WHAT IS GENITAL HERPES? — Genital herpes is a common sexually transmitted disease that is caused by the herpes simplex virus. It is estimated that at least one in five adults in the United States is infected with the virus, but many people have no symptoms and do not realize that they are infected.
Genital herpes is a lifelong condition that, at the present time, cannot be cured. However, the infection can be managed with medication and self-care measures. Infected individuals are encouraged to talk to their sexual partner and use condoms and take other preventive measures; genital herpes can be spread even when there are no visible ulcers or blisters.
Being diagnosed with genital herpes can be an emotional and distressing experience, and it is important for patients to speak with their healthcare provider about how to manage symptoms and avoid passing the virus to their sexual partner. Counseling and support groups can also be beneficial to individuals living with genital herpes infection.
Cause — Genital herpes is caused by infection with the herpes simplex virus (HSV, usually type 2 (HSV-2)). It can also be caused by herpes simplex virus type 1 (HSV-1), the most common cause of oral herpes (cold sores on the mouth and lips).
The virus can be passed from one person to another during oral, anal, or vaginal sex, even if the person with herpes has no visible ulcers or sores.
SIGNS AND SYMPTOMS — Many people infected with genital herpes never experience symptoms. The symptoms of genital herpes can vary widely depending on whether an individual is experiencing an initial or recurrent episode.
Initial episode — For most people, the first herpes outbreak is the most severe, and symptoms tend to be more severe in women than men. The first outbreak usually occurs within a few weeks of infection with the virus. Symptoms tend to resolve within two to three weeks.
The signs of an initial (or primary) episode of genital herpes include multiple blisters in the genital area. For women, the sites most frequently involved includes the vagina, vulva, buttocks, anus, and thighs; for men, the penis, scrotum, anus, buttocks and thighs may be affected. Signs and symptoms typically include blisters that become painful ulcers. Blisters on the penis and outer labia may crust over and heal. New lesions may develop for up to 5 to 7 days after the first group appears. Some individuals also get blisters in non-genital areas such as the mouth and lips. There may also be tender, swollen lymph nodes in the groin, painful urination, and flu-like symptoms such as joint pain, fever, and headache.
A small percentage of people develop additional non-genital symptoms, including meningitis (inflammation of the tissue covering the brain and spinal cord) and an inability to urinate (from the effects of the virus on the nervous system). The virus can also cause proctitis (inflammation of the rectum or anus), particularly in men who have sex with men.
Latent stage — After the initial outbreak, the virus travels to a bundle of nerves at the base of the spine, where it remains inactive for a period of time. This is called the latent stage. Patients have no symptoms during this stage.
Recurrent episodes — Many people experience recurrent episodes of genital herpes, which occur when the virus travels through nerves to the skin's surface, causing an outbreak of ulcers. These recurrent episodes tend to be milder than the initial outbreak, and some recurrences cause no noticeable symptoms at all. When blisters are present, they are usually present for a shorter duration, about 10 days on average.
Ulcers may develop in the same area as during the first outbreak, or may appear in other areas. Sexual contact in the area where herpes lesions develop is not necessary; for example, it is possible to have lesions around the anus without having had anal sex.
Likelihood of recurrence — Recurrence is more common in individuals infected with HSV-2 compared to those with HSV-1. In one study of individuals infected with HSV-2, 89 percent had one recurrence over the 13 months following the initial episode, 38 percent had up to six recurrences, and 20 percent had more than ten [1]. The likelihood of an individual experiencing recurrences appears to be related to the length and severity of the person's initial episode.
However, it is also possible to have a recurrence many years (20 to 40 years) after the initial HSV infection was acquired. This type of delayed herpes outbreak can be especially distressing for those who never had symptoms during the initial infection, and it may cause concern about the sexual activities of past or present sexual partner(s).
Prodrome — As many as 50 percent of people with recurrences experience mild symptoms before a recurrent outbreak; these may include itching, tingling, or pain in the buttocks, legs, and hips. Recurrences tend to become less frequent and less severe after the first year.
Triggers for recurrence — Illness, stress, sunlight, birth control pills, and fatigue can trigger recurrent herpes outbreaks. Menstruation in women may also trigger an outbreak.
Shedding stage — Viral shedding means that the virus is present in the urinary and genital tract. During this period, often called asymptomatic shedding or asymptomatic reactivation (because no ulcers are present), the infection can be transmitted between sexual partners. Shedding of HSV-2 occurs approximately 20 percent of the time (an average of 72 days per year), mostly before, during, or after ulcers are present. The virus is shed on 3 percent of days when there are no signs or symptoms of the virus. Some people with HSV shed virus more frequently than others.
DIAGNOSIS — The diagnosis of genital herpes is based on an individual's history of possible exposure to the virus, the presence of characteristic signs and symptoms, and the results of diagnostic tests. A careful diagnosis is especially important for distinguishing genital herpes from other sexually transmitted diseases, particularly those that also produce genital ulcers, such syphilis and chancroid.
Along with a patient's history and physical symptoms, several diagnostic tests may be used to diagnose genital herpes. These tests can usually confirm infection and identify which virus (HSV-1 or HSV-2) is responsible. They can also detect asymptomatic shedding in individuals with known infection, although routine testing for this purpose is not usually performed.
Culture test — A culture test determines if herpes simplex virus is present on the skin and in secretions from the urinary and genital tracts. This is the test most commonly used to diagnose genital herpes; however, this test detects the virus in only about 50 percent of individuals with genital ulcers. The culture test is more likely to detect the virus when ulcers are new and open, as compared to when they are older and healing. Therefore, it is important to see a healthcare provider within 48 hours of the first symptoms. The test is also more sensitive in individuals experiencing an initial episode of genital herpes than in individuals experiencing a recurrent episode.
Blood test — Blood tests are often used when a person believes he or she may have been exposed to the herpes virus in the past, but has no visible ulcers. A blood test can detect antibodies (proteins that are produced by the body in response to a foreign substance) to HSV-1 and HSV-2. Having a positive test for these antibodies indicates that an individual has been infected with the virus at some time in the past, although it is usually not possible to know when or from whom the virus was transmitted.
Because the antibody response takes time, the results of this test may be negative during the first episode of genital herpes. Within three to four months after an initial episode, HSV antibodies can usually be detected. The antibody test remains positive for life.
Blood tests may be helpful for couples in which one person has a history of genital herpes and the other does not. It is possible for a person to have HSV antibodies (indicating past infection), even if they have no memory or history of genital herpes.
Determining the type of herpes (1 or 2) can also help to predict the likelihood of future recurrences, given that type 2 recurs more frequently than type 1 (see "Likelihood of recurrence" above).
Polymerase chain reaction (PCR) test — The polymerase chain reaction (PCR) test is a very sensitive test for identifying the herpes virus in cells and secretions from the urinary and genital tracts. The PCR test is more sensitive than the culture test, but is not routinely used due to it's higher cost.
TRANSMISSION AND RISK FACTORS
Transmission between sexual partners — The herpes virus is most often transmitted between partners during oral, anal, or vaginal sex. It is possible for a person to develop genital herpes after exposure to a cold sore on an infected person's lip during oral sex; in this case, genital herpes may be due to infection with HSV-1. Transmission from person to person can occur even if there are no visible ulcers, as a result of asymptomatic viral shedding. However, the risk of transmission is much greater when a person has signs or symptoms of active infection. Individuals do not need to be concerned about the possibility of viral transmission from environmental surfaces (door knobs, toilet seats, utensils, bed sheets).
The risk of transmission from an infected male to an uninfected female partner is slightly higher than the risk of transmission from an infected female to an uninfected male partner. The risk of infection is also higher in men or women who receive anal sex.
If both sexual partners have the same type of herpes virus (eg, HSV-1 or HSV-2), there is no risk of repeated transmission. It is possible for a person with one type of herpes virus to become infected with the other type; for this reason, testing to determine virus type is important.
One study examined rates of genital herpes transmission in heterosexual couples in whom only one partner was initially infected [2]. Over one year, the virus was transmitted to the other partner in 10 percent of couples. In 70 percent of cases, infection occurred at a time when there were no symptoms.
Transmission of HSV may occur within a short time in new sexual relationships. In one study of 199 patients with newly acquired HSV genital infection, the average time from the first sexual encounter to the time a person was infected with HSV was 3.5 months (range 1.5 to 10 months) [3].
Pregnancy and herpes — Women who have a first outbreak of genital herpes near the time of delivery are at risk of transmitting herpes to their newborn.
Women who acquire genital herpes before becoming pregnant are not likely to pass the virus to the baby. However, it is possible for this to happen, particularly if the mother has symptoms of pain or burning, or has active lesions at the time of delivery. In patients with one or more recurrences during pregnancy, preventive antiviral therapy with acyclovir should be considered. A caesarean delivery is usually recommended in women who experience an outbreak of symptoms at the time of labor.
Since genital herpes in infants is a very serious condition, women should inform their healthcare provider if they have a history of the infection. Women with no history of genital herpes whose partner has a history of cold sores (generally HSV-1) or genital herpes (generally HSV-2) should avoid oral, vaginal, and anal sex during the last trimester of pregnancy. In this situation, condoms are recommended during the entire pregnancy. Careful planning during the pregnancy and precautions during pregnancy and at the time of delivery can reduce the likelihood of transmission and allow for a normal birth.
GENITAL HERPES AND HIV — Individuals with genital herpes are at an increased risk of acquiring HIV. During an outbreak, blisters and ulcers make it easier for a partner's genital fluids to enter the body. Therefore, if a person with herpes is exposed to HIV through sexual contact while herpetic lesions are present, HIV can more easily travel through the skin.
TREATMENT — Although there is no cure for genital herpes, the infection can be managed with antiviral drug therapy and self-care measures. A summary of the antiviral medications is available in table 1 (show table 1).
Antiviral drug therapy — Several antiviral drugs are available for treating genital herpes. There are two regimens of drug therapy for genital herpes: episodic therapy and suppressive therapy.
Episodic therapy — Episodic therapy is treatment with antiviral drugs as soon as the symptoms of genital herpes begin. The medication is stopped after 7 to 10 days. Antiviral medications can alleviate pain, reduce the healing time of ulcers, and shorten the duration of viral shedding (the time during which the virus can be transmitted to a partner).
Episodic therapy is usually recommended for individuals who have fewer than six recurrences each year. Unfortunately, episodic treatment does not reduce the frequency of recurrences. Antiviral treatment of recurrent episodes is most likely to be effective if started within 24 hours of the first symptoms.
Suppressive therapy — Suppressive therapy refers to the continuous use of antiviral drugs, even when there are no symptoms. Suppressive therapy increases the time between recurrences, decreases the number of recurrences, shortens the duration of symptoms during a recurrence, and can reduce the risk of transmission of HSV to an uninfected partner.
Suppressive therapy is usually recommended for HSV-positive individuals who have six or more recurrences each year and those with a weakened immune system due to the human immunodeficiency virus (HIV), use of immune-suppressing drugs, or other factors.
Suppressive therapy may also be considered for people who are in a sexual relationship with a partner who does not have a history of genital herpes or antibodies to HSV-1 or 2 (as determined by blood testing). This approach has been demonstrated to reduce transmission to the susceptible person by approximately one-half.
Antiviral medications — Three antiviral medications are used to treat genital herpes: acyclovir, famciclovir, and valacyclovir. They are usually taken by mouth (in pill form). Acyclovir (Zovirax®) — Acyclovir (Zovirax®) is the oldest and least expensive antiviral medication. It usually requires more frequent dosing than famciclovir and valacyclovir. It is available in pill, liquid, and injectable forms. Famciclovir (Famvir®) — Famciclovir (Famvir®) is another drug available for the treatment of genital herpes. It is usually taken two or three times per day. Valacyclovir (Valtrex®) — Valacyclovir (Valtrex®) may be more convenient than acyclovir and famciclovir because it is taken one to two times per day.
Self-care measures — In addition to antiviral medications, local treatments may be used to relieve the pain of a herpes outbreak. Sitting in a few inches of cool water (called a sitz bath) can temporarily decrease pain. This can be done in a bathtub or a specially designed sitz bath, available at most pharmacies without a prescription. Women who are having trouble urinating may find it helpful to urinate in the sitz bath or at the end of a warm bath. Soaps and bubble baths should be avoided. It is important to keep the genital area clean and dry, and to avoid tight or irritating underwear and clothing.
