Sexually Transmitted Diseases - I. I. Mavrov 2005

Urogenital infections caused by human papillomaviruses

A very common infectious disease of the urogenital Organs, genital warts (condyloma acuminata) are benign growths of the epidermis and the underlying papillary layer of the dermis.

Etiology. The CAUSATIVE AGENT OF genital warts belongs to the Papovaviridae family. Virions with a diameter of 40-50 nm contain circular DNA. The virus replicates in human epithelial Cells, forming basophilic inclusions (Lüpschütz bodies) visible under a Light Microscope. Electron Cell/15.html">Microscopy has established that these inclusions are aggregates of Viral Particles. The Development of warts is facilitated by local irritants: discharge from the Vagina, Urethra, or rectum in various pathological conditions, maceration, Pregnancy, and accumulation of smegma (see insert plate XI, 4-5).

Epidemiology. The disease occurs with equal frequency in both men and women (especially at the age of 22-24 years who are sexually active). The incubation period ranges from 1 to 9 months, averaging 3 months. Of note is The high frequency of the coexistence of genital warts with cervical and Ovarian Cancer.

Transmission routes. The virus can be transmitted by humans through Direct and Indirect contact. The sexual transmission route of this pathogen has been proven (J. Oriel, 1981). Genital warts are detected in 65-70% of affected individuals upon examination of both sexual partners. They are frequently associated with other Sexually Transmitted Infections. Intrauterine transmission is also possible.

The disease generally follows a benign course, but malignant transformation of genital warts into carcinoma may occur. Therefore, for cancer Prevention purposes, genital warts are always removed regardless of their shape, size, and localization, especially since cases of spontaneous resolution are not observed. Removed warts must undergo histological examination to rule out malignant transformation.

Clinical Features. Genital warts appear as small neoplasms on a thin or short stalk, resembling cauliflower or a cockscomb in shape. In some patients, they are single, while in others they are multiple. In certain cases (especially in women), such formations can reach a large size.

Depending on their Location, warts may be Skin-colored, pale pink, or intensely red, and whitish in cases of maceration. Occasionally, they are eroded and discharge a foul-smelling fluid.

Genital warts are usually painless, but when located, for example, along the corona of the glans Penis, they can be painful, particularly following mechanical trauma.

In men, genital warts are located on the corona of the glans penis, but sometimes exclusively on the urethral mucosa (Fig. 39). In some patients, endourethral localization is combined with extraurethral lesions. Warts may be found along the entire length of the penile urethra and in the region of the fossa navicularis. They are typically accompanied by chronic recurrent urethritis.

In women, genital warts are observed on the external genitalia, in the urethra, vagina, on the cervix, Perineum, and around the anus (Fig. 40). Frequently, they are localized solely at the urethral meatus and the inner wall. A deeper location within the urethra is also possible, in which case they cause symptoms of persistent urethritis. Patients complain of discomfort during urination and vague pain in the lower abdomen and the external genital area.

In the urethra, warts are arranged in a ring-like fashion, primarily around the external meatus. This is often accompanied by simultaneous involvement of the Clitoris and external genitalia.

On the vaginal fornices and the vaginal portion of the cervix, genital warts are predominantly detected in pregnant women. Sometimes they reach significant sizes, blocking the vaginal introitus or the external urethral meatus, and involving the perineal and perianal regions.

On the cervix, warts coalesce to form large light-yellow or white plaques on an infiltrated base. They may cover the entire surface of one or both Lips of the external os.

The most dangerous (in both men and women) are giant condylomata acuminata, which are capable of tissue destruction.

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Fig. 39. Genital warts of the male genitalia.

Fig. 40. Genital warts of the female genitalia.

Occasionally in women (especially pregnant ones), warts can proliferate to large sizes within a few weeks or months. Vaginal and cervical secretions accumulate between the overgrown lobules of the warts and subsequently decompose. Individual lobules of the growths disintegrate, accompanied by a foul odor.

Giant condylomas can be symmetrically located on the Labia Majora and minora, completely covering the vulvar cleft, and extending to the femorocrural folds. Sometimes they are found between the buttocks, as well as isolated in the perianal region with extension onto the mucosa of the external anal sphincter.

During The formation of genital warts, symptoms are often absent, and patients seek medical attention only during their rapid growth. Significant discharge can cause maceration and weeping, as well as ulceration of the warts and the underlying skin, resulting in itching and burning sensation.

Depending on the localization of the genital warts, patients may report various types of pain during urination, sexual intercourse, defecation, etc. Patients with large warts have difficulty walking.

Diagnosis OF GENITAL warts is based on the characteristic clinical picture. Warts localized within the urethra can only be detected using urethroscopy. Genital warts should be differentiated from broad condylomas (condylomata lata) associated with secondary Syphilis. Unlike genital warts, broad condylomas have a broad base, are firm, and do not bleed. In doubtful cases, discharge is examined for the presence of Treponema pallidum and serological tests for syphilis are performed.

Pathomorphological examination of genital warts reveals pronounced epithelial acanthosis and papillomatosis. The process typically begins with epidermal proliferation, followed by the development of papillomatosis. Despite rapid cell proliferation, the hyperplastic epithelium retains its typical Structure. In the edematous Connective Tissue, infiltration (by plasma cells and lymphocytes) may be observed.

Blood and Lymphatic Vessels of the affected area are significantly dilated and participate in the formation of papillary growths. Numerous mitoses, parakeratosis, and acanthosis are observed in the epidermal cells, As a result of which The surface of the warts is covered with a thickened, poorly keratinized epithelium. Bands of keratinized epithelium are noted at the edges of the papillae, with proliferating, non-keratinized epithelium located inward from them. In the center of the papillary growths lie the connective tissue cores of the papilla containing capillaries.

Treatment. Therapy is aimed at the direct removal or destruction of condylomas.

The most common treatment involves podophyllin (a cytostatic agent): a gauze pad moistened with a 10–20% alcoholic solution of the drug (podophyllin – 20 g, 70% ethanol – 70 ml, collodion – 10 g) is applied to the condylomas initially for 3 hours, with the exposure time gradually increased up to 24 hours. The treatment is repeated 1 or 2 times a week until the condylomas disappear. High-dose podophyllin application exerts a systemic (resorptive) effect, which can lead to neuropathy, hypokalemia, coma, and even death. Podophyllin should not be prescribed to pregnant women, as treatment with this drug may result in fetal demise.

Genital warts are dusted daily with a 1:1 mixture of resorcinol and an inert powder or dermatol. Healthy surrounding skin should be protected with a layer of petroleum jelly. A 5% fluorouracil cream is also used with great success. Other treatment options include tri- or bichloroacetic acid, interferon, laser therapy, cryocoagulation, or electrocoagulation.

Endourethral condylomas are removed via diathermocoagulation under ureteroscopic guidance, scraped with a curette (sharp spoon), or excised using the cutting edge of a urethroscope inserted without an obturator. Cryodestruction using a standalone cryoprobe is also highly effective.

Diathermocoagulation is widely used to treat cervical condylomas. If the lesions are few, a single cauterization session is performed; extensive lesions require 2–3 sessions.

Cryosurgery (topical application of liquid nitrogen) offers certain advantages over other treatment Methods because it does not require general or local anesthesia and is often effective for treating condylomas that are refractory to standard medical therapy.

The surgical approach involves standard disinfection followed by local anesthesia, after which the condylomas are excised using scissors or a scalpel. A pressure dressing is then applied to the wound surface for 5–6 days.