected in Lesions

Epithelial Anchorage




1-4, 7, 10, 28, 41

5, 8, 12, 14-25, 36, 46, 47

Mucous membrane

6, 11, 16, 18, 30, 31, 33-35, 39, 40, 42-45, 51-58


Table 2: Oncogenic Potential of Musculotropic HPV Types



Oncogenic Potential

HPV Types


6, 11, 34, 40, 42-45, 53-55, 57, 58


16, 18, 30, 31, 33, 35, 39, 45, 51, 52, 56

  1. Incubation Period
    The incubation period of genital wart is long and variable. It is estimated to be around 3 months with a range from 3 weeks to 8 months.
    Perinatal acquired HPV infection may not manifest for up to two years.
  2. Complications
    1. Buschke- Löwenstein Tumor
      This lesion enlarged from a pre-existing benign anogenital wart (mainly HPV 6). This is an extremely rare semi-malignant tumor and can occasionally transform into a squamous cell carcinoma. There is penetration of underlying tissue by compression that sometimes mimics microinvasion and may create difficulties in differentiating it from a true carcinoma.
    2. Bowenoid Papulosis
      This is a rather common entity in patients of both sexes. HPV type 16 has been demonstrated in about 80% of cases. It present clinically as smooth papules that are either erythematous, reddish-violaceous or brownish in colour. Some cases have regressed spontaneously within 1-2 years of observation; in others, the lesions have persisted for more than 10 years. Progression to carcinoma or true Bowen's disease is very rare.
    3. Cervical Intra-epithelial Neoplasia (CIN) and Invasive Carcinoma
      Epidemiological studies have shown that these condition is associated with HPV infection in particular type 16 and 18. Patients with history of anogenital warts or history of sexual contact with patient with genital wart should be regularly screened by cervical cytology.
    4. Laryngeal Papillomas
      Laryngeal papillomatosis in children is probably acquired from mother with genital warts during delivery. They are usually type 6 and type 11.
  3. Condylomata:

Special Considerations:

External genital warts

- 20% podophyllin in compound tinc of
benzoin –3 hours/wk/4-6 week


<0.5 ml /session.<10cm2 area /session and
<2 cm dia/session


- TCA-80-90%, cryotherapy

Anal warts

-TCA 80-90%,Surgery,cryo

Intra meatal

-Podophyllin../5% 5FU

Cervical warts

-Electrocautery, cryo, surgery

Sexual Assault-

Cultures for N. gonorrhoeae and
C. trachomatis


Wet mounts for T vaginalis,
B. vaginosis, candidiasis


HIV,VDRL,HBV serology


  1. Hep B vaccination
  2. Antimicrobial TRT-chlamydia, gonorrhea, T vaginalis, B vaginosis
  3. Inj ceftriaxone 250 mg
  4. IM stat
  5. T metronidazole 2 gm
  6. PO stat
  7. T Doxycycline 100 mg
  8. BD –7 days
  9. Anti retroviral TRT- offer if assailant
  10. HIV +/not available - start within 72 hrs.

All patients with STD require HIV,VDRL and Hep B serology testing.

Repeated at 3months

All patients to be educated safe sexual behavior, encouraged to keep one sexual partner and be counseled for treatment, follow-up, possible complications and recurrences

Therapy of Anogenital Warts



Podophyllin                       (10-25%) 
Podophyllotoxin                 (0.5%) 
Trichloroacetic                   acid
5-FU                                 (5%) 
IFN- intralesional


Curettage and cautery

CO2 laser


IFN-, IFN- (subcutaneous, low doses, cyclic therapy)


Treatment of choice in genital wart in pregnancy (AIIMS Nov 09)
A. Salicylic acid with lactic acid solution
B. Podophyllotoxin
C. Imiquimod
D. Cryotherapy


Ans-D. Cryotherapy


All the species of HPV commonly are associated with malignant potential causing vulval warts except? (AIIMS May 08)
A. HPV 16
B. HPV 31
C. HPV 6
D. HPV 18


Ans. C. HPV 6

  1. Cervical Warts
    1. Recommended Regimens for Vaginal Warts
    2. Cryotherapy with liquid nitrogen. TCA or BCA 80%--90% applied to warts.
    3. Recommended Regimens for Urethral Meatus Warts
    4. Cryotherapy with liquid nitrogen Podophyllin 10%--25% in compound tincture of benzoin.