Acetaminophen (Tylenol®) or ibuprofen (Advil®) may also help relieve the pain of genital ulcers. Over-the-counter creams and ointments are generally not recommended.
COUNSELING AND SUPPORT — The diagnosis of genital herpes can cause feelings of shame, fear, and distress. While these reactions are normal, it is important to remember that genital herpes is a manageable condition. Education is important for infected individuals and their partner to know what to expect and how to protect themselves.
Many patients find that counseling, either with their family healthcare provider or a mental health professional, is helpful in dealing with the issues that come with a diagnosis of genital herpes. Counseling may be especially important for people who have tested positive for the virus but have not developed symptoms, as these individuals may have difficulty understanding the impact of the disease in the absence of any physical signs.
There are many genital herpes support groups in the United States and worldwide; these provide a safe environment for people to share their experiences and feelings, and also to access accurate information about the disease. Infected individuals are encouraged to speak with their healthcare provider or visit the websites listed below (see "Where to get more information" below).
PREVENTION — Because all sexually active persons are at some risk of acquiring genital herpes, it is important to communicate with a sexual partner before the first sexual encounter. Discussing herpes can be uncomfortable and embarrassing, but it ensures that both partners understand the possibility of transmitting the infection through sexual activity. Regular testing for sexually transmitted diseases is also recommended, especially if one or both partners has other sexual partners.
After being diagnosed with genital herpes, it is still possible to have a safe and healthy sex life; however, it is important to take precautions. Use of a latex condom with every sexual encounter can reduce the risk that an infected male will pass the herpes virus to an uninfected male or female partner. Condoms are less effective in preventing an infected woman from transmitting the virus to an uninfected man, although there is probably some benefit. Even when a person is symptom-free, use of a condom is recommended. Sex should be avoided any time genital ulcers are present. Oral sex should be avoided if there are ulcers or blisters around the mouth, as a person with the oral form of herpes can give a partner genital herpes by performing oral sex.
SUMMARY Genital herpes is an infection that is spread during sex. Symptoms of genital herpes include blisters in the genital area (eg, penis, buttocks, anus, vulva). The blisters become painful ulcers. Some people have no symptoms at all. Many people have an outbreak of genital herpes more than once in their life. Later outbreaks can also cause blisters and painful ulcers. Outbreaks may occur frequently (eg, once per month) or rarely (eg, once per ten years). Sometimes, outbreaks are triggered by illness, stress, sunlight, birth control pills, or being tired. Several tests are available to diagnose genital herpes. Some tests use blood while others require a swab of the blister. It is possible to spread herpes even if there are no visible ulcers. It is not possible to catch herpes by touching a surface (door knobs, toilet seat, bed sheets). It is possible to spread herpes from the mouth (from a cold sore) to the genitals. Several medications are available to treat genital herpes (acyclovir, valacyclovir, and famciclovir). These drugs help to speed healing of ulcers and lower the risk of spreading the virus. Some people take the medicine every day to prevent future outbreaks or prevent spread to their sex partner. There are ways to lower the risk of being infected with genital herpes. Men should use a latex condom every time they have sex. Sex (oral, vaginal, and anal) is not recommended if a person has blisters or ulcers.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Phone: (404) 639-3534
Toll-free: (800) 311-3435
(www.cdc.gov)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/)
Herpes Resource Center
American Social Health Association
Phone: (800) 230-6039
(www.ashastd.org)
[1,2,4-12]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Benedetti, J, Corey, L, Ashley, R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med 1994; 121:847.
2. Mertz, GJ, Benedetti, J, Ashley, R, et al. Risk factors for the sexual transmission of genital herpes. Ann Intern Med 1992; 116:197.
3. Wald, A, Krantz, E, Selke, S, et al. Knowledge of partners' genital herpes protects against herpes simplex virus type 2 acquisition. J Infect Dis 2006; 194:42.
4. Fleming, DT, McQuillan, GM, Johnson, RE, et al. Herpes simplex virus type 2 in the United States, 1976 to 1994. N Engl J Med 1997; 337:1105.
5. Centers for Disease Control and Prevention, Division of Sexually Transmitted Diseases. Sexually Transmitted Diseases Surveillance, Other Sexually Transmitted Diseases, 2003 (www.cdc.gov/std/stats/03pdf/otherSTDs.pdf).
6. Corey, L, Adams, HG, Brown, ZA, Holmes, KK. Genital herpes simplex virus infections: Clinical manifestations, course, and complications. Ann Intern Med 1983; 98:958.
7. Kimberlin, DW, Rouse, DJ. Clinical practice. Genital herpes. N Engl J Med 2004; 350:1970.
8. Douglas, JM, Critchlow, C, Benedetti, J, et al. A double-blind study of oral acyclovir for suppression of recurrences of genital herpes simplex virus infection. N Engl J Med 1984; 310:1551.
9. Sacks, SL. Famciclovir suppression of asymptomatic and symptomatic recurrent anogenital herpes simplex virus shedding in women: a randomized, double-blind, double-dummy, placebo-controlled, parallel-group, single-center trial. J Infect Dis 2004; 189:1341.
10. Fife, KH, Barbarash, RA, Rudolph, T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection: Results of an international, multicenter, double-blind, randomized clinical trial. Sex Transm Dis 1997; 24:481.
11. Bodsworth, NJ, Crooks, RJ, Borelli, S, et al. Valaciclovir versus aciclovir in patient initiated treatment of recurrent genital herpes: A randomised, double blind clinical trial. Genitourin Med 1997; 73:110.
12. Corey, L, Wald, A, Patel, R, et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med 2004; 350:11.
Monday, October 15, 2007
Condyloma (genital warts) in women
INTRODUCTION — Condyloma acuminata (genital warts) are the most common sexually transmitted condition in the United States. Although warts affect both genders, one study showed that women accounted for 67 percent of patients.
CAUSES — Condyloma are caused by the human papillomavirus (HPV), which infects the epithelial layer (the outer layer) of the skin and mucous membranes. Over 70 different types of HPV have been identified, each of which infects a specific area of the body. Researchers have labeled the HPV types as being at high or low risk for causing cervical cancer. The HPV viruses that cause most genital warts are low-risk types. HPV types 6 and 11 are a major cause of warts, and types 16 and 18 are major causes of cervical cancer. (See "Patient information: Screening for cervical cancer").
HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). It is not possible to become infected with HPV by touching a toilet seat.
SYMPTOMS — Rarely, women with genital warts have itching, burning, or tenderness in the genital area, depending upon the number of warts and their location. However, most women with warts do not have any symptoms at all.
Warts appear skin-colored or pink, and may be smooth and flat or raised with a rough texture. They are usually located on the labia or at the opening of the vagina, but can also be around or inside the anus (show picture 1).
Warts may appear weeks to a year or more after HPV exposure; it is not usually possible to know when, how, or from whom the infection was transmitted.
DIAGNOSIS — Most women with genital warts can be diagnosed based upon a healthcare provider's visual examination. In some women, further examination with colposcopy (examination of the vulva, vagina, and cervix) or anoscopy (examination of the anus and rectum) is recommended. For these tests, the healthcare provider uses a magnifying device to closely inspect the skin or tissue for evidence of HPV infection. A weak acid solution (called acetic acid) is applied to the skin or tissue, which can further aid in the diagnosis; this does not cause pain.
A biopsy (removal of a small piece of tissue) is recommended if the provider is uncertain whether the area in question is a genital wart, if the wart does not respond to treatment, if the lesion is very large, if the patient has a weakened immune system due to HIV or medications, or if the lesion has an unusual appearance. Most women with genital warts will not need a biopsy.
TREATMENT — Treatment of warts usually involves a topical medication that is applied by the patient or healthcare provider. Other treatments, such as oral medications and surgery, are generally reserved for patients with very large areas of warts or warts that do not improve with topical treatments. A summary of these treatments is provided here (show table 1).
To eliminate the wart(s); a course of treatment over several weeks is generally required. Even with treatment, it may not be possible to eradicate the HPV virus from the genital area; therefore, it is possible that the warts will recur. There is currently no treatment that will eradicate the HPV virus itself.
Treatment is not necessary if the warts are not bothersome. Furthermore, 10 to 30 percent of genital warts will resolve on their own without treatment
Medical treatments — Medical treatments include medications that are applied directly to the wart. There are two broad categories of medical therapy: those that directly destroy the wart tissue (cytodestructive therapies) and those that work through the patient's immune system to clear the wart (immune-mediated therapies). Some treatments must be applied in the healthcare provider's office while others can be applied by the patient at home.
Podophyllin — Podophyllin is a plant-based resin that destroys the wart tissue. It is only used for vulvar lesions; using it on the cervix or vaginal tissues can cause chemical burns. The healthcare provider applies the solution directly to the warts with a cotton swab, and the patient should wash the area one to four hours later to avoid excessive skin irritation. The treatment is repeated weekly for four to six weeks, or until the lesions have cleared.
Studies have reported 40 to 75 percent of patients are cleared of warts after using podophyllin, but 25 to 100 percent have a recurrence over time [1]. Adverse effects range from mild skin irritation to ulceration and pain.
Podophyllotoxin — Podophyllotoxin (Condylox®) contains the biologically active compound from podophyllin, but it can be self-administered. Using a cotton swab, the patient applies a 0.5 percent gel or liquid solution to the warts twice daily for three consecutive days. No more than 0.5 ml of medication should be used per treatment session, and no more than a 3 cm by 3 cm area should be treated. No treatment is used for the following four days; the treatment cycle can be repeated up to four times until the warts have resolved.
Clinical studies have described wart clearance rates of 29 to 90 percent [2]. Podophyllotoxin may be recommended as a first-line treatment if the patient is willing and able to apply it. Podophyllotoxin may be more effective than podophyllin.
Bichloroacetic acid and trichloroacetic acid — Both bichloroacetic acid (BCA) and trichloroacetic acid (TCA) are acids that destroy the wart tissue. TCA is used most commonly, and must be applied by a health care provider. An 80 to 90 percent TCA solution is applied sparingly to the wart tissue, which will turn white as the solution dries. Petroleum jelly may be applied to the normal tissue surrounding the wart to prevent the acid from reaching these areas. Once weekly application is required for four to six weeks, or until the lesions have cleared. Side effects of TCA may include pain and burning.
One trial that evaluated TCA in women showed a 70 percent clearance rate [3]. In contrast to podophyllin, TCA can be used on the cervix and vagina, and is safe for use during pregnancy.
Imiquimod — Imiquimod (Aldara®) is a cream that causes an immune response; this causes the body to eliminate the wart. The patient applies the cream directly to the wart tissue (generally at bedtime), and then washes the area with water six to 10 hours later. The drug is applied every other day for a total of three days per week, for up to 16 weeks. Side effects may include mild irritation and redness. Imiquimod should not be used internally on vaginal warts, and it is not recommended for use during pregnancy.
Randomized trials show a 50 percent clearance rate with 10 to 20 percent recurrence rates [4].
Interferon — Interferon is a medication that causes an immune response. It is available in several treatment forms (intramuscular injection, topical gel, subcutaneous injection), but studies have determined that it most effective when given as a subcutaneous (under the skin) injection at the base of the wart two to three times per week for up to nine weeks. Several clinical trials have shown clearance rates of about 20 to 60 percent [5], although other trials have failed to show any benefit [6], perhaps due to too brief a period of follow-up.
Side effects of interferon include flu-like symptoms, fatigue, lack of appetite, and local pain. Given these side effects, the variable rates of effectiveness, and the need for multiple treatments per week, interferon is not generally recommended as a first-line treatment. It may be used in combination with surgical and/or other medical treatments, especially in patients with warts that do not improve with other treatments.
Interferon is not safe for use during pregnancy.
Surgical treatment — Surgery is generally reserved for patients with: Lesions that do not respond to medical therapy Extensive or bulky disease, where medical therapy alone is often inadequate Lesions involving the vagina, urethra, or anus Areas that have associated pre-cancerous changes
Surgical management options include excisional (removal) and ablative (destructive) procedures. These treatments are often used in a combined fashion.
Cryotherapy — Cryotherapy uses a chemical (either nitrous oxide or liquid nitrogen) to freeze the wart tissue. The treatment can be done in a healthcare provider's office, and does not usually require any anesthesia. Studies have reported 50 to 80 percent clearance of warts after cryotherapy. Cryotherapy can be used during pregnancy.
Cryotherapy often causes pain during the procedure; other side effects can include skin irritation, swelling, blistering, and ulceration. For these reasons, medical therapies, such as podophyllin, podophyllotoxin, and trichloroacetic acid may be recommended before trying cryotherapy.
Electrocautery — Electrocautery uses electrical energy to burn away wart tissues. Patients are treated in an operating room after receiving local anesthesia to prevent pain. It can be used for vaginal lesions.
Excision — Excision involves the removal of an area of warts by surgically cutting it out. Most patients are treated in an operating room after receiving anesthesia to prevent pain. Rarely, excision causes pain, scar formation, and infection.
Excisional therapy is effective. Most studies show success rates of 36 to 100 percent and recurrence rates of 8 to 65 percent within one year [7].
Laser — Lasers produce light energy, which is absorbed by water within wart tissues, leading to its destruction. Physicians who perform laser treatment require specific training and specialized equipment. Patients are treated in an operating room after receiving local anesthesia to prevent pain.
Laser therapy is preferred when multiple warts are spread over a large area. Laser is also useful for treating cervical and vaginal warts, when surgical excision is not possible or would be difficult. Risks of laser surgery include scarring, pain, and changes in the skin's appearance (usually lightened color). Rarely, patients may develop chronic pain in the area of treatment.
Laser therapy clears lesions in 40 to 100 percent of warts, and long-term recurrences occur in 4 to 77 percent of patients.
Ultrasonic aspiration — The CUSA technique (Cavitron ultrasonic aspirator-CUSA) uses ultrasound (sound waves) to break up and remove warts. With this technique, removal of the outer layer of skin occurs without damage to underlying tissue. Patients are treated in an operating room after receiving general anesthesia to induce sleep and prevent pain. One study showed this technique to be effective in the treatment of warts [8]. CUSA requires that a healthcare provider undergo specialized training and purchase specialized equipment, so it is not widely available.
FOLLOW UP — Following successful treatment of warts, some patients will be instructed to examine themselves periodically to monitor for new warts; other patients will be asked to return to their healthcare provider at regular intervals for examination. Most patients who develop recurrent or persistent warts do so within three to six months of treatment. Recurrence is more common in persons with a weakened immune system (due to HIV or certain medications); more frequent follow-up or self-monitoring of these patients is reasonable so that treatment may begin promptly.
It is important to understand that complete elimination of visible warts does not necessarily mean that HPV has been eradicated. Therefore, warts may recur even after successful initial treatment. In this situation, the same treatment may be used again and is likely to be successful.
PREVENTION
HPV vaccine — A vaccine (Gardasil®) is now available to help prevent infection with some types of HPV (types 6, 11, 16, and 18), which in turn can prevent most cases of cervical cancer and genital warts. The vaccine was proven to be safe and effective in several large clinical trials [9,10].
The vaccine is currently recommended for all girls and women between ages 9 and 26 years. Decisions about the age at which to start HPV immunization have been guided by data regarding the ages of peak HPV infection and the estimated duration of vaccine protection. While it is not known exactly how long the vaccine protects against HPV infection, clinical trials prove protection for at least 4 years [11]. Further study is underway to determine if a booster shot is needed after this time.
The vaccine has not been studied in women over 26 years old and thus its effectiveness is uncertain. Women over this age are more likely to have been exposed to the four types of HPV (6, 11, 16, and 18), and the vaccine does not protect against viral strains to which the patient has already been exposed.
The vaccine is given by injection and requires three doses; the first injection is followed by a second and third dose two and six months later.
It is not known if vaccination of men could help to reduce the incidence of cervical cancer in women. Studies are currently underway to address this question.
Sexual contact — Avoiding contact with infected individuals is one way to reduce the risk of becoming infected or transmitting HPV. However, from a practical standpoint this is difficult, as many people are infected and do not have any signs or symptoms of infection. Condoms do not provide complete protection; contact (hand to genitals or genitals to genitals) involving areas not covered by the condom can result in transmission of HPV.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
American Cancer Society
(www.cancer.org, search for HPV)
National HPV and Cervical Cancer Public Education Campaign
Telephone: 1-866-280-6605
(www.cervicalcancercampaign.org)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdhpv.htm)
Center for Disease Control and Prevention
(www.cdc.gov/std/HPV/STDFact-HPV.htm)
American Social Health Association
(www.ashastd.org/hpv/hpv_learn.cfm)
[1-16]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Stone, KM, Becker, TM, Hadgu, A, Kraus, SJ. Treatment of external genital warts: a randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation. Genitourin Med 1990; 66:16.
2. Greenberg, MD, Rutledge, LH, Reid, R, et al. A double-blind, randomized trial of 0.5% podofilox and placebo for the treatment of genital warts in women. Obstet Gynecol 1991; 77:735.
3. Abdullah, AN, Walzman, M, Wade, A. Treatment of external genital warts comparing cryotherapy (liquid nitrogen) and trichloroacetic acid. Sex Transm Dis 1993; 20:344.
4. Beutner, KR, Spruance, SL, Hougham, AJ, et al. Treatment of genital warts with an immune-response modifier (imiquimod). J Am Acad Dermatol 1998; 38:230.
5. Eron, LJ, Judson, F, Tucker, S, et al. Interferon therapy for condylomata acuminata. NEJM 1059; 315:1059.
6. Recurrent condylomata acuminata treated with recombinant interferon alpha-2a. A multicenter double-blind placebo-controlled clinical trial. Condylomata International Collaborative Study Group. Acta Derm Venereol 1993; 73:223.
7. Jensen, SL. Comparison of podophyllin application with simple surgical excision in clearance and recurrence of perianal condylomata acuminata. Lancet 1985; 2:1146.
8. Rader, JS, Leake, JF, Dillon, MB, Rosenshein, NB. Ultrasonic surgical aspiration in the treatment of vulvar disease. Obstet Gynecol 1991; 77:573.
9. Koutsky, LA, Ault, KA, Wheeler, CM, et al. A controlled trial of a human papillomavirus type 16 vaccine. N Engl J Med 2002; 347:1645.
10. Harper, DM, Franco, EL, Wheeler, C, et al. Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet 2004; 364:1757.
11. Harper, DM, Franco, EL, Wheeler, CM, et al. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomised control trial. Lancet 2006; 367:1247.
12. Bosch, FX, Manos, MM, Munoz, N, et al. Prevalence of human papillomavirus in cervical cancer: A worldwide perspective. International biological study on cervical cancer (IBSCC) Study group. J Natl Cancer Inst 1995; 87:796.
13. Schiffman, MH, Bauer, HM, Hoover, RN, et al Epidemiologic evidence showing that human papillomavirus infection causes most cervical intraepithelial neoplasia. J Natl Cancer Inst 1993; 85:958.
14. Mitchell, MF, Tortolero-Luna, G, Wright, T, Sarkar, A. Cervical human papillomavirus infection and intraepithelial neoplasia: a review. J Natl Cancer Inst Monogr 1996; :17.
15. Kaufman, RH, Adam, E, Icenogle, J, Reeves, WC. Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: sensitivity, specificity, and cost-effectiveness. Am J Obstet Gynecol 1997; 177:930.
16. Manos, MM. HPV testing for clarifying borderline cervical smear results. BMJ 2001; 322:878.
CAUSES — Condyloma are caused by the human papillomavirus (HPV), which infects the epithelial layer (the outer layer) of the skin and mucous membranes. Over 70 different types of HPV have been identified, each of which infects a specific area of the body. Researchers have labeled the HPV types as being at high or low risk for causing cervical cancer. The HPV viruses that cause most genital warts are low-risk types. HPV types 6 and 11 are a major cause of warts, and types 16 and 18 are major causes of cervical cancer. (See "Patient information: Screening for cervical cancer").
HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). It is not possible to become infected with HPV by touching a toilet seat.
SYMPTOMS — Rarely, women with genital warts have itching, burning, or tenderness in the genital area, depending upon the number of warts and their location. However, most women with warts do not have any symptoms at all.
Warts appear skin-colored or pink, and may be smooth and flat or raised with a rough texture. They are usually located on the labia or at the opening of the vagina, but can also be around or inside the anus (show picture 1).
Warts may appear weeks to a year or more after HPV exposure; it is not usually possible to know when, how, or from whom the infection was transmitted.
DIAGNOSIS — Most women with genital warts can be diagnosed based upon a healthcare provider's visual examination. In some women, further examination with colposcopy (examination of the vulva, vagina, and cervix) or anoscopy (examination of the anus and rectum) is recommended. For these tests, the healthcare provider uses a magnifying device to closely inspect the skin or tissue for evidence of HPV infection. A weak acid solution (called acetic acid) is applied to the skin or tissue, which can further aid in the diagnosis; this does not cause pain.
A biopsy (removal of a small piece of tissue) is recommended if the provider is uncertain whether the area in question is a genital wart, if the wart does not respond to treatment, if the lesion is very large, if the patient has a weakened immune system due to HIV or medications, or if the lesion has an unusual appearance. Most women with genital warts will not need a biopsy.
TREATMENT — Treatment of warts usually involves a topical medication that is applied by the patient or healthcare provider. Other treatments, such as oral medications and surgery, are generally reserved for patients with very large areas of warts or warts that do not improve with topical treatments. A summary of these treatments is provided here (show table 1).
To eliminate the wart(s); a course of treatment over several weeks is generally required. Even with treatment, it may not be possible to eradicate the HPV virus from the genital area; therefore, it is possible that the warts will recur. There is currently no treatment that will eradicate the HPV virus itself.
Treatment is not necessary if the warts are not bothersome. Furthermore, 10 to 30 percent of genital warts will resolve on their own without treatment
Medical treatments — Medical treatments include medications that are applied directly to the wart. There are two broad categories of medical therapy: those that directly destroy the wart tissue (cytodestructive therapies) and those that work through the patient's immune system to clear the wart (immune-mediated therapies). Some treatments must be applied in the healthcare provider's office while others can be applied by the patient at home.
Podophyllin — Podophyllin is a plant-based resin that destroys the wart tissue. It is only used for vulvar lesions; using it on the cervix or vaginal tissues can cause chemical burns. The healthcare provider applies the solution directly to the warts with a cotton swab, and the patient should wash the area one to four hours later to avoid excessive skin irritation. The treatment is repeated weekly for four to six weeks, or until the lesions have cleared.
Studies have reported 40 to 75 percent of patients are cleared of warts after using podophyllin, but 25 to 100 percent have a recurrence over time [1]. Adverse effects range from mild skin irritation to ulceration and pain.
Podophyllotoxin — Podophyllotoxin (Condylox®) contains the biologically active compound from podophyllin, but it can be self-administered. Using a cotton swab, the patient applies a 0.5 percent gel or liquid solution to the warts twice daily for three consecutive days. No more than 0.5 ml of medication should be used per treatment session, and no more than a 3 cm by 3 cm area should be treated. No treatment is used for the following four days; the treatment cycle can be repeated up to four times until the warts have resolved.
Clinical studies have described wart clearance rates of 29 to 90 percent [2]. Podophyllotoxin may be recommended as a first-line treatment if the patient is willing and able to apply it. Podophyllotoxin may be more effective than podophyllin.
Bichloroacetic acid and trichloroacetic acid — Both bichloroacetic acid (BCA) and trichloroacetic acid (TCA) are acids that destroy the wart tissue. TCA is used most commonly, and must be applied by a health care provider. An 80 to 90 percent TCA solution is applied sparingly to the wart tissue, which will turn white as the solution dries. Petroleum jelly may be applied to the normal tissue surrounding the wart to prevent the acid from reaching these areas. Once weekly application is required for four to six weeks, or until the lesions have cleared. Side effects of TCA may include pain and burning.
One trial that evaluated TCA in women showed a 70 percent clearance rate [3]. In contrast to podophyllin, TCA can be used on the cervix and vagina, and is safe for use during pregnancy.
Imiquimod — Imiquimod (Aldara®) is a cream that causes an immune response; this causes the body to eliminate the wart. The patient applies the cream directly to the wart tissue (generally at bedtime), and then washes the area with water six to 10 hours later. The drug is applied every other day for a total of three days per week, for up to 16 weeks. Side effects may include mild irritation and redness. Imiquimod should not be used internally on vaginal warts, and it is not recommended for use during pregnancy.
Randomized trials show a 50 percent clearance rate with 10 to 20 percent recurrence rates [4].
Interferon — Interferon is a medication that causes an immune response. It is available in several treatment forms (intramuscular injection, topical gel, subcutaneous injection), but studies have determined that it most effective when given as a subcutaneous (under the skin) injection at the base of the wart two to three times per week for up to nine weeks. Several clinical trials have shown clearance rates of about 20 to 60 percent [5], although other trials have failed to show any benefit [6], perhaps due to too brief a period of follow-up.
Side effects of interferon include flu-like symptoms, fatigue, lack of appetite, and local pain. Given these side effects, the variable rates of effectiveness, and the need for multiple treatments per week, interferon is not generally recommended as a first-line treatment. It may be used in combination with surgical and/or other medical treatments, especially in patients with warts that do not improve with other treatments.
Interferon is not safe for use during pregnancy.
Surgical treatment — Surgery is generally reserved for patients with: Lesions that do not respond to medical therapy Extensive or bulky disease, where medical therapy alone is often inadequate Lesions involving the vagina, urethra, or anus Areas that have associated pre-cancerous changes
Surgical management options include excisional (removal) and ablative (destructive) procedures. These treatments are often used in a combined fashion.
Cryotherapy — Cryotherapy uses a chemical (either nitrous oxide or liquid nitrogen) to freeze the wart tissue. The treatment can be done in a healthcare provider's office, and does not usually require any anesthesia. Studies have reported 50 to 80 percent clearance of warts after cryotherapy. Cryotherapy can be used during pregnancy.
Cryotherapy often causes pain during the procedure; other side effects can include skin irritation, swelling, blistering, and ulceration. For these reasons, medical therapies, such as podophyllin, podophyllotoxin, and trichloroacetic acid may be recommended before trying cryotherapy.
Electrocautery — Electrocautery uses electrical energy to burn away wart tissues. Patients are treated in an operating room after receiving local anesthesia to prevent pain. It can be used for vaginal lesions.
Excision — Excision involves the removal of an area of warts by surgically cutting it out. Most patients are treated in an operating room after receiving anesthesia to prevent pain. Rarely, excision causes pain, scar formation, and infection.
Excisional therapy is effective. Most studies show success rates of 36 to 100 percent and recurrence rates of 8 to 65 percent within one year [7].
Laser — Lasers produce light energy, which is absorbed by water within wart tissues, leading to its destruction. Physicians who perform laser treatment require specific training and specialized equipment. Patients are treated in an operating room after receiving local anesthesia to prevent pain.
Laser therapy is preferred when multiple warts are spread over a large area. Laser is also useful for treating cervical and vaginal warts, when surgical excision is not possible or would be difficult. Risks of laser surgery include scarring, pain, and changes in the skin's appearance (usually lightened color). Rarely, patients may develop chronic pain in the area of treatment.
Laser therapy clears lesions in 40 to 100 percent of warts, and long-term recurrences occur in 4 to 77 percent of patients.
Ultrasonic aspiration — The CUSA technique (Cavitron ultrasonic aspirator-CUSA) uses ultrasound (sound waves) to break up and remove warts. With this technique, removal of the outer layer of skin occurs without damage to underlying tissue. Patients are treated in an operating room after receiving general anesthesia to induce sleep and prevent pain. One study showed this technique to be effective in the treatment of warts [8]. CUSA requires that a healthcare provider undergo specialized training and purchase specialized equipment, so it is not widely available.
FOLLOW UP — Following successful treatment of warts, some patients will be instructed to examine themselves periodically to monitor for new warts; other patients will be asked to return to their healthcare provider at regular intervals for examination. Most patients who develop recurrent or persistent warts do so within three to six months of treatment. Recurrence is more common in persons with a weakened immune system (due to HIV or certain medications); more frequent follow-up or self-monitoring of these patients is reasonable so that treatment may begin promptly.
It is important to understand that complete elimination of visible warts does not necessarily mean that HPV has been eradicated. Therefore, warts may recur even after successful initial treatment. In this situation, the same treatment may be used again and is likely to be successful.
PREVENTION
HPV vaccine — A vaccine (Gardasil®) is now available to help prevent infection with some types of HPV (types 6, 11, 16, and 18), which in turn can prevent most cases of cervical cancer and genital warts. The vaccine was proven to be safe and effective in several large clinical trials [9,10].
The vaccine is currently recommended for all girls and women between ages 9 and 26 years. Decisions about the age at which to start HPV immunization have been guided by data regarding the ages of peak HPV infection and the estimated duration of vaccine protection. While it is not known exactly how long the vaccine protects against HPV infection, clinical trials prove protection for at least 4 years [11]. Further study is underway to determine if a booster shot is needed after this time.
The vaccine has not been studied in women over 26 years old and thus its effectiveness is uncertain. Women over this age are more likely to have been exposed to the four types of HPV (6, 11, 16, and 18), and the vaccine does not protect against viral strains to which the patient has already been exposed.
The vaccine is given by injection and requires three doses; the first injection is followed by a second and third dose two and six months later.
It is not known if vaccination of men could help to reduce the incidence of cervical cancer in women. Studies are currently underway to address this question.
Sexual contact — Avoiding contact with infected individuals is one way to reduce the risk of becoming infected or transmitting HPV. However, from a practical standpoint this is difficult, as many people are infected and do not have any signs or symptoms of infection. Condoms do not provide complete protection; contact (hand to genitals or genitals to genitals) involving areas not covered by the condom can result in transmission of HPV.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
American Cancer Society
(www.cancer.org, search for HPV)
National HPV and Cervical Cancer Public Education Campaign
Telephone: 1-866-280-6605
(www.cervicalcancercampaign.org)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdhpv.htm)
Center for Disease Control and Prevention
(www.cdc.gov/std/HPV/STDFact-HPV.htm)
American Social Health Association
(www.ashastd.org/hpv/hpv_learn.cfm)
[1-16]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Stone, KM, Becker, TM, Hadgu, A, Kraus, SJ. Treatment of external genital warts: a randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation. Genitourin Med 1990; 66:16.
2. Greenberg, MD, Rutledge, LH, Reid, R, et al. A double-blind, randomized trial of 0.5% podofilox and placebo for the treatment of genital warts in women. Obstet Gynecol 1991; 77:735.
3. Abdullah, AN, Walzman, M, Wade, A. Treatment of external genital warts comparing cryotherapy (liquid nitrogen) and trichloroacetic acid. Sex Transm Dis 1993; 20:344.
4. Beutner, KR, Spruance, SL, Hougham, AJ, et al. Treatment of genital warts with an immune-response modifier (imiquimod). J Am Acad Dermatol 1998; 38:230.
5. Eron, LJ, Judson, F, Tucker, S, et al. Interferon therapy for condylomata acuminata. NEJM 1059; 315:1059.
6. Recurrent condylomata acuminata treated with recombinant interferon alpha-2a. A multicenter double-blind placebo-controlled clinical trial. Condylomata International Collaborative Study Group. Acta Derm Venereol 1993; 73:223.
7. Jensen, SL. Comparison of podophyllin application with simple surgical excision in clearance and recurrence of perianal condylomata acuminata. Lancet 1985; 2:1146.
8. Rader, JS, Leake, JF, Dillon, MB, Rosenshein, NB. Ultrasonic surgical aspiration in the treatment of vulvar disease. Obstet Gynecol 1991; 77:573.
9. Koutsky, LA, Ault, KA, Wheeler, CM, et al. A controlled trial of a human papillomavirus type 16 vaccine. N Engl J Med 2002; 347:1645.
10. Harper, DM, Franco, EL, Wheeler, C, et al. Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet 2004; 364:1757.
11. Harper, DM, Franco, EL, Wheeler, CM, et al. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomised control trial. Lancet 2006; 367:1247.
12. Bosch, FX, Manos, MM, Munoz, N, et al. Prevalence of human papillomavirus in cervical cancer: A worldwide perspective. International biological study on cervical cancer (IBSCC) Study group. J Natl Cancer Inst 1995; 87:796.
13. Schiffman, MH, Bauer, HM, Hoover, RN, et al Epidemiologic evidence showing that human papillomavirus infection causes most cervical intraepithelial neoplasia. J Natl Cancer Inst 1993; 85:958.
14. Mitchell, MF, Tortolero-Luna, G, Wright, T, Sarkar, A. Cervical human papillomavirus infection and intraepithelial neoplasia: a review. J Natl Cancer Inst Monogr 1996; :17.
15. Kaufman, RH, Adam, E, Icenogle, J, Reeves, WC. Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: sensitivity, specificity, and cost-effectiveness. Am J Obstet Gynecol 1997; 177:930.
16. Manos, MM. HPV testing for clarifying borderline cervical smear results. BMJ 2001; 322:878.
Condyloma (genital warts) in women
INTRODUCTION — Condyloma acuminata (genital warts) are the most common sexually transmitted condition in the United States. Although warts affect both genders, one study showed that women accounted for 67 percent of patients.
CAUSES — Condyloma are caused by the human papillomavirus (HPV), which infects the epithelial layer (the outer layer) of the skin and mucous membranes. Over 70 different types of HPV have been identified, each of which infects a specific area of the body. Researchers have labeled the HPV types as being at high or low risk for causing cervical cancer. The HPV viruses that cause most genital warts are low-risk types. HPV types 6 and 11 are a major cause of warts, and types 16 and 18 are major causes of cervical cancer. (See "Patient information: Screening for cervical cancer").
HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). It is not possible to become infected with HPV by touching a toilet seat.
SYMPTOMS — Rarely, women with genital warts have itching, burning, or tenderness in the genital area, depending upon the number of warts and their location. However, most women with warts do not have any symptoms at all.
Warts appear skin-colored or pink, and may be smooth and flat or raised with a rough texture. They are usually located on the labia or at the opening of the vagina, but can also be around or inside the anus (show picture 1).
Warts may appear weeks to a year or more after HPV exposure; it is not usually possible to know when, how, or from whom the infection was transmitted.
DIAGNOSIS — Most women with genital warts can be diagnosed based upon a healthcare provider's visual examination. In some women, further examination with colposcopy (examination of the vulva, vagina, and cervix) or anoscopy (examination of the anus and rectum) is recommended. For these tests, the healthcare provider uses a magnifying device to closely inspect the skin or tissue for evidence of HPV infection. A weak acid solution (called acetic acid) is applied to the skin or tissue, which can further aid in the diagnosis; this does not cause pain.
A biopsy (removal of a small piece of tissue) is recommended if the provider is uncertain whether the area in question is a genital wart, if the wart does not respond to treatment, if the lesion is very large, if the patient has a weakened immune system due to HIV or medications, or if the lesion has an unusual appearance. Most women with genital warts will not need a biopsy.
TREATMENT — Treatment of warts usually involves a topical medication that is applied by the patient or healthcare provider. Other treatments, such as oral medications and surgery, are generally reserved for patients with very large areas of warts or warts that do not improve with topical treatments. A summary of these treatments is provided here (show table 1).
To eliminate the wart(s); a course of treatment over several weeks is generally required. Even with treatment, it may not be possible to eradicate the HPV virus from the genital area; therefore, it is possible that the warts will recur. There is currently no treatment that will eradicate the HPV virus itself.
Treatment is not necessary if the warts are not bothersome. Furthermore, 10 to 30 percent of genital warts will resolve on their own without treatment
Medical treatments — Medical treatments include medications that are applied directly to the wart. There are two broad categories of medical therapy: those that directly destroy the wart tissue (cytodestructive therapies) and those that work through the patient's immune system to clear the wart (immune-mediated therapies). Some treatments must be applied in the healthcare provider's office while others can be applied by the patient at home.
Podophyllin — Podophyllin is a plant-based resin that destroys the wart tissue. It is only used for vulvar lesions; using it on the cervix or vaginal tissues can cause chemical burns. The healthcare provider applies the solution directly to the warts with a cotton swab, and the patient should wash the area one to four hours later to avoid excessive skin irritation. The treatment is repeated weekly for four to six weeks, or until the lesions have cleared.
Studies have reported 40 to 75 percent of patients are cleared of warts after using podophyllin, but 25 to 100 percent have a recurrence over time [1]. Adverse effects range from mild skin irritation to ulceration and pain.
Podophyllotoxin — Podophyllotoxin (Condylox®) contains the biologically active compound from podophyllin, but it can be self-administered. Using a cotton swab, the patient applies a 0.5 percent gel or liquid solution to the warts twice daily for three consecutive days. No more than 0.5 ml of medication should be used per treatment session, and no more than a 3 cm by 3 cm area should be treated. No treatment is used for the following four days; the treatment cycle can be repeated up to four times until the warts have resolved.
Clinical studies have described wart clearance rates of 29 to 90 percent [2]. Podophyllotoxin may be recommended as a first-line treatment if the patient is willing and able to apply it. Podophyllotoxin may be more effective than podophyllin.
Bichloroacetic acid and trichloroacetic acid — Both bichloroacetic acid (BCA) and trichloroacetic acid (TCA) are acids that destroy the wart tissue. TCA is used most commonly, and must be applied by a health care provider. An 80 to 90 percent TCA solution is applied sparingly to the wart tissue, which will turn white as the solution dries. Petroleum jelly may be applied to the normal tissue surrounding the wart to prevent the acid from reaching these areas. Once weekly application is required for four to six weeks, or until the lesions have cleared. Side effects of TCA may include pain and burning.
One trial that evaluated TCA in women showed a 70 percent clearance rate [3]. In contrast to podophyllin, TCA can be used on the cervix and vagina, and is safe for use during pregnancy.
Imiquimod — Imiquimod (Aldara®) is a cream that causes an immune response; this causes the body to eliminate the wart. The patient applies the cream directly to the wart tissue (generally at bedtime), and then washes the area with water six to 10 hours later. The drug is applied every other day for a total of three days per week, for up to 16 weeks. Side effects may include mild irritation and redness. Imiquimod should not be used internally on vaginal warts, and it is not recommended for use during pregnancy.
Randomized trials show a 50 percent clearance rate with 10 to 20 percent recurrence rates [4].
Interferon — Interferon is a medication that causes an immune response. It is available in several treatment forms (intramuscular injection, topical gel, subcutaneous injection), but studies have determined that it most effective when given as a subcutaneous (under the skin) injection at the base of the wart two to three times per week for up to nine weeks. Several clinical trials have shown clearance rates of about 20 to 60 percent [5], although other trials have failed to show any benefit [6], perhaps due to too brief a period of follow-up.
Side effects of interferon include flu-like symptoms, fatigue, lack of appetite, and local pain. Given these side effects, the variable rates of effectiveness, and the need for multiple treatments per week, interferon is not generally recommended as a first-line treatment. It may be used in combination with surgical and/or other medical treatments, especially in patients with warts that do not improve with other treatments.
Interferon is not safe for use during pregnancy.
Surgical treatment — Surgery is generally reserved for patients with: Lesions that do not respond to medical therapy Extensive or bulky disease, where medical therapy alone is often inadequate Lesions involving the vagina, urethra, or anus Areas that have associated pre-cancerous changes
Surgical management options include excisional (removal) and ablative (destructive) procedures. These treatments are often used in a combined fashion.
Cryotherapy — Cryotherapy uses a chemical (either nitrous oxide or liquid nitrogen) to freeze the wart tissue. The treatment can be done in a healthcare provider's office, and does not usually require any anesthesia. Studies have reported 50 to 80 percent clearance of warts after cryotherapy. Cryotherapy can be used during pregnancy.
Cryotherapy often causes pain during the procedure; other side effects can include skin irritation, swelling, blistering, and ulceration. For these reasons, medical therapies, such as podophyllin, podophyllotoxin, and trichloroacetic acid may be recommended before trying cryotherapy.
Electrocautery — Electrocautery uses electrical energy to burn away wart tissues. Patients are treated in an operating room after receiving local anesthesia to prevent pain. It can be used for vaginal lesions.
Excision — Excision involves the removal of an area of warts by surgically cutting it out. Most patients are treated in an operating room after receiving anesthesia to prevent pain. Rarely, excision causes pain, scar formation, and infection.
Excisional therapy is effective. Most studies show success rates of 36 to 100 percent and recurrence rates of 8 to 65 percent within one year [7].
Laser — Lasers produce light energy, which is absorbed by water within wart tissues, leading to its destruction. Physicians who perform laser treatment require specific training and specialized equipment. Patients are treated in an operating room after receiving local anesthesia to prevent pain.
Laser therapy is preferred when multiple warts are spread over a large area. Laser is also useful for treating cervical and vaginal warts, when surgical excision is not possible or would be difficult. Risks of laser surgery include scarring, pain, and changes in the skin's appearance (usually lightened color). Rarely, patients may develop chronic pain in the area of treatment.
Laser therapy clears lesions in 40 to 100 percent of warts, and long-term recurrences occur in 4 to 77 percent of patients.
Ultrasonic aspiration — The CUSA technique (Cavitron ultrasonic aspirator-CUSA) uses ultrasound (sound waves) to break up and remove warts. With this technique, removal of the outer layer of skin occurs without damage to underlying tissue. Patients are treated in an operating room after receiving general anesthesia to induce sleep and prevent pain. One study showed this technique to be effective in the treatment of warts [8]. CUSA requires that a healthcare provider undergo specialized training and purchase specialized equipment, so it is not widely available.
FOLLOW UP — Following successful treatment of warts, some patients will be instructed to examine themselves periodically to monitor for new warts; other patients will be asked to return to their healthcare provider at regular intervals for examination. Most patients who develop recurrent or persistent warts do so within three to six months of treatment. Recurrence is more common in persons with a weakened immune system (due to HIV or certain medications); more frequent follow-up or self-monitoring of these patients is reasonable so that treatment may begin promptly.
It is important to understand that complete elimination of visible warts does not necessarily mean that HPV has been eradicated. Therefore, warts may recur even after successful initial treatment. In this situation, the same treatment may be used again and is likely to be successful.
PREVENTION
HPV vaccine — A vaccine (Gardasil®) is now available to help prevent infection with some types of HPV (types 6, 11, 16, and 18), which in turn can prevent most cases of cervical cancer and genital warts. The vaccine was proven to be safe and effective in several large clinical trials [9,10].
The vaccine is currently recommended for all girls and women between ages 9 and 26 years. Decisions about the age at which to start HPV immunization have been guided by data regarding the ages of peak HPV infection and the estimated duration of vaccine protection. While it is not known exactly how long the vaccine protects against HPV infection, clinical trials prove protection for at least 4 years [11]. Further study is underway to determine if a booster shot is needed after this time.
The vaccine has not been studied in women over 26 years old and thus its effectiveness is uncertain. Women over this age are more likely to have been exposed to the four types of HPV (6, 11, 16, and 18), and the vaccine does not protect against viral strains to which the patient has already been exposed.
The vaccine is given by injection and requires three doses; the first injection is followed by a second and third dose two and six months later.
It is not known if vaccination of men could help to reduce the incidence of cervical cancer in women. Studies are currently underway to address this question.
Sexual contact — Avoiding contact with infected individuals is one way to reduce the risk of becoming infected or transmitting HPV. However, from a practical standpoint this is difficult, as many people are infected and do not have any signs or symptoms of infection. Condoms do not provide complete protection; contact (hand to genitals or genitals to genitals) involving areas not covered by the condom can result in transmission of HPV.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
American Cancer Society
(www.cancer.org, search for HPV)
National HPV and Cervical Cancer Public Education Campaign
Telephone: 1-866-280-6605
(www.cervicalcancercampaign.org)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdhpv.htm)
Center for Disease Control and Prevention
(www.cdc.gov/std/HPV/STDFact-HPV.htm)
American Social Health Association
(www.ashastd.org/hpv/hpv_learn.cfm)
[1-16]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Stone, KM, Becker, TM, Hadgu, A, Kraus, SJ. Treatment of external genital warts: a randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation. Genitourin Med 1990; 66:16.
2. Greenberg, MD, Rutledge, LH, Reid, R, et al. A double-blind, randomized trial of 0.5% podofilox and placebo for the treatment of genital warts in women. Obstet Gynecol 1991; 77:735.
3. Abdullah, AN, Walzman, M, Wade, A. Treatment of external genital warts comparing cryotherapy (liquid nitrogen) and trichloroacetic acid. Sex Transm Dis 1993; 20:344.
4. Beutner, KR, Spruance, SL, Hougham, AJ, et al. Treatment of genital warts with an immune-response modifier (imiquimod). J Am Acad Dermatol 1998; 38:230.
5. Eron, LJ, Judson, F, Tucker, S, et al. Interferon therapy for condylomata acuminata. NEJM 1059; 315:1059.
6. Recurrent condylomata acuminata treated with recombinant interferon alpha-2a. A multicenter double-blind placebo-controlled clinical trial. Condylomata International Collaborative Study Group. Acta Derm Venereol 1993; 73:223.
7. Jensen, SL. Comparison of podophyllin application with simple surgical excision in clearance and recurrence of perianal condylomata acuminata. Lancet 1985; 2:1146.
8. Rader, JS, Leake, JF, Dillon, MB, Rosenshein, NB. Ultrasonic surgical aspiration in the treatment of vulvar disease. Obstet Gynecol 1991; 77:573.
9. Koutsky, LA, Ault, KA, Wheeler, CM, et al. A controlled trial of a human papillomavirus type 16 vaccine. N Engl J Med 2002; 347:1645.
10. Harper, DM, Franco, EL, Wheeler, C, et al. Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet 2004; 364:1757.
11. Harper, DM, Franco, EL, Wheeler, CM, et al. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomised control trial. Lancet 2006; 367:1247.
12. Bosch, FX, Manos, MM, Munoz, N, et al. Prevalence of human papillomavirus in cervical cancer: A worldwide perspective. International biological study on cervical cancer (IBSCC) Study group. J Natl Cancer Inst 1995; 87:796.
13. Schiffman, MH, Bauer, HM, Hoover, RN, et al Epidemiologic evidence showing that human papillomavirus infection causes most cervical intraepithelial neoplasia. J Natl Cancer Inst 1993; 85:958.
14. Mitchell, MF, Tortolero-Luna, G, Wright, T, Sarkar, A. Cervical human papillomavirus infection and intraepithelial neoplasia: a review. J Natl Cancer Inst Monogr 1996; :17.
15. Kaufman, RH, Adam, E, Icenogle, J, Reeves, WC. Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: sensitivity, specificity, and cost-effectiveness. Am J Obstet Gynecol 1997; 177:930.
16. Manos, MM. HPV testing for clarifying borderline cervical smear results. BMJ 2001; 322:878.
CAUSES — Condyloma are caused by the human papillomavirus (HPV), which infects the epithelial layer (the outer layer) of the skin and mucous membranes. Over 70 different types of HPV have been identified, each of which infects a specific area of the body. Researchers have labeled the HPV types as being at high or low risk for causing cervical cancer. The HPV viruses that cause most genital warts are low-risk types. HPV types 6 and 11 are a major cause of warts, and types 16 and 18 are major causes of cervical cancer. (See "Patient information: Screening for cervical cancer").
HPV is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). It is not possible to become infected with HPV by touching a toilet seat.
SYMPTOMS — Rarely, women with genital warts have itching, burning, or tenderness in the genital area, depending upon the number of warts and their location. However, most women with warts do not have any symptoms at all.
Warts appear skin-colored or pink, and may be smooth and flat or raised with a rough texture. They are usually located on the labia or at the opening of the vagina, but can also be around or inside the anus (show picture 1).
Warts may appear weeks to a year or more after HPV exposure; it is not usually possible to know when, how, or from whom the infection was transmitted.
DIAGNOSIS — Most women with genital warts can be diagnosed based upon a healthcare provider's visual examination. In some women, further examination with colposcopy (examination of the vulva, vagina, and cervix) or anoscopy (examination of the anus and rectum) is recommended. For these tests, the healthcare provider uses a magnifying device to closely inspect the skin or tissue for evidence of HPV infection. A weak acid solution (called acetic acid) is applied to the skin or tissue, which can further aid in the diagnosis; this does not cause pain.
A biopsy (removal of a small piece of tissue) is recommended if the provider is uncertain whether the area in question is a genital wart, if the wart does not respond to treatment, if the lesion is very large, if the patient has a weakened immune system due to HIV or medications, or if the lesion has an unusual appearance. Most women with genital warts will not need a biopsy.
TREATMENT — Treatment of warts usually involves a topical medication that is applied by the patient or healthcare provider. Other treatments, such as oral medications and surgery, are generally reserved for patients with very large areas of warts or warts that do not improve with topical treatments. A summary of these treatments is provided here (show table 1).
To eliminate the wart(s); a course of treatment over several weeks is generally required. Even with treatment, it may not be possible to eradicate the HPV virus from the genital area; therefore, it is possible that the warts will recur. There is currently no treatment that will eradicate the HPV virus itself.
Treatment is not necessary if the warts are not bothersome. Furthermore, 10 to 30 percent of genital warts will resolve on their own without treatment
Medical treatments — Medical treatments include medications that are applied directly to the wart. There are two broad categories of medical therapy: those that directly destroy the wart tissue (cytodestructive therapies) and those that work through the patient's immune system to clear the wart (immune-mediated therapies). Some treatments must be applied in the healthcare provider's office while others can be applied by the patient at home.
Podophyllin — Podophyllin is a plant-based resin that destroys the wart tissue. It is only used for vulvar lesions; using it on the cervix or vaginal tissues can cause chemical burns. The healthcare provider applies the solution directly to the warts with a cotton swab, and the patient should wash the area one to four hours later to avoid excessive skin irritation. The treatment is repeated weekly for four to six weeks, or until the lesions have cleared.
Studies have reported 40 to 75 percent of patients are cleared of warts after using podophyllin, but 25 to 100 percent have a recurrence over time [1]. Adverse effects range from mild skin irritation to ulceration and pain.
Podophyllotoxin — Podophyllotoxin (Condylox®) contains the biologically active compound from podophyllin, but it can be self-administered. Using a cotton swab, the patient applies a 0.5 percent gel or liquid solution to the warts twice daily for three consecutive days. No more than 0.5 ml of medication should be used per treatment session, and no more than a 3 cm by 3 cm area should be treated. No treatment is used for the following four days; the treatment cycle can be repeated up to four times until the warts have resolved.
Clinical studies have described wart clearance rates of 29 to 90 percent [2]. Podophyllotoxin may be recommended as a first-line treatment if the patient is willing and able to apply it. Podophyllotoxin may be more effective than podophyllin.
Bichloroacetic acid and trichloroacetic acid — Both bichloroacetic acid (BCA) and trichloroacetic acid (TCA) are acids that destroy the wart tissue. TCA is used most commonly, and must be applied by a health care provider. An 80 to 90 percent TCA solution is applied sparingly to the wart tissue, which will turn white as the solution dries. Petroleum jelly may be applied to the normal tissue surrounding the wart to prevent the acid from reaching these areas. Once weekly application is required for four to six weeks, or until the lesions have cleared. Side effects of TCA may include pain and burning.
One trial that evaluated TCA in women showed a 70 percent clearance rate [3]. In contrast to podophyllin, TCA can be used on the cervix and vagina, and is safe for use during pregnancy.
Imiquimod — Imiquimod (Aldara®) is a cream that causes an immune response; this causes the body to eliminate the wart. The patient applies the cream directly to the wart tissue (generally at bedtime), and then washes the area with water six to 10 hours later. The drug is applied every other day for a total of three days per week, for up to 16 weeks. Side effects may include mild irritation and redness. Imiquimod should not be used internally on vaginal warts, and it is not recommended for use during pregnancy.
Randomized trials show a 50 percent clearance rate with 10 to 20 percent recurrence rates [4].
Interferon — Interferon is a medication that causes an immune response. It is available in several treatment forms (intramuscular injection, topical gel, subcutaneous injection), but studies have determined that it most effective when given as a subcutaneous (under the skin) injection at the base of the wart two to three times per week for up to nine weeks. Several clinical trials have shown clearance rates of about 20 to 60 percent [5], although other trials have failed to show any benefit [6], perhaps due to too brief a period of follow-up.
Side effects of interferon include flu-like symptoms, fatigue, lack of appetite, and local pain. Given these side effects, the variable rates of effectiveness, and the need for multiple treatments per week, interferon is not generally recommended as a first-line treatment. It may be used in combination with surgical and/or other medical treatments, especially in patients with warts that do not improve with other treatments.
Interferon is not safe for use during pregnancy.
Surgical treatment — Surgery is generally reserved for patients with: Lesions that do not respond to medical therapy Extensive or bulky disease, where medical therapy alone is often inadequate Lesions involving the vagina, urethra, or anus Areas that have associated pre-cancerous changes
Surgical management options include excisional (removal) and ablative (destructive) procedures. These treatments are often used in a combined fashion.
Cryotherapy — Cryotherapy uses a chemical (either nitrous oxide or liquid nitrogen) to freeze the wart tissue. The treatment can be done in a healthcare provider's office, and does not usually require any anesthesia. Studies have reported 50 to 80 percent clearance of warts after cryotherapy. Cryotherapy can be used during pregnancy.
Cryotherapy often causes pain during the procedure; other side effects can include skin irritation, swelling, blistering, and ulceration. For these reasons, medical therapies, such as podophyllin, podophyllotoxin, and trichloroacetic acid may be recommended before trying cryotherapy.
Electrocautery — Electrocautery uses electrical energy to burn away wart tissues. Patients are treated in an operating room after receiving local anesthesia to prevent pain. It can be used for vaginal lesions.
Excision — Excision involves the removal of an area of warts by surgically cutting it out. Most patients are treated in an operating room after receiving anesthesia to prevent pain. Rarely, excision causes pain, scar formation, and infection.
Excisional therapy is effective. Most studies show success rates of 36 to 100 percent and recurrence rates of 8 to 65 percent within one year [7].
Laser — Lasers produce light energy, which is absorbed by water within wart tissues, leading to its destruction. Physicians who perform laser treatment require specific training and specialized equipment. Patients are treated in an operating room after receiving local anesthesia to prevent pain.
Laser therapy is preferred when multiple warts are spread over a large area. Laser is also useful for treating cervical and vaginal warts, when surgical excision is not possible or would be difficult. Risks of laser surgery include scarring, pain, and changes in the skin's appearance (usually lightened color). Rarely, patients may develop chronic pain in the area of treatment.
Laser therapy clears lesions in 40 to 100 percent of warts, and long-term recurrences occur in 4 to 77 percent of patients.
Ultrasonic aspiration — The CUSA technique (Cavitron ultrasonic aspirator-CUSA) uses ultrasound (sound waves) to break up and remove warts. With this technique, removal of the outer layer of skin occurs without damage to underlying tissue. Patients are treated in an operating room after receiving general anesthesia to induce sleep and prevent pain. One study showed this technique to be effective in the treatment of warts [8]. CUSA requires that a healthcare provider undergo specialized training and purchase specialized equipment, so it is not widely available.
FOLLOW UP — Following successful treatment of warts, some patients will be instructed to examine themselves periodically to monitor for new warts; other patients will be asked to return to their healthcare provider at regular intervals for examination. Most patients who develop recurrent or persistent warts do so within three to six months of treatment. Recurrence is more common in persons with a weakened immune system (due to HIV or certain medications); more frequent follow-up or self-monitoring of these patients is reasonable so that treatment may begin promptly.
It is important to understand that complete elimination of visible warts does not necessarily mean that HPV has been eradicated. Therefore, warts may recur even after successful initial treatment. In this situation, the same treatment may be used again and is likely to be successful.
PREVENTION
HPV vaccine — A vaccine (Gardasil®) is now available to help prevent infection with some types of HPV (types 6, 11, 16, and 18), which in turn can prevent most cases of cervical cancer and genital warts. The vaccine was proven to be safe and effective in several large clinical trials [9,10].
The vaccine is currently recommended for all girls and women between ages 9 and 26 years. Decisions about the age at which to start HPV immunization have been guided by data regarding the ages of peak HPV infection and the estimated duration of vaccine protection. While it is not known exactly how long the vaccine protects against HPV infection, clinical trials prove protection for at least 4 years [11]. Further study is underway to determine if a booster shot is needed after this time.
The vaccine has not been studied in women over 26 years old and thus its effectiveness is uncertain. Women over this age are more likely to have been exposed to the four types of HPV (6, 11, 16, and 18), and the vaccine does not protect against viral strains to which the patient has already been exposed.
The vaccine is given by injection and requires three doses; the first injection is followed by a second and third dose two and six months later.
It is not known if vaccination of men could help to reduce the incidence of cervical cancer in women. Studies are currently underway to address this question.
Sexual contact — Avoiding contact with infected individuals is one way to reduce the risk of becoming infected or transmitting HPV. However, from a practical standpoint this is difficult, as many people are infected and do not have any signs or symptoms of infection. Condoms do not provide complete protection; contact (hand to genitals or genitals to genitals) involving areas not covered by the condom can result in transmission of HPV.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
American Cancer Society
(www.cancer.org, search for HPV)
National HPV and Cervical Cancer Public Education Campaign
Telephone: 1-866-280-6605
(www.cervicalcancercampaign.org)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdhpv.htm)
Center for Disease Control and Prevention
(www.cdc.gov/std/HPV/STDFact-HPV.htm)
American Social Health Association
(www.ashastd.org/hpv/hpv_learn.cfm)
[1-16]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Stone, KM, Becker, TM, Hadgu, A, Kraus, SJ. Treatment of external genital warts: a randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation. Genitourin Med 1990; 66:16.
2. Greenberg, MD, Rutledge, LH, Reid, R, et al. A double-blind, randomized trial of 0.5% podofilox and placebo for the treatment of genital warts in women. Obstet Gynecol 1991; 77:735.
3. Abdullah, AN, Walzman, M, Wade, A. Treatment of external genital warts comparing cryotherapy (liquid nitrogen) and trichloroacetic acid. Sex Transm Dis 1993; 20:344.
4. Beutner, KR, Spruance, SL, Hougham, AJ, et al. Treatment of genital warts with an immune-response modifier (imiquimod). J Am Acad Dermatol 1998; 38:230.
5. Eron, LJ, Judson, F, Tucker, S, et al. Interferon therapy for condylomata acuminata. NEJM 1059; 315:1059.
6. Recurrent condylomata acuminata treated with recombinant interferon alpha-2a. A multicenter double-blind placebo-controlled clinical trial. Condylomata International Collaborative Study Group. Acta Derm Venereol 1993; 73:223.
7. Jensen, SL. Comparison of podophyllin application with simple surgical excision in clearance and recurrence of perianal condylomata acuminata. Lancet 1985; 2:1146.
8. Rader, JS, Leake, JF, Dillon, MB, Rosenshein, NB. Ultrasonic surgical aspiration in the treatment of vulvar disease. Obstet Gynecol 1991; 77:573.
9. Koutsky, LA, Ault, KA, Wheeler, CM, et al. A controlled trial of a human papillomavirus type 16 vaccine. N Engl J Med 2002; 347:1645.
10. Harper, DM, Franco, EL, Wheeler, C, et al. Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet 2004; 364:1757.
11. Harper, DM, Franco, EL, Wheeler, CM, et al. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomised control trial. Lancet 2006; 367:1247.
12. Bosch, FX, Manos, MM, Munoz, N, et al. Prevalence of human papillomavirus in cervical cancer: A worldwide perspective. International biological study on cervical cancer (IBSCC) Study group. J Natl Cancer Inst 1995; 87:796.
13. Schiffman, MH, Bauer, HM, Hoover, RN, et al Epidemiologic evidence showing that human papillomavirus infection causes most cervical intraepithelial neoplasia. J Natl Cancer Inst 1993; 85:958.
14. Mitchell, MF, Tortolero-Luna, G, Wright, T, Sarkar, A. Cervical human papillomavirus infection and intraepithelial neoplasia: a review. J Natl Cancer Inst Monogr 1996; :17.
15. Kaufman, RH, Adam, E, Icenogle, J, Reeves, WC. Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: sensitivity, specificity, and cost-effectiveness. Am J Obstet Gynecol 1997; 177:930.
16. Manos, MM. HPV testing for clarifying borderline cervical smear results. BMJ 2001; 322:878.
Chlamydia
INTRODUCTION — Chlamydia is the most common sexually transmitted infection in the United States [1]. Approximately four million cases of Chlamydia are estimated to occur annually in the United States, although only about one quarter of those people are tested and receive treatment. Chlamydia and gonorrhea (another sexually transmitted infection) cause similar signs and symptoms. However, chlamydia tends to have fewer symptoms and causes more significant long-term complications than gonorrhea. Infection rates are highest in adolescent women. (See "Patient information: Gonorrhea").
CAUSES — Chlamydia infections are caused by a bacterium known as Chlamydia trachomatis, a one-celled microorganism that is too tiny to be seen with the naked eye. This bacterium is usually transmitted during sexual intercourse. It is not possible to become infected by touching an object (eg, toilet seat).
A person can become infected when the bacterium invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), or vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include multiple sexual partners, a recent new sex partner, or a history of a previous STD.
SYMPTOMS — Infection with Chlamydia can cause mild to severe symptoms. However, some infected individuals have no symptoms at all, which allows the disease to be spread from person to person before it is detected.
Women — The most common site of infection in women is the cervix (show figure 1). Only about 50 percent of women with cervical Chlamydia or cervicitis, experience symptoms, usually vaginal discharge, abnormal vaginal bleeding, or abdominal pain. Another common symptom is pain during sexual intercourse. Lower abdominal pain can be a symptom of early pelvic inflammatory disease (see below).
Cervicitis is often accompanied by infection of the female urethra, or urethritis. Urethritis can cause symptoms similar to a urinary tract infection (UTI), including a frequent urge to urinate, burning during urination, and low abdominal pain.
Men — Men with Chlamydia typically develop urethritis, which can cause pain during urination and discharge from the penis. However, up to 30 percent of men with chlamydial urethritis experience no symptoms. In a small number of cases, chlamydia can also cause infection of the epididymis, known as epididymitis, which can cause testicular pain and tenderness, swelling in the scrotum, and swelling of the epididymis itself (show figure 2). Chlamydia can also cause infection of the male prostate gland, or prostatitis.
Proctitis is an infection of the anus and/or rectum. Chlamydial proctitis occurs mainly in men who have sex with men (MSM). Symptoms are rare, but may include anal or rectal pain, discharge, a persistent desire to move the bowels, and constipation.
Related disorders — Lymphogranuloma venereum (LGV) is a chlamydial infection that affects the lymph glands. It is rare in developed countries such as the United States. It is more common in men who have sex with men.
Uncommonly, people with chlamydial urethritis develop a form of arthritis, known as reactive arthritis. This is usually associated with a rash, typically develops within one month of infection, and can cause symptoms for several months. It can cause a cluster of seemingly unrelated features, including arthritis, uveitis (an inflammation of the eye), and urethritis. (See "Patient information: Reactive arthritis (formerly Reiter syndrome)").
DIAGNOSIS — Chlamydia can be easily identified with testing. Testing may be done because infection is suspected or as a routine screening procedure. These tests are highly sensitive and can be used on direct swabs of the cervix or urethra, or urine samples. These tests may also be used on vaginal samples, which can be collected by the patient herself (self-administered vaginal swabs). However, testing has to be done in the laboratory, and results typically take about 24 to 48 hours to be processed.
Annual testing is recommended for all sexually active women younger than 25 years old.
Other sexually transmitted infections — A person who is found to have a sexually transmitted infection (STI) or has a partner with an STI should consider testing for other infections, including HIV, gonorrhea, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect abnormal cervical changes associated with the human papillomavirus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors. (See "Patient information: Genital herpes").
COMPLICATIONS — Chlamydia in women can lead to a serious infection known as pelvic inflammatory disease (PID). Approximately 30 percent of women with chlamydia infection will develop PID if untreated. PID can cause scarring of the fallopian tubes, which can lead to infertility and an increased risk of ectopic pregnancy (a pregnancy that develops in the fallopian tube rather than the uterus). (See "Patient information: Ectopic (tubal) pregnancy").
Infants infected during birth can develop an eye infection, which can potentially cause blindness or a lung infection. As a result, pregnant women are routinely tested for Chlamydia during pregnancy, and infants are routinely given a one-time eye treatment with an antibiotic ointment immediately after birth. This infection has nearly been eliminated as a result of testing and treatment during pregnancy.
TREATMENT — Treatment of Chlamydia is the same for women and men. For the treatment of uncomplicated cervical, urethral, or anorectal infection, most experts favor the use of a one-time antibiotic by mouth, azithromycin (show table 1). This helps to ensure that the treatment is completed and decreases the risk of treatment failure. Azithromycin is safe to take during pregnancy.
An alternate regimen is doxycycline 100 mg twice daily for 10 days. Doxycycline is not used in pregnant women because of the risk of harm to developing teeth and bones in the fetus.
Patients infected with Chlamydia are sometimes also infected with gonorrhea. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Gonorrhea").
Sexual partner treatment — Current or recent sexual partners of a person diagnosed with Chlamydia should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary to test for and treat sexually transmitted infections. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
Sexual contact should be avoided for one week after both partners have been treated and all symptoms have resolved. It is possible to become infected with Chlamydia more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated.
PREVENTION — The most effective way to prevent Chlamydia is to avoid sexual intercouse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine screening for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of STIs than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if you have signs or symptoms of Chlamydia. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Chlamydia is a sexually transmitted infection that can be transmitted during sex. Men do not have to ejaculate to spread the infection. It is not possible to become infected by touching an object (eg, toilet seat) (see "Causes" above). Some people with chlamydia have no symptoms. Some women have pain in the pelvis or abnormal vaginal bleeding (see "Symptoms" above). Men with Chlamydia can have pain during urination or discharge from the penis. Some men have no symptoms (see "Men" above). Chlamydia can be easily identified with testing. (see "Diagnosis" above). Untreated Chlamydia can lead to a serious complication in women, called pelvic inflammatory disease (PID). PID can lead to infertility (trouble becoming pregnant) and other serious health problems (see "Complications" above). A medication is needed to cure the infection. Anyone who is infected or who has had sex with someone who is infected should be treated. The person should not have sex until one week after treatment. (see "Treatment" above). A latex condom can reduce the risk of Chlamydia. Testing for infections like Chlamydia is recommended before having sex with a new partner. Do not have sex if either person has discharge from the penis or vagina, pain with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdclam.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/chlamydia.html)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
2. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
3. Golden, MR, Whittington, WL, Handsfield, HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676.
4. Miller, WC. Screening for chlamydial infection: are we doing enough?. Lancet 2005; 365:456.
CAUSES — Chlamydia infections are caused by a bacterium known as Chlamydia trachomatis, a one-celled microorganism that is too tiny to be seen with the naked eye. This bacterium is usually transmitted during sexual intercourse. It is not possible to become infected by touching an object (eg, toilet seat).
A person can become infected when the bacterium invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), or vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include multiple sexual partners, a recent new sex partner, or a history of a previous STD.
SYMPTOMS — Infection with Chlamydia can cause mild to severe symptoms. However, some infected individuals have no symptoms at all, which allows the disease to be spread from person to person before it is detected.
Women — The most common site of infection in women is the cervix (show figure 1). Only about 50 percent of women with cervical Chlamydia or cervicitis, experience symptoms, usually vaginal discharge, abnormal vaginal bleeding, or abdominal pain. Another common symptom is pain during sexual intercourse. Lower abdominal pain can be a symptom of early pelvic inflammatory disease (see below).
Cervicitis is often accompanied by infection of the female urethra, or urethritis. Urethritis can cause symptoms similar to a urinary tract infection (UTI), including a frequent urge to urinate, burning during urination, and low abdominal pain.
Men — Men with Chlamydia typically develop urethritis, which can cause pain during urination and discharge from the penis. However, up to 30 percent of men with chlamydial urethritis experience no symptoms. In a small number of cases, chlamydia can also cause infection of the epididymis, known as epididymitis, which can cause testicular pain and tenderness, swelling in the scrotum, and swelling of the epididymis itself (show figure 2). Chlamydia can also cause infection of the male prostate gland, or prostatitis.
Proctitis is an infection of the anus and/or rectum. Chlamydial proctitis occurs mainly in men who have sex with men (MSM). Symptoms are rare, but may include anal or rectal pain, discharge, a persistent desire to move the bowels, and constipation.
Related disorders — Lymphogranuloma venereum (LGV) is a chlamydial infection that affects the lymph glands. It is rare in developed countries such as the United States. It is more common in men who have sex with men.
Uncommonly, people with chlamydial urethritis develop a form of arthritis, known as reactive arthritis. This is usually associated with a rash, typically develops within one month of infection, and can cause symptoms for several months. It can cause a cluster of seemingly unrelated features, including arthritis, uveitis (an inflammation of the eye), and urethritis. (See "Patient information: Reactive arthritis (formerly Reiter syndrome)").
DIAGNOSIS — Chlamydia can be easily identified with testing. Testing may be done because infection is suspected or as a routine screening procedure. These tests are highly sensitive and can be used on direct swabs of the cervix or urethra, or urine samples. These tests may also be used on vaginal samples, which can be collected by the patient herself (self-administered vaginal swabs). However, testing has to be done in the laboratory, and results typically take about 24 to 48 hours to be processed.
Annual testing is recommended for all sexually active women younger than 25 years old.
Other sexually transmitted infections — A person who is found to have a sexually transmitted infection (STI) or has a partner with an STI should consider testing for other infections, including HIV, gonorrhea, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect abnormal cervical changes associated with the human papillomavirus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors. (See "Patient information: Genital herpes").
COMPLICATIONS — Chlamydia in women can lead to a serious infection known as pelvic inflammatory disease (PID). Approximately 30 percent of women with chlamydia infection will develop PID if untreated. PID can cause scarring of the fallopian tubes, which can lead to infertility and an increased risk of ectopic pregnancy (a pregnancy that develops in the fallopian tube rather than the uterus). (See "Patient information: Ectopic (tubal) pregnancy").
Infants infected during birth can develop an eye infection, which can potentially cause blindness or a lung infection. As a result, pregnant women are routinely tested for Chlamydia during pregnancy, and infants are routinely given a one-time eye treatment with an antibiotic ointment immediately after birth. This infection has nearly been eliminated as a result of testing and treatment during pregnancy.
TREATMENT — Treatment of Chlamydia is the same for women and men. For the treatment of uncomplicated cervical, urethral, or anorectal infection, most experts favor the use of a one-time antibiotic by mouth, azithromycin (show table 1). This helps to ensure that the treatment is completed and decreases the risk of treatment failure. Azithromycin is safe to take during pregnancy.
An alternate regimen is doxycycline 100 mg twice daily for 10 days. Doxycycline is not used in pregnant women because of the risk of harm to developing teeth and bones in the fetus.
Patients infected with Chlamydia are sometimes also infected with gonorrhea. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Gonorrhea").
Sexual partner treatment — Current or recent sexual partners of a person diagnosed with Chlamydia should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary to test for and treat sexually transmitted infections. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
Sexual contact should be avoided for one week after both partners have been treated and all symptoms have resolved. It is possible to become infected with Chlamydia more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated.
PREVENTION — The most effective way to prevent Chlamydia is to avoid sexual intercouse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine screening for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of STIs than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if you have signs or symptoms of Chlamydia. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Chlamydia is a sexually transmitted infection that can be transmitted during sex. Men do not have to ejaculate to spread the infection. It is not possible to become infected by touching an object (eg, toilet seat) (see "Causes" above). Some people with chlamydia have no symptoms. Some women have pain in the pelvis or abnormal vaginal bleeding (see "Symptoms" above). Men with Chlamydia can have pain during urination or discharge from the penis. Some men have no symptoms (see "Men" above). Chlamydia can be easily identified with testing. (see "Diagnosis" above). Untreated Chlamydia can lead to a serious complication in women, called pelvic inflammatory disease (PID). PID can lead to infertility (trouble becoming pregnant) and other serious health problems (see "Complications" above). A medication is needed to cure the infection. Anyone who is infected or who has had sex with someone who is infected should be treated. The person should not have sex until one week after treatment. (see "Treatment" above). A latex condom can reduce the risk of Chlamydia. Testing for infections like Chlamydia is recommended before having sex with a new partner. Do not have sex if either person has discharge from the penis or vagina, pain with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdclam.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/chlamydia.html)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
2. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
3. Golden, MR, Whittington, WL, Handsfield, HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676.
4. Miller, WC. Screening for chlamydial infection: are we doing enough?. Lancet 2005; 365:456.
Blood and body fluid exposure
INTRODUCTION — Exposure to blood or other bodily fluids can cause many serious infections, including the human immunodeficiency virus (HIV, the virus that causes AIDS). While most people are not exposed to these fluids, a number of situations can arise where exposures may occur, such as finding a syringe with needle, helping an injured person, or being the victim of an assault or rape.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Chlamydia
INTRODUCTION — Chlamydia is the most common sexually transmitted infection in the United States [1]. Approximately four million cases of Chlamydia are estimated to occur annually in the United States, although only about one quarter of those people are tested and receive treatment. Chlamydia and gonorrhea (another sexually transmitted infection) cause similar signs and symptoms. However, chlamydia tends to have fewer symptoms and causes more significant long-term complications than gonorrhea. Infection rates are highest in adolescent women. (See "Patient information: Gonorrhea").
CAUSES — Chlamydia infections are caused by a bacterium known as Chlamydia trachomatis, a one-celled microorganism that is too tiny to be seen with the naked eye. This bacterium is usually transmitted during sexual intercourse. It is not possible to become infected by touching an object (eg, toilet seat).
A person can become infected when the bacterium invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), or vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include multiple sexual partners, a recent new sex partner, or a history of a previous STD.
SYMPTOMS — Infection with Chlamydia can cause mild to severe symptoms. However, some infected individuals have no symptoms at all, which allows the disease to be spread from person to person before it is detected.
Women — The most common site of infection in women is the cervix (show figure 1). Only about 50 percent of women with cervical Chlamydia or cervicitis, experience symptoms, usually vaginal discharge, abnormal vaginal bleeding, or abdominal pain. Another common symptom is pain during sexual intercourse. Lower abdominal pain can be a symptom of early pelvic inflammatory disease (see below).
Cervicitis is often accompanied by infection of the female urethra, or urethritis. Urethritis can cause symptoms similar to a urinary tract infection (UTI), including a frequent urge to urinate, burning during urination, and low abdominal pain.
Men — Men with Chlamydia typically develop urethritis, which can cause pain during urination and discharge from the penis. However, up to 30 percent of men with chlamydial urethritis experience no symptoms. In a small number of cases, chlamydia can also cause infection of the epididymis, known as epididymitis, which can cause testicular pain and tenderness, swelling in the scrotum, and swelling of the epididymis itself (show figure 2). Chlamydia can also cause infection of the male prostate gland, or prostatitis.
Proctitis is an infection of the anus and/or rectum. Chlamydial proctitis occurs mainly in men who have sex with men (MSM). Symptoms are rare, but may include anal or rectal pain, discharge, a persistent desire to move the bowels, and constipation.
Related disorders — Lymphogranuloma venereum (LGV) is a chlamydial infection that affects the lymph glands. It is rare in developed countries such as the United States. It is more common in men who have sex with men.
Uncommonly, people with chlamydial urethritis develop a form of arthritis, known as reactive arthritis. This is usually associated with a rash, typically develops within one month of infection, and can cause symptoms for several months. It can cause a cluster of seemingly unrelated features, including arthritis, uveitis (an inflammation of the eye), and urethritis. (See "Patient information: Reactive arthritis (formerly Reiter syndrome)").
DIAGNOSIS — Chlamydia can be easily identified with testing. Testing may be done because infection is suspected or as a routine screening procedure. These tests are highly sensitive and can be used on direct swabs of the cervix or urethra, or urine samples. These tests may also be used on vaginal samples, which can be collected by the patient herself (self-administered vaginal swabs). However, testing has to be done in the laboratory, and results typically take about 24 to 48 hours to be processed.
Annual testing is recommended for all sexually active women younger than 25 years old.
Other sexually transmitted infections — A person who is found to have a sexually transmitted infection (STI) or has a partner with an STI should consider testing for other infections, including HIV, gonorrhea, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect abnormal cervical changes associated with the human papillomavirus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors. (See "Patient information: Genital herpes").
COMPLICATIONS — Chlamydia in women can lead to a serious infection known as pelvic inflammatory disease (PID). Approximately 30 percent of women with chlamydia infection will develop PID if untreated. PID can cause scarring of the fallopian tubes, which can lead to infertility and an increased risk of ectopic pregnancy (a pregnancy that develops in the fallopian tube rather than the uterus). (See "Patient information: Ectopic (tubal) pregnancy").
Infants infected during birth can develop an eye infection, which can potentially cause blindness or a lung infection. As a result, pregnant women are routinely tested for Chlamydia during pregnancy, and infants are routinely given a one-time eye treatment with an antibiotic ointment immediately after birth. This infection has nearly been eliminated as a result of testing and treatment during pregnancy.
TREATMENT — Treatment of Chlamydia is the same for women and men. For the treatment of uncomplicated cervical, urethral, or anorectal infection, most experts favor the use of a one-time antibiotic by mouth, azithromycin (show table 1). This helps to ensure that the treatment is completed and decreases the risk of treatment failure. Azithromycin is safe to take during pregnancy.
An alternate regimen is doxycycline 100 mg twice daily for 10 days. Doxycycline is not used in pregnant women because of the risk of harm to developing teeth and bones in the fetus.
Patients infected with Chlamydia are sometimes also infected with gonorrhea. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Gonorrhea").
Sexual partner treatment — Current or recent sexual partners of a person diagnosed with Chlamydia should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary to test for and treat sexually transmitted infections. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
Sexual contact should be avoided for one week after both partners have been treated and all symptoms have resolved. It is possible to become infected with Chlamydia more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated.
PREVENTION — The most effective way to prevent Chlamydia is to avoid sexual intercouse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine screening for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of STIs than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if you have signs or symptoms of Chlamydia. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Chlamydia is a sexually transmitted infection that can be transmitted during sex. Men do not have to ejaculate to spread the infection. It is not possible to become infected by touching an object (eg, toilet seat) (see "Causes" above). Some people with chlamydia have no symptoms. Some women have pain in the pelvis or abnormal vaginal bleeding (see "Symptoms" above). Men with Chlamydia can have pain during urination or discharge from the penis. Some men have no symptoms (see "Men" above). Chlamydia can be easily identified with testing. (see "Diagnosis" above). Untreated Chlamydia can lead to a serious complication in women, called pelvic inflammatory disease (PID). PID can lead to infertility (trouble becoming pregnant) and other serious health problems (see "Complications" above). A medication is needed to cure the infection. Anyone who is infected or who has had sex with someone who is infected should be treated. The person should not have sex until one week after treatment. (see "Treatment" above). A latex condom can reduce the risk of Chlamydia. Testing for infections like Chlamydia is recommended before having sex with a new partner. Do not have sex if either person has discharge from the penis or vagina, pain with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdclam.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/chlamydia.html)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
2. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
3. Golden, MR, Whittington, WL, Handsfield, HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676.
4. Miller, WC. Screening for chlamydial infection: are we doing enough?. Lancet 2005; 365:456.
CAUSES — Chlamydia infections are caused by a bacterium known as Chlamydia trachomatis, a one-celled microorganism that is too tiny to be seen with the naked eye. This bacterium is usually transmitted during sexual intercourse. It is not possible to become infected by touching an object (eg, toilet seat).
A person can become infected when the bacterium invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), or vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include multiple sexual partners, a recent new sex partner, or a history of a previous STD.
SYMPTOMS — Infection with Chlamydia can cause mild to severe symptoms. However, some infected individuals have no symptoms at all, which allows the disease to be spread from person to person before it is detected.
Women — The most common site of infection in women is the cervix (show figure 1). Only about 50 percent of women with cervical Chlamydia or cervicitis, experience symptoms, usually vaginal discharge, abnormal vaginal bleeding, or abdominal pain. Another common symptom is pain during sexual intercourse. Lower abdominal pain can be a symptom of early pelvic inflammatory disease (see below).
Cervicitis is often accompanied by infection of the female urethra, or urethritis. Urethritis can cause symptoms similar to a urinary tract infection (UTI), including a frequent urge to urinate, burning during urination, and low abdominal pain.
Men — Men with Chlamydia typically develop urethritis, which can cause pain during urination and discharge from the penis. However, up to 30 percent of men with chlamydial urethritis experience no symptoms. In a small number of cases, chlamydia can also cause infection of the epididymis, known as epididymitis, which can cause testicular pain and tenderness, swelling in the scrotum, and swelling of the epididymis itself (show figure 2). Chlamydia can also cause infection of the male prostate gland, or prostatitis.
Proctitis is an infection of the anus and/or rectum. Chlamydial proctitis occurs mainly in men who have sex with men (MSM). Symptoms are rare, but may include anal or rectal pain, discharge, a persistent desire to move the bowels, and constipation.
Related disorders — Lymphogranuloma venereum (LGV) is a chlamydial infection that affects the lymph glands. It is rare in developed countries such as the United States. It is more common in men who have sex with men.
Uncommonly, people with chlamydial urethritis develop a form of arthritis, known as reactive arthritis. This is usually associated with a rash, typically develops within one month of infection, and can cause symptoms for several months. It can cause a cluster of seemingly unrelated features, including arthritis, uveitis (an inflammation of the eye), and urethritis. (See "Patient information: Reactive arthritis (formerly Reiter syndrome)").
DIAGNOSIS — Chlamydia can be easily identified with testing. Testing may be done because infection is suspected or as a routine screening procedure. These tests are highly sensitive and can be used on direct swabs of the cervix or urethra, or urine samples. These tests may also be used on vaginal samples, which can be collected by the patient herself (self-administered vaginal swabs). However, testing has to be done in the laboratory, and results typically take about 24 to 48 hours to be processed.
Annual testing is recommended for all sexually active women younger than 25 years old.
Other sexually transmitted infections — A person who is found to have a sexually transmitted infection (STI) or has a partner with an STI should consider testing for other infections, including HIV, gonorrhea, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV" and see "Patient information: Hepatitis B").
Women are advised to have an annual cervical cancer screening (Pap smear), which can detect abnormal cervical changes associated with the human papillomavirus. (See "Patient information: Screening for cervical cancer").
Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").
Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors. (See "Patient information: Genital herpes").
COMPLICATIONS — Chlamydia in women can lead to a serious infection known as pelvic inflammatory disease (PID). Approximately 30 percent of women with chlamydia infection will develop PID if untreated. PID can cause scarring of the fallopian tubes, which can lead to infertility and an increased risk of ectopic pregnancy (a pregnancy that develops in the fallopian tube rather than the uterus). (See "Patient information: Ectopic (tubal) pregnancy").
Infants infected during birth can develop an eye infection, which can potentially cause blindness or a lung infection. As a result, pregnant women are routinely tested for Chlamydia during pregnancy, and infants are routinely given a one-time eye treatment with an antibiotic ointment immediately after birth. This infection has nearly been eliminated as a result of testing and treatment during pregnancy.
TREATMENT — Treatment of Chlamydia is the same for women and men. For the treatment of uncomplicated cervical, urethral, or anorectal infection, most experts favor the use of a one-time antibiotic by mouth, azithromycin (show table 1). This helps to ensure that the treatment is completed and decreases the risk of treatment failure. Azithromycin is safe to take during pregnancy.
An alternate regimen is doxycycline 100 mg twice daily for 10 days. Doxycycline is not used in pregnant women because of the risk of harm to developing teeth and bones in the fetus.
Patients infected with Chlamydia are sometimes also infected with gonorrhea. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Gonorrhea").
Sexual partner treatment — Current or recent sexual partners of a person diagnosed with Chlamydia should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary to test for and treat sexually transmitted infections. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.
Sexual contact should be avoided for one week after both partners have been treated and all symptoms have resolved. It is possible to become infected with Chlamydia more than once.
Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated.
PREVENTION — The most effective way to prevent Chlamydia is to avoid sexual intercouse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine screening for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of STIs than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if you have signs or symptoms of Chlamydia. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.
SUMMARY Chlamydia is a sexually transmitted infection that can be transmitted during sex. Men do not have to ejaculate to spread the infection. It is not possible to become infected by touching an object (eg, toilet seat) (see "Causes" above). Some people with chlamydia have no symptoms. Some women have pain in the pelvis or abnormal vaginal bleeding (see "Symptoms" above). Men with Chlamydia can have pain during urination or discharge from the penis. Some men have no symptoms (see "Men" above). Chlamydia can be easily identified with testing. (see "Diagnosis" above). Untreated Chlamydia can lead to a serious complication in women, called pelvic inflammatory disease (PID). PID can lead to infertility (trouble becoming pregnant) and other serious health problems (see "Complications" above). A medication is needed to cure the infection. Anyone who is infected or who has had sex with someone who is infected should be treated. The person should not have sex until one week after treatment. (see "Treatment" above). A latex condom can reduce the risk of Chlamydia. Testing for infections like Chlamydia is recommended before having sex with a new partner. Do not have sex if either person has discharge from the penis or vagina, pain with urination, or a genital rash or sore (see "Prevention" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/stdclam.htm)
American Social Health Association
(www.ashastd.org/stdfaqs/chlamydia.html)
Centers for Disease Control and Prevention
(www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm)
[1-4]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
2. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.
3. Golden, MR, Whittington, WL, Handsfield, HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676.
4. Miller, WC. Screening for chlamydial infection: are we doing enough?. Lancet 2005; 365:456.
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