Genital warts

These are ordinary warts that have grown in the one place nobody wants to find them. They are caused by human papillomavirus, the same HPV that gets talked about in connection with cervical cancer, and that is where the biggest fear people bring to the consulting room comes from. Almost always the fear is misplaced: one set of virus types causes warts, an entirely different set causes cancer. It is worth taking calmly, because warts are nearly always a story about nuisance and patience rather than danger. That said, there are a handful of situations in which a harmless-looking lump needs a doctor without delay, and they are set out below.

What they look like and where they grow

A typical wart is a small soft growth, skin-coloured, pinkish or darker than the skin around it. The surface is rough, sometimes lobed; several warts side by side merge, and the cluster resembles a miniature cauliflower. There are also flat, barely visible ones that turn up by chance.

They grow on the genitals, in the groin, on the perineum, around and inside the anus, and in places nobody normally looks: inside the vagina, on the cervix, in the urethra. Warts around the anus do not imply anal sex — the virus travels easily across the skin on fingers or during ordinary washing.

Most of the time there is nothing to feel. Sometimes there is itching, mild burning, discomfort during sex and, if underwear or a razor catches a wart, bleeding. If a growth has settled inside the urethra, the urine stream changes: it sprays, veers sideways or stops and starts. Weeks or months pass between catching the virus and the first warts appearing, occasionally years, so working out from the dates who it came from achieves nothing and usually only damages a relationship.

What gets mistaken for them

More than half of these scares come to nothing, because what is taken for warts is normal anatomy. It helps to know the common look-alikes.

• A neat row of identical tiny bumps around the rim of the glans: these are pearly penile papules, a normal variant. They are not infectious, do not grow and need no treatment.
• Small pale dots on the skin of the scrotum, the penis or the inner surface of the labia minora: sebaceous glands, also normal.
• Fine, symmetrical graininess at the vaginal entrance: vestibular papillomatosis, a harmless finding that was mistakenly burnt off for decades.
• Firm shiny nodules with a dimple in the centre: molluscum contagiosum, a different viral infection with different treatment.
• Soft stalked tags in the groin creases: ordinary skin tags, unrelated to this group of HPV.
• Moist flat growths together with a rash on the body and general malaise: this can be syphilis, and there the timescale is not months.

This is why the diagnosis comes from a doctor's eyes rather than from an internet image search. An examination is usually enough; if needed, magnification is used, internal areas are checked, and a piece of tissue is taken for analysis when the appearance is unusual.

Where the virus comes from

HPV passes on through skin-to-skin and mucosa-to-mucosa contact: chiefly vaginal and anal sex, less often oral sex, and also shared sex toys and hands. A condom lowers the risk but does not remove it, because the virus lives on skin that a condom does not cover.

The scale is worth grasping: the great majority of people who have ever been sexually active carry this virus or have carried it. In most it shows no sign of itself and clears on its own within a year or so, because the immune system deals with it. Warts appear in a minority. Someone carrying the virus without warts passes it on just the same, and generally has no idea.

What does not happen: warts are not caught from towels, cutlery, toilet seats, swimming pools or kissing. What is easy, though, is moving them from one spot to another on your own body by scratching and touching.

The cancer question, answered properly

There are over two hundred types of HPV, and they play different roles. Warts are produced by the types called low-risk: they are good at making growths but do not cause cancer. Cervical cancer, along with cancers of the anus, throat, penis and vulva, is the work of other, high-risk types, and those do not produce warts. They grow silently, which is precisely what makes them dangerous.

Three conclusions follow. First: a wart does not turn into cancer, and removing it out of fear of cancer is pointless. Second: having warts does not guarantee that high-risk types are absent, because several can be acquired at once. Third, and most important: cervical screening is needed whether or not there are warts, and it follows the usual schedule of whichever country you live in. Warts are no reason either to bring it forward or to skip it.

How they are removed

Treatment is not compulsory. In roughly one person in three the warts disappear on their own within six months, and if there are only a few, causing no trouble and not growing, a doctor may suggest simply keeping an eye on them. They are removed when they bother you, enlarge, or get in the way in daily life or in sex.

The methods fall into two groups. The first is preparations applied to the wart: creams and solutions, some of which the patient uses at home in courses to a set pattern, others applied only by a clinician. They do not work instantly and they cause redness, soreness and small raw areas, which is an expected part of the process. The second group is physical removal in one or several sessions: freezing with liquid nitrogen, electrical cautery, laser, or cutting away under local anaesthetic. The choice depends on how many warts there are, where they sit and how they look; in awkward places such as the urethra or the rectum a specialist takes over.

The honest expectation: treatment removes the growths, not the virus. In about a third of people the warts come back over the following months, and that does not mean the treatment was poor or that anyone has reinfected you. Repeat courses are routine. Over time the immune system usually gains the upper hand and the recurrences stop.

What hinders treatment, and what not to do:

• do not buy the pharmacy preparations sold for warts on hands and feet — they are made for thick skin and leave burns on mucous membranes;
• do not cut, burn or tie off the growths yourself;
• do not spread the preparation onto healthy skin or into broken skin, and keep to the contact time given in the leaflet;
• bear in mind that some creams damage latex, so condoms and diaphragms may let you down during treatment days — check this with your doctor;
• stop smoking: in smokers, warts respond worse to every kind of treatment and return more often;
• avoid sex while a course is running, and use a condom afterwards.

When waiting is a mistake

Any new lump in this area is worth a consultation, if only to establish what it is. But some features mean the visit cannot be put off.

• The lesion bleeds for no clear reason, has ulcerated, has become hard, is fixed to the tissue underneath, or is unevenly coloured or dark.
• It is growing fast, particularly if it is a single lump rather than a scattering of small ones.
• It will not heal and does not respond to treatment that normally works.
• You cannot pass urine, the stream has changed abruptly, or there is blood in the urine.
• Pain, bleeding from the anus, or a sensation of something inside it.
• Warts multiplying rapidly in someone whose immunity is weakened: with HIV, after a transplant, or during immune-suppressing treatment.

There is one reason for pressing this point: very occasionally what looks like a stubborn wart is a pre-cancerous change or a tumour of the skin or mucous membrane. It is rare, but it is why an atypical lesion is sent for analysis rather than burnt off blind. It is also worth remembering that warts often keep company with other sexually transmitted infections, so a first visit is a sensible moment to be tested for those as well.

Pregnancy and birth

In pregnancy warts often become more active than usual: there are more of them, they enlarge, they are irritated more easily and they bleed. This reflects the shift in immunity and the richer blood supply, not any threat to the baby.

The risk to the child is very small. The virus is rarely passed on during birth, and in isolated cases it causes growths in the baby's airway, but this is exceptional and a caesarean does not prevent it. Warts on their own are therefore not a reason to operate: a caesarean is considered only if the growths are large enough to block the birth canal or to threaten heavy bleeding.

Treatment during pregnancy is possible but limited: some of the preparations applied to the skin are not for use in pregnancy, and the doctor chooses among the safe options. There is usually no hurry, because after delivery warts often shrink and clear on their own within a few weeks, so treatment is frequently deferred until then. The team looking after the pregnancy must be told about the warts.

The vaccine, and what to tell a partner

The HPV vaccine protects against both the wart-causing types and the main high-risk ones. It is given to adolescents of both sexes before they become sexually active, which is when it works best; the exact age and number of doses are set by each country's immunisation schedule and differ from one to another. Adults are offered it in certain situations too, and that is worth discussing. One thing it cannot do is cure warts that have already appeared. The vaccine is about the future, not about today's problem.

About partners. There is no need to ring round everyone from past years: because the interval before warts appear is long and unpredictable, it would achieve nothing. A current partner, though, does well to be checked, since they may have warts they know nothing about, especially internal ones. Two people cannot keep reinfecting each other with the same type of virus, so using condoms indefinitely within a couple for that reason alone makes little sense; it is a question to talk through with a doctor for your own circumstances.

Online consultation

A remote appointment is a good way to take the first step, the one many people put off for months. The doctor will consider what the thing you have found resembles, say whether a face-to-face examination is needed and how urgently, and explain which features mean tomorrow rather than next month. They will help you choose between watching and treating, and set out what to expect from each method and why a recurrence is not a failure. Pregnancy, the vaccine, the conversation with a partner and how warts relate to cervical screening can all be covered as well. The warning signs listed above are not assessed through a screen: those need examining.

This material is for information only and does not replace medical advice.