Recommended Regimens for Anal Warts


Cryotherapy with liquid nitrogen TCA or BCA 80%--90% applied to warts.
Surgical removal.


Recommended Regimens for Oral Warts


Cryotherapy with liquid nitrogen
Surgical removal.

Special Considerations


Imiquimod, podophyllin, and podofilox should not be used during pregnancy.

Treatment: Cryotherapy, TCA


Characteristic Syphilis Herpes Chancroid LGV Donovan osis
Etiologic agent T. pallidum HSV-1 & HSV-
H. ducreyi C.trachomatis
L1, L2, L3
Granuloma inguinale               
Incubation period 10-90 days
(avg. 21 days)
3-14 days 3-10 days
(avg. 4-7days)
3 days-6 weeks 1-360 days
(avg 8- 12 weeks)
Initial lesions Papule Papule -
Papule or
pustule, or
Presenting lesion Chancre Vesicles or ulcers Ulcer/bubo Ulcer/bubo Papule or ulcer
Number and
distribution of
Usually one Multiple, may Coalesce; Bilateral in
unilateral in
Single or
Usually single,
Diameter .03-3 cm 1-2 mm Variable 2-10 mm Variable
Edges Sharply
round, or oval
Erythematous Undermined,
Elevated, irregular
Depth Superficial or deep Superficial Excavated,
Superficial or
Base Smooth, nonpurulent,
erythematous, nonvascular
bleeds easily
Red & velvety, bleeds easily
Induration Usually
None None Occasionally
Pain Uncommon Common, often with prodrome of tingling Common,
Variable Uncommon
Lymphadenopathy Firm, nontender,
Usually present in primary infection, and absent in
Tender, may
Tender, may
None, pseudo buboes (may be)

Neisseria gonorrhoea, a gram-negative intracellular diplococcus arranged in pairs with their apposing surfaces slightly flattened to produce the characteristic reniform shape.


It primarily affects columnar epithelium in genital mucosal surfaces of the urethra, accessory ducts and gland, as well as endocervix. In adult woman, the vulva and vagina, lined by stratified epithelium, are not susceptible to the gonococcus, but vulvovaginitis happens in pre-pubertal girls.

Extra-genitourinary sites including the rectum, oropharynx and eyes may be involved. Eyes of new born may be infected non-sexually during birth from infected mother (ophthalmia neonatorum).

  1. Incubation Period
    Incubation period in men is usually 2 to 5 days.Clinical Features.
    1. Clinical Features in the Male
      1. In male patients, thick, copious, purulent (condense milk-like) urethral discharge is the usual presentation
      2. This is accompanied by varying degree of dysuria.
      3. Examination show a reddened external urthral meatus. Without effective treatment, infection could extend to posterior urethra, causing severe pain on urination with urgency and frequency.
      4. Proctitis may be asymptomatic or presented with anal discharge, pruritus, tenesmus and rectal bleeding. Protoscopy shows inflamed mucous membrane with little mucopus. Pharyngitis usually appears normal, but occasionally erythema and purulent exudate is present.
  2. Female
    1. Up to 50-75% of female with gonorrhoea is asymptomatic.
    2. Cervix, being the commonest site of initial infection, could appear normal or to the other extreme of marked cervicitis with a mucopurulent exudate. The patient may complain of a vaginal discharge, especially when trichomoniasis coexists.
    3. Involvement of urethra causes little dysuria, purulent secretion and frequency.
    4. The combination of urethritis and cervicitis on examination is very suggestive of the diagnosis as both site are infected in most patients: gonococcus isolated in 90% of patient from cervix, 75% from both cervix and urethra, and 50% also have rectal infection.
Gonococcal ophthalmia develop within 7 days of birth and is usually bilateral with intense conjunctivitis, copious purulent secretion and lid edema. Ulceration of cornea healing with scarring seriously affects vision.
  1. Complications
    Complication of gonorrhoea in man, which are now rare because of the availability of effective antibiotics, include:
    Cowperitis presents as fever, malaise and severe pain in the perineum with frequency, urgency, painful defecation, and sometime acute urinary retention. Rectal examination is agonizingly painful.
  2. Periurethral Abscess presents as painful local swelling in the bulb or the fossa navicularis in the penis.
  3. Urethral Stricture could lead to obstructive symptoms and damages as well as recurrent urinary infection, leading to renal failure.
    Stricture may occur anywhere in the urethra but most commonly in the bulb. It is diagnosed by anterior urethroscopy or by urethrogram. Urologist's help is valuable in the management.
  4. Prostatitis is uncommon as attacks are cut short by the use of antibiotics. Symptoms include fever, perineal discomfort, pain on defecation and variable urinary complaints. Rectal examination may show a large, tense and fluctuant mass bulging into the rectum.
  5. Epididymitis, affecting 1% of patients, usually presented with acute onset of unilateral painful scrotal swelling. Examination showed inflamed epididymis with hydrocele and tender thickened vas. The epididymis is destroyed and bilateral disease result in sterility.
    Complications in female patients include:
  6. Bartholinitis And Abscess usually causes difficulty in walking because of the painful genital swelling. Pus can be expressed from the tender inflammed spherical fluctuant bartholin gland in the lower third of the labia.
  7. Pelvic Infection occurs in about 10% of female with gonorrhoea and causes acute attacks of bilateral lower abdominal pain with fever, nausea, vomiting, deep dyspareunia, vaginal discharge, dysuria and menstrual abnormalities. Pelvic examination reveals forniceal tenderness, cervical tenderness on movement and adnexal masses. Long term sequelae include chronic pelvic inflammatory disease, infertility and increase risk of ectopic pregnancy.
  8. Fitz-Hugh-Curtis Syndrome (acute gonococcal perihepatitis) consists of acute onset of upper right-quadrant abdominal pain and tenderness aggravated by breathing, coughing or movement, and referred to the right shoulder accompanying an attack of gonococcal PID. Laparoscopy, occasionally needed to exclude other acute abdominal conditions, show typical "violin string" adhesions.
  9. Disseminated Gonococcal Infection, which affects less than 1% of patients, is seen more frequently in women, especially during menstruation and pregnancy. It is characterised by fever, skin rash and arthritis, rarely meningitis, endocarditis and hepatitis.
Typical skin rash consists of a few painful crops of erythematous papules which become vesicopustular and haemorrhagic with necrotic centres, especially common on extremities associated with arthritis.

Joint involvement can be an additive asymmetrical arthritis affecting the knees and the small joints on hands and feet, with tenosynovitis of the wrist; or mono/oligoarthritis affecting the knee, wrist or ankle simulating acute septic arthritis. The diagnosis is clinical plus demonstrating the presence of gonococci in oral, rectal or genital sites, or by blood culture, synovial fluid culture.
  1. Investigations
    1. Smear of exudate typically shows polymorphs with intracellular gram-negative diplococci. This is very reliable (95% detection rate) in symptomatic urethritis in male patients and give a rapid presumptive diagnosis in clinics. For cervical, rectal or asymptomatic urethral infection, smear detects only about 50 percent of cases.
    2. Culture, for example in Thayer-Martin medium, detects 95-100 percent of symptomatic male urethral infections and 80-90 percent of cervical, rectal or pharyngeal infections. Besides giving a confirmatory diagnosis especially in women, oral and rectal infection or in disseminated disease, culture allows drug sensitivity testing, checking on the effects of treatment & test of cure, and documentation and subtyping of infection in legal proceedings such as sexual assault or rape.  
  2. TRT
    Uncomplicated: - Cefixime 400 mg stat or
    Inj ceftriaxone 250 mg IM tat(in pt) or

    Ciprofloxacin 500 mg BD –3 days
    Doxycycline 100 mg BD –7 days

    Special Considerations:
    1. Rectal, pharyngeal, conjunctivitis: - Inj ceftriaxone 250 mg IM stat
    2. Complicated,: - Inj ceftriaxone 1 g IM/IV OD –7 days (scrotal support, analgesics, sedatives SOS. avoid alcohol)
    3. Meningitis, - Inj ceftriaxone 1 g IM/IV BD –14 days
    4. Endocarditis, - Inj ceftriaxone 1 g IM/IV OD –30 days
    5. Ophthalmia neonatorum, - Inj ceftriaxone 50 mg/kg IM stat(max 125 mg)
    6. Children born to mothers of gonorrhoea, - Inj ceftriaxone 50 mg/kg IM stat(max 125 mg)
    7. Pregnancy, - Inj. ceftriaxone 250 mg IM stat
    8. HIV, - Same TRT
    9. Resistant strains - Spectinomycin 2 g IM stat
  3. Non-Gonococcal Urethritis And Non-Specific Genital Infection
    1. Definition
      1. In genito-urinary medicine, urethritis is broadly divided into gonococcal and non-gonococcal.
      2. Non-gonococcal urethritis (NGU) in male is referred to as inflammation of the urethra not caused by Neisseria Gonorrhoeae but some specific identifiable pathogens e.g. Chlamydia and ureaplasma or some non-specific unidentificable or unknown pathogens.
      3. Non-specific urethritis (NSU) refers to urethritis in which no identifiable pathogens have been found.
      4. Post-gonococcal urethritis refers to urethritis occurred after curative therapy for urethra gonorrhoea.
      5. In female, non-specific genital infection (NSGI) is a more preferred term as other than the urethra, vagina and cervix are the common sites for genital infections.
    2. Aetiology
      1. The suspected causes of infections are as follows:
      2. Chlamydia trachomatis (Group D to K) 40%
      3. Ureaplasma urealyticum 20-40%
      4. Trichomonas vaginalis (rare) < 2%
      5. Candidasis (rare) < 2%
      6. Herpes simplex (rare) < 2%
      7. Secondary to bacterial urinary tract infection < 2%
      8. Unknown 10-20%
    3. Incubation Period
      It varies from one week to six weeks with an average of two to three weeks. The average incubation period is considerably longer than gonococcal urethritis.
  4. Clinical Features
    1. NGU
      A definite history of venereal exposure accompanied by a mucoid or muco-purulent urethral discharge. Urethral discomfort in terms of dysuria, urethra itch, tingling or burning sensation is invariable. Rarer manifestations with urinary frequency, hematuria and urgency are occasionally encountered. Persistent or atypical urethral symptoms like perineal pain, inner thigh discomfort, pain during ejaculation, may hint ascending infections like epididymitis, orchitis or prostatitis.
    2. NSGI
      Majority of female patients can be asymptomatic. Vaginal discharge can be the only manifestation.
    3. Complications
      1. NGU
        1. Local complications
          • Littritis                         
          • Balanoposthitis
          • Acute epididymo-orchitis
          • cystitis
          • acute and chronic prostatitis    
          • acute proctocolitis
          • paraurethral abscess    
          • urethral stricture
        2. Systemic complications
          • Pneumonia    
          • Endocarditis
          • Acute perihepatitis (Fitz-Hugh-Curtis Syndrome)
      2. NSGI
        1. Local
          • Salpingitis,
          • Skenitis,
          • Bartholinitis,
          • Cystitis
        2. Long term
          • Infertility,
          • Ectopic pregnancy,  
          • Pelvic inflammatory diseases
        3. In newborn
          • Ophthalmia neonatorum,
          • Pneumonia
        4.  Systemic
          • Perihepatitis
STD Drug of choice
•  Chancroid
•  Gonorrhoeae
•  LGV
•  Donovanosis
•  Herpes genitalis
•  Trichomonas vaginalis
•  Genital warts (condyloma accuminata)
•  Wart in pregnancy
Azithromycin / Erythromycin
Doxycycline /Tetracycline
Azithromycin /Doxycycline
Imiquimod, Trichloro acetic acid

Test Your Skills Now!
Take a Quiz now
Reviewer Name