Human Papilloma Virus -Genital Warts Genital Herpes

1. Yuzbasheva Nihal 221B
Genital Warts
Genital Herpes

2. Genital Warts
 Human papillomavirus (HPV) causes warts and anogenital malignancy
 HPV can reside in epithelial basal cells and lead to subclinical or latent
infection
 Numerous types of HPV viruses have been identified: low-, intermediat
e-, and high-risk groups

3. Genital Warts
 Detection of high-risk genotypes (n 5 13) from genital specimens is considered a major determ
inant associated with the development of cervical cancer
55%
20%
16%
9%
HPV 16
HPV 58, 52, 33, 45, 39, 35, 68
HPB 18
Other HPVs

4. Genital Warts
 Incidence

5. Genital Warts
 Regression and Persistence
Infection with HPV
Lesions (<10%)
(within 6-8 week)
Cervical Squamous
Intraepithelial Neoplasia
(within 2 years)
Squamous Cell
Carcinoma (SCC)
Asymptomatic
Infection (>90%)
Elimination or
Regression of Virus
Normal Cervix (effective
immune system)

6. Genital Warts
 Risk Factors

7. Genital Warts
Genital
Contact
• Sexual intercourse
Extragenital
• Undergarments
• Surgical Gloves
• Biopsy Forceps
Vertical
• Mother >
• Neonate (at birth) >
• Respiratory
papillomatosis

8. Genital Warts
Papules with projections of uniform size are a
common finding on the shaft of the penis.
Genital warts, anus. Projections are large and
numerous in warm moist areas.

9. Genital Warts
Warts may spread extensively in the warm moist creases of the groi
n. The surface projections are numerous on these very large warts
Broad-based wart on the shaft of a penis. There
are numerous projections on the surface

10. Genital Warts
Multiple small warts under the foreskin. Multiple in
oculations occur on a moist surface. Each wart cons
ists of many discrete, narrow projections
A huge flat wart extends over the shaft of the penis. The characteristic su
rface projections are absent.

11. Genital Warts
A wart with long surface projections extends fro
m the urethral meatus.
Warts spread extensively in the intertriginous are
as adjacent to the scrotum

12. Genital Warts
Warts have spread extensively over the moist intertriginous
services of the vulva
Numerous warts are present on the vulva and vaginal areas. Secondar
y syphilis may have similar presentation

13. Genital Warts
These flat plaques are missi
ng surface projections. A
biopsy was required to
establish the diagnosis
Mass of warts on apposing
surfaces of the anus

14. Genital Warts
A cluster of small warts with
prominent surface projecti-
ons are present in the anus
There are numerous brown
papules about the anus.
Magnification was required
to see the diagnostic
projections

15. Genital Warts
 Genital warts frequently recur after treatment
 There are two possible reasons:
Latent virus exists beyond
the treatment areas in
clinically normal skin
Warts that are flat and
inconspicuous, especially on
the penile shaft and urethral
meatus, escape treatment

16. Genital Warts
 Oral Condyloma in Patients with Genital Human Papillomavirus Infection
Oral condylomata that can be visualized without
magnification are surprisingly uncommon
This HIV patient had a cluster of warts at the periphery of the
hard palate. They regenerated from oral sexual contact.

17. Genital Warts
 Pearly Penile Papules
An anatomic variant of
normal papules most
commonly found on the
corona of the penis. They
are sometimes mistaken
for warts. No treatment is
required
A group of papules found
just proximal to the
corona of the penis is
sometimes mistaken for
warts.

18. Genital Warts
 Genital Warts in Children
Sexual Abuse (50% of cases)
“If child abuse is recognized or suspected, it has to be reported to the authorities.”
A child with warts on the hands
A mother with hand warts
Sexual play among children
“It is not known whether children can acquire condylomata acuminata from adults with
anogenital warts through modes of transmission other than skin-to-skin contact”

19. Genital Warts
 Diagnosis
 A clinical diagnosis can be made in most cases
 The differential diagnosis includes seborrheic keratoses, nevi, molluscum co
ntagiosum, and pearly penile papules:
- Condyloma Lata – tend to be smoother, moist, more rounded, and darkfield-
positive for Treponema pallidum
- Molluscum Contagiosum – papules with central dimple, caused by a pox
virus; rarely involves mucosal surfaces
 Biopsy suspicious lesions
 Viral Typing Using Standard Cervical Screening Specimens

20. Genital Warts
 Diagnosis
 Cytology (Pap smear test)
In the figure above, both are fro
m the CP Pap-smear that shows
characteristics of the infection d
ue to HPV. In diagram “a”, the c
ytoplasm has shown irregularity
of the outline. Besides, the het-
erogenousity of the nucleus is
seen in variety in shapes and
colours. Meanwhile in diagram
“b”, the hyperchromatic nucleus
is significantly clear with coarse
chromatin. There is also
binucleation occur one of the
infected cells marked with “#”

21. Genital Warts
 Vaccination
 Gardasil is a vaccine indicated to males and females (9 to 26 years):
- Cervical cancer, precancerous or dysplastic lesions, and genital warts caused by HPV t
ypes 6, 11, 16, and 18
 Gardasil 9
- against cancers caused by HPV types 16, 18, 31, 33, 45 and 58, and is used for preven
tion of genital warts caused by HPV types 6 and 11
 Cervarix
- against HPV types 16 and 18
 THESE ARENOT LIVE VACCINES

22. Genital Warts
 Treatment

23. Genital Warts
 Treatment

24. Genital Warts
 Other Treatment Methods
• 50% to 90% is effective and less destructive
• Most effective on small, moist warts
• Excessive application causes scars
Trichloroacetic Acid.
•Plant compound that causes cells to arrest in mitosis
• Relatively ineffective in dry areas, such as the scrotum, penile
shaft, and labia majora
Podophyllum Resin
•In cases of genital warts that are resistant to all other treatments
• Irritation makes it intolerable for some patients.
5-Fluorouracil Cream
•The CO2 laser is an ideal method for treating both primary and
recurrent condylomata acuminata in men and women because of
its precision and the wound’s rapid healing without scarring
Carbon Dioxide Laser

25. Genital Herpes Simplex
 Genital herpes simplex virus (HSV) infection is primarily a disease of
young adults
 It is a recurrent, lifelong infection
 There are two serotypes: HSV-1 and HSV-2
 Most genital cases are caused by HSV-2
 Most persons infected with HSV-2 have not been diagnosed.

26. Genital Herpes Simplex
 Prevelence
66%
26%
4%2%2%
Estimated Prevalence of STDs in the U.S.
Genital Herpes Human Papillomavirus Chlamydia Hepatitis B HIV/AIDS

27. Genital Herpes Simplex
 Risk Factors

28. Genital Herpes Simplex
 Previous infection with HSV-1:
- reduces the rate of acquisition of genital HSV-2 infection
- reduces the severity of initial HSV-2 infection
- may increase the proportion of persons acquiring HSV-2 asymptomatically
or subclinically
 The rates of HSV infection are increasing; the highest prevalence is in
patients with the human immunodeficiency virus (HIV).
 The treatment of genital herpes decreases the rates of HIV infection

29. Genital Herpes Simplex
 First-Episode Infections
 First-episode infections include true primary infections and
nonprimary first-episode infections
 Patients with true primary infections have seronegative test
results and never been infected with any type of herpesvirus
 Patients with nonprimary first-episode infections have been
infected at another site with either type 1 or type 2 virus (e.g.
oral area) and have serum antibody and humoral immunity

30. Genital Herpes Simplex
 First Episode Infections
More extensive and more systemic symptoms
Longer viral shedding (15-16days)
Spreads easily over moist surfaces
Extensive genital disease or pharyngitis
Vesicles in 6 days after contact, in 2-3 days center depresses
Crusts form and the lesion heals in the next 1 or 2 weeks

31. Genital Herpes Simplex
Vesicles are discrete and can be confused
with warts and molluscum contagiosum. The
primary lesion is a vesicle that rapidly
becomes umbilicated.
A group of vesicles has ruptured, leaving an
erosion. Tense vesicles are at the periphery.

32. Genital Herpes Simplex
Scattered erosions
covered with exudate
Vesicles appeared 6 days
after contact with an
asymptomatic carrier

33. Genital Herpes Simplex
Scattered vesicles are macerated by
opposing surfaces to form erosions
Numerous erosions are present over the very
wide surface area of these large labia

34. Genital Herpes Simplex
Numerous erosions are present
on the labia and thighs and
ulcers present over the clitoris
Numerous umbilicated vesicles
have appeared over a wide
area. They retained their
structure because they were
not macerated by opposing
surfaces

35. Genital Herpes Simplex
Primary anal herpes. Lesions
become numerous in this
intertriginous area. Purulent
material becomes trapped
between apposing skin surfaces
Primary anal herpes. Numerous
erosions are present in this
intertriginous area. Crusts do not
form on apposing skin surfaces

36. Genital Herpes Simplex
Primary herpes simplex. The appearance of extensive
erosions appears 6 days after oral sexual contact
Recurrent herpes simplex. There is a periodic appearance of
erosions in the oral cavity

37. Genital Herpes Simplex
 Recurrent Infection
in females may be so minor or that it is unnoticed
Recurrences cannot be predicted, but often follow intercourse
Itching or pain may precede the recurrent lesion
A small group of vesicles appears
Umbilicates in 1 or 2 days then erodes and crusts
The lesion heals in 10 to 14 days
Vesicles are not seen under the foreskin or on the moist surfaces
Can be cultured for ap. 5 days from active genital lesions

38. Genital Herpes Simplex
A small group of vesicles
periodically recurs on the
same area on the shaft
of the penis
A small group of tiny
vesicles

39. Genital Herpes Simplex
A group of erosions A single large erosion

40. Genital Herpes Simplex
A group of tiny erosions and crusts A group of tiny crusts

41. Genital Herpes Simplex
 Frequency of Recurrence
 Approximately 80% to 90% of persons with symptomatic
first episodes of HSV-2 genital infection will have a recurrent
episode within the following year, compared with 50% to 60
% of patients with HSV-1 infection
 Reactivation decreases in frequency over time in patients.
Of patients with primary HSV-2, 95% have recurrences, with
a median time to the first recurrence of approximately 50
days
 Fifty percent of patients with primary HSV-1 have recurrent
outbreaks, and the median time to the first recurrence is 1
year

42. Genital Herpes Simplex
Anatomic Site
• The frequency of recurrences of
genital HSV-2 herpes is higher
than that of HSV-1 orolabial
infection
• HSV-2 genital infections occur
six times more frequently than
HSV-1 genital infections
Asymptomatic Transmission
• Asymptomatic viral shedding is
the primary mode of
herpesvirus transmission
• Acyclovir therapy substantially
decreases but does not totally
eliminate symptomatic or
asymptomatic viral shedding or
the potential for transmission
Asymptomatic Shedding
• Most persons who have
serologic evidence of infection
with HSV-2 are asymptomatic
• Asymptomatic shedding occurs
most commonly in the first year
after the primary episode
(particularly the first 3 months),
during the prodromal period, in
the week after a symptomatic
recurrence, and in HSV-2
infections versus HSV-1.

43. Genital Herpes Simplex
 Prevention
Avoiding sexual contact
Use of spermicidal foams and
condoms
Contact should be avoided
when active lesions are present

44. Genital Herpes Simplex
 Diagnosis
 Polymerase Chain Reaction
 Culture
 Histopathologic Studies
 Serology
 Indications:
- Pregnant Women
- Monogamous Couