Human Papilloma Virus

Human Papilloma Virus: Excerpt from The 5-Minute Pediatric Consult

Kristen Feemster, MDSarah E. Winters, MDJane Lavelle, MD

Human Papilloma Virus - BASICS

Human Papilloma Virus - description

• Members of the Papovaviridae family, the human papilloma viruses cause warts of the skin and mucous membranes. Exophytic venereal warts or condylomata acuminata are caused by human papillomavirus (HPV) types 6 and 11.
• Warts can be found on the external genitalia and the urethra, vagina, cervix, anus, and mouth. Human papillomavirus types 6 and 11 are also associated with squamous cell carcinoma of the external genitalia.
• Virus types 16, 18, 31, 33, and 35 typically cause subclinical infection in the anogenital region and have been associated with intraepithelial genital carcinomas.
• HPV can also cause recurrent respiratory papillomatosis (RRP) in infants and young children. RRP primarily impacts the larynx but can also cause lesions anywhere along the respiratory tract.

Human Papilloma Virus - general prevention

• Condom use may diminish transmission.
• Examine partners; treat those infected.
• Pap smear to assess for cervical dysplasia
• Vaccination to prevent HPV types 6, 11,16, and 18.
• HPV infection is not a reportable disease.

Human Papilloma Virus - epidemiology

• General:
  • HPV is the most common viral STI.
  • Genital warts and HPV infection are diseases of young adults 16–25 years of age.
  • Cervical cancer is the leading cause of female malignancy in the developing world.
• Genital HPV:
  • Peak prevalence among women 18–24 years of age
  • 20% sexually active adolescents are infected with HPV.
  • <1% of adolescents develop genital warts.
  • 21% of HPV positive women have low-grade squamous intraepithelial lesions (LSIL) on Pap smear.
  • 500,000 new cases of cervical cancer diagnosed each year internationally
• RRP:
  • RRP impacts 4.3 per 100,000 children, mostly those age 2–3 years.
  • 67% of children with RRP are born to mothers who had condyloma during pregnancy.

Human Papilloma Virus - risk factors

• Infants:
  • Primarily vertical transmission at birth
• Adolescents:
  • Behavioral risks, including young age at 1st coitus, multiple partners, cigarette use, and having older male partners
  • Biologic risk in adolescent girls secondary to cervical anatomy

Human Papilloma Virus - pathophysiology

• Transmission is primarily through sexual contact.
• It can also be acquired during the birth process.
• Transmission from nongenital sites occurs rarely.
• The incubation period is variable and ranges from 3 months to several years.
• The virus is trophic for epithelial cells and infects the basal layer of actively dividing cells.
• Infection results in koilocytosis and nuclear atypia. Genital infections may progress to severe dysplasia and carcinoma in situ (CIS).
• Spontaneous regression of clinical disease occurs in 90% of low-risk types and 75% of high-risk types
• Recurrence is common.

Human Papilloma Virus - associated conditions

• Epidermodysplasia verruciformis
• Other STDs

Human Papilloma Virus - DIAGNOSIS

Human Papilloma Virus - signs & symptoms

Human Papilloma Virus - history

• Genital HPV:
  • Most patients have no symptoms.
  • Presence of warts, often painless
  • Vaginal, urethral, or anal discharge, bleeding, local pain
  • Dysuria
  • Pruritus
• RRP:
  • Infants have hoarse or weak cry, stridor and failure to thrive
  • Older children have hoarseness, stridor, dysphonia and obstructive sleep apnea.

Human Papilloma Virus - physical exam

• Genital HPV:
  • Warts appear as soft, sessile tumors with surfaces ranging from smooth to rough with many fingerlike projections.
  • HPV may also cause flat keratotic plaques that project only slightly with a hyperpigmented surface and are difficult to identify without the addition of acetic acid.
  • Subclinical infection is common, causing many foci of epithelial hyperplasia invisible to the examiner.
  • In males, infection is found on the penis, urethra, scrotum, and perianal areas.
  • In females, infection involves the urethra, vagina, cervix, and perianal area.
  • Diagnosis is made by visual inspection of the anogenital region. Cervical dysplasia is clinically inapparent on exam.
• RRP:
  • Often normal exam, but may be evident on respiratory exam

Human Papilloma Virus - tests

Human Papilloma Virus - lab

• Application of 3–5% acetic acid for 5 minutes causes lesions to appear white and thus more readily apparent and can help with the detection of cervical disease.
• Tissue specimens may show koilocytosis typical for HPV infection.
• Pap smear with liquid cytology to assess for evidence of cervical dysplasia resulting from HPV infection
• Colposcopy aids the diagnosis of cervical lesions.
• Polymerase chain reaction is commercially available for HPV typing.

Human Papilloma Virus - diag proced-surgery

• Genital HPV:
  • Pap smear or colposcopy to screen for cervical dysplasia
• RRP:
  • Direct visualization of the airway through laryngoscopy

Human Papilloma Virus - differencial diagnosis

• Genital HPV:
  • Condyloma lata
  • Molluscum contagiosum
  • Pink pearly papules or hypertrophic papillae of the penis
  • Lipomas
  • Fibromas
  • Adenomas
• RRP:
  • Croup
  • Vocal cord paralysis
  • Other forms of nasal, laryngeal, pharyngeal or tracheal obstruction

Human Papilloma Virus - TREATMENT

Human Papilloma Virus - general measures

• To date, no therapy exists that eradicates the virus. Recurrences are likely due to reinfection.
• Most patients require a course of therapy rather than a single treatment.
• Genital HPV:
  • Lesions on mucosal surfaces respond better to topical treatments.
  • All available therapies have equal efficacy in eradicating warts, ranging from 22–94%, with the significant rate of relapse of 25% within 3 months (see table in “Medication”):
    • Consider size, location, number of warts, previous treatment, and patient preference.
    • Also consider patient preference, expense, and side effects.
    • Patients with extensive lesions should be referred to physicians who routinely treat these lesions.
  • Treatment:
    • External: See table in “Medication.”
    • Meatal: Cryotherapy or podophyllin
    • Anal: Cryotherapy or trichloroacetic acid
    • Vaginal: Trichloroacetic acid
    • Cervical: Refer to an expert.
• RRP:
  • Surgical excision

Human Papilloma Virus - medication

Treatment for External Warts

Human Papilloma Virus - prognosis

Therapy will not eradicate the virus; thus, HPV causes recurrent disease.

Human Papilloma Virus - patient monitoring

• Follow-up should continue until the warts have disappeared.
• Patients should return for recurrent disease.
• Latent infection and recurrent disease are common.
• Young women should have a Pap smear within three years of coitarche and annually thereafter.

Human Papilloma Virus - bibliography

Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: Elsevier; 2005
1. Brentjens MH, Yeung-Yue KA, Lee PC, et al. Human papillomavirus: A review. Dermatol Clin. 2002;20 (Apr):315–331.
Kahn JA, Hillard PA. Human papillomavirus (HPV) In Children and Adolescents. In: Emans SJ, Goldstein DP, eds. Pediatric and Adolescent Gynecology. 5th ed. Boston: Lippincott Williams & Wilkins; 2005: 649–684.
2. Gunter J. Genital and perianal warts: New treatment opportunities for human papillomavirus infection. Am J Obstet Gynecol. 2003;189(3 suppl):S3–S11.
Neinstein LS. Adolescent Health Care: A Practical Guide. 4th ed. Baltimore: Urban & Schwarzenberg; 2002.Oriel D. Genital human papillomavirus infection. In: Holmes KK, Mardh P, Sparling PF, et al., eds. Sexually Transmitted Diseases. 2nd ed. New York: McGraw-Hill; 1990:433–441.
3. U.S. Department of Health and Human Services. 2006 Guidelines for treatment of sexually transmitted diseases. MMWR Recomm Rep. 2006;55(RR-11):1–91.

Human Papilloma Virus - CODES

Human Papilloma Virus - icd9

• 078.11 Condyloma acuminatum
• 091.3 Condyloma latum

Human Papilloma Virus - FAQ

• Q: What treatment is indicated during pregnancy?
• A: Most experts recommend surgical removal if necessary. Podophyllin is absolutely contraindicated.
• Q: Should partners of patients with genital warts be referred for examination?
• A: Recurrence is due to reactivation of the virus; reinfection plays no role. Partner may benefit from an examination to evaluate for the presence of warts, and for education and counseling. There is no information regarding prophylaxis to prevent infection, so treatment for this is not indicated. Most partners have subclinical infection. Female partners/patients should follow the routine recommendations for Pap smear screening.
• Q: Are genital warts in children always indicative of sexual abuse?
• A: No. The HPV virus has an incubation period of many months. Thus, warts transmitted to infants at the time of birth may not become clinically apparent for 1–2 years. Whether the incubation period can be longer than this remains unknown. Thus, maternal history and, potentially, examination are both important factors. However, all children with anogenital warts should be carefully evaluated by experienced clinicians for child abuse. It is possible that caregivers may transmit the virus to children through close but nonsexual contact; thus, this history is also important in older children.
• Q: Will young women still need to get PAP smears if they have received the HPV vaccine.
• A: Yes.The vaccine does offer good protection against the strains most commonly associated with genital warts and cervical cancer, 6, 11, 16 and 18. However, these strains are not the only ones that can cause infection or lead to cervical cancer. It is important to continue regular screening to ensure that one has not been exposed to other strains that may cause cervical dysplasia.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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