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Anogenitalny (venereal) warts

Anogenitalny warts (condylomas, Condylomata acuminata) represent benign warts with localization on generative organs and in perianal area.

Epidemiology

The reliable assessment of an incidence is difficult as the disease is characterized by the long latent course and a possibility of emergence of clinically expressed defeats later a long span after infection.

Classification
Sharp-pointed warts. Warts in the form of papules. Warts in the form of spots.
Huge condyloma of Bushke — Lovenshteyna (it vtrechatsya seldom).
Intraepithelial neoplasia (bowenoid papulez and Bowen's illness).

Etiology

More than 20 types of a virus of papilloma of the person colonizing urinogenital system, which are characterized low (types 6, 11, 42, 43, 44), an average (types 31, 33, 35, 51, 52, 58) and high (types 16, 18, 45, 56) by oncogenous risk are so far described.
As infestant more than in 90% of cases serves the virus 6 and 11 of types. Development of an intraepithelial neoplasia is connected with oncogenous types of a virus, as a rule, with the 16th type.

Pathogeny

Infection occurs at sexual contacts with the patient, however clinically expressed manifestations can arise later a long span. Therefore emergence of anogenitalny warts in one of sexual partners at monogamous communication cannot serve as the proof of sexual contacts of the patient with other persons.
As a rule, anogenitalny warts arise in the places which are exposed to traumatizing at sexual contacts and can be both single, and multiple. Merge of elements in plaques is more often observed at persons with an immunodeficiency or a diabetes mellitus.
On early durations of gestation increase in the sizes and quantity of warts which existence at the time of delivery increases risk of development of a papillomatosis of a throat of newborns is quite often noted.
Infection at children can happen when passing the newborn in patrimonial ways of sick mother, at virus autoinoculation in the presence of hand warts; besides, the contact way of transfer from the persons which are carrying out care of children is possible.
In all cases of detection of anogenitalny warts at children it is necessary to exclude sexual violence. It, according to numerous researches, serves as a disease origin more than at 40% of children with anogenitalny warts.

Clinical signs and symptoms of an illness

At men the centers of defeat are most often localized in preputial area (a balanus, a coronal furrow, a bridle, an internal leaf of a prepuce; at the cut-off prepuce as well on a penis body). Defeat of a scrotum, inguinal and perianal area, a crotch is possible. At 20 — 25% of men anogenitalny warts are localized in an outside opening of an urethra.
At women small and big vulvar lips, a clitoris, a threshold and walls of a vagina, a hymen, a neck of uterus, perianal area are involved in process. At 4 — 8% of women the outside opening of an urethra is surprised.
Anus condylomas arise at the persons practicing proctal sexual contacts more often.
Clinical manifestations can include a hyperemia in the field of defeat, existence of cracks, an itch, burning, bloody allocations and pain at sexual contacts.
Existence on a mucous membrane genital, proctal, sometimes inguinal area and a crotch of single or multiple (5 — 15 and more) speakers over not struck surface of painless finger-shaped elements with a diameter of 1 — 10 mm is characteristic of sharp-pointed condylomas. Localization in preputial area, in the field of an outside opening of an urethra, small vulvar lips, an entrance to a vagina, a wall of a vagina, a neck of uterus, an anus is typical.
Warts in the form of papules develop mainly on skin of anogenitalny area, can be single or multiple, 1 in size — 10 mm, with the expressed pigmentation and a hyperkeratosis and lack of finger-shaped protrusions. Localization on an outside leaf of a prepuce, skin of a penis, a scrotum, in the field of big vulvar lips, pubic and perianal area, a crotch is typical.
Warts in the form of spots are located on a mucous membrane of genital area, can be single or multiple; color of spots various — grayish-white, pinkish-red, red-brown.
The huge condyloma of Bushke — Lovenshteyna meets extremely seldom. Its development is caused by viruses 6 and 11 of types. It is characterized by aggressive growth deep into with an invasion in the subject structural formations of a derma. More often men get sick. It is clinically shown by existence of small knots or papillomas which quickly merge, form the defeat center with the wide basis and a surface in the form of vegetations which orogovevat and macerated, secondary infection of the centers is quite often noted. Typical localization: in the field of a coronal furrow, in a penis body, an internal leaf of a prepuce.
The intraepithelial neoplasia is subdivided into a bowenoid papulez and Boven's illness. Its development is connected with oncogenous types of a virus (more often with type 16). Defeat extends to all thickness of a mucous membrane. To one of the most significant risk factors serve age (bovenovidny papulez arises at persons 25 more often — 35 years, Boven's illness — 40 — 50 years). The disease is characterized by emergence on a mucous membrane and skin of anogenitalny area of papules and spots (at Boven's illness — with a velvet surface). Spots on a mucous membrane can be brown, orange-red, gray-white, on skin — ash-gray or brownish-black.
Anogenitalny warts not only cause cosmetic defects, but also can interfere with normal sex life and promote developing of mental disorders (sense of guilt, alarm, fear of rather possible child-bearing, risk of development of oncological diseases, etc.).

The diagnosis and the recommended clinical trials

Diagnostic methods:
• survey of anogenitalny area at good lighting (for identification of small elements it is necessary to use a magnifying glass);
• survey of women with use of a mirror of Cuzco for identification of damages of a vagina and a neck of uterus;
• a meatoskopiya (survey of a navicula by means of an otoscope);
• an uretroskopiya (in the presence of warts of an outside opening of an urethra) for definition of proximal border of damage of an urethra (it is carried out according to indications; it is necessary approximately in 5% of cases);
• an anoskopiya (it is carried out in the presence of proctal warts; it is necessary approximately at 30% of patients);
• test from 3% solution of acetic acid after which processing anogenitalny warts within several minutes keep grayish-white coloring. The method possesses low specificity in this connection false positive results at other diseases can be observed (a vulvovaginitis, skleratrofichesky lichenins, red flat deprive, psoriasis, a balanoposthitis, eczema, genital herpes). However test with acetic acid helps to specify defeat borders before carrying out a biopsy or surgical treatment;
• histologic research is recommended to be conducted at an atypical clinical picture for the purpose of the differential diagnosis, at suspicion on the malignant nature of papular or spotty elements, at localization of condylomas on a neck of uterus, at new multiple sharp-pointed warts at persons 35 — 40 years are more senior;
• cytologic research of a bioptat from a neck of uterus;
• kolposkopichesky research;
• consultation at specialists (the pediatrician, the gynecologist, the dermatovenerologist, the obstetrician-gynecologist, the urologist, the proctologist, the otolaryngologist).
In the presence of anogenitalny warts carrying out inspection for the purpose of an exception of other infectious diseases sexually transmitted is necessary.

Differential diagnosis of a disease

The differential diagnosis is carried out with a papular necklace of a penis (at men) and a micropapillomatosis of small vulvar lips (at women).
Papular necklace of a penis
it is observed at teenagers and characterized by existence of the separate papules with a diameter of 1 — 2 mm located in 1 — 2 row which is localized on a circle of a wreath of a balanus or in the field of a prepuce bridle. Unlike condylomas of a papule do not merge, have a smooth surface, vascular drawing is absent.

The micropapillomatosis of small vulvar lips is considered norm option. It is characterized by existence on an internal surface of small vulvar lips and area of an entrance of the vagina of the symmetrized not merging papules of the correct form.
The sebaceous glands located in the field of a prepuce and a vulva at healthy faces can also mistakenly be regarded as multiple warts in the form of papules.
Besides the differential diagnosis should be carried out with such diseases as a contagious mollusk, fibroepitelialny papilloma, a seborrheal keratosis.

Treatment

Use of condoms before full treatment at sexual contacts with new partners is necessary (constant sexual partners are, as a rule, already infected).
The persons having sexual contacts with sick condylomas within the previous 6 months need to conduct examination on STD.
The choice of a method of treatment depends on morphological features and prevalence of anogenitalny warts. Now there is no treatment method which leads to full elimination of a virus from an organism and guarantees lack of recurrence which frequency makes 20 — 30%.
Patients have to be informed on the disease, results and possible complications of treatment.
Out-patient treatment:
Podophyllotoxin, 0,15% cream or
0,5% solution to inflict on the centers defeats 2 r / over days, 3 days (carry out 1 — 4 course with an interval of 3 — 7 days; in the absence of effect after 4 courses of treatment it is necessary to replace HP) (at localization of warts on a penis more convenient to use 0,5% solution, in a vulva and an anus — 0,15% cream) or
Imikvimod, 5%o cream to inflict on the centers defeats 3 r / week before going to bed, washes off with soap, 12 weeks in the morning (at men) or 8 weeks (at women).
Hospitalization:
Trichloroacetic acid, 80 — 90% solution to apply on a wart, once (if necessary to repeat treatment in 1 — 2 week). When causing excess amount of drug or its hit on healthy fabric for neutralization bicarbonate is used sodium. Use of trichloroacetic acid is more effective at sharp-pointed or papular warts of the small size, than in the presence of big or keratosic warts.
If necessary carry out surgical treatment, electrocoagulation, CO2-lazernye surgical interventions, a cryolysis.

Assessment of efficiency of treatment

Lack of clinical displays of a viral infection.

Complications and side effects of treatment

Forming of keloid hems. Trichloroacetic acid should be used with care because of a possibility of formation of deep ulcers and hems.

Mistakes and unreasonable appointments

Use of podophyllotoxin for pregnant women is contraindicated.

Forecast

Despite treatment duration (1 — 6 month) and existence of high risk of development of recurrence, eventually is possible achievement of absolute clinical recovery.
 
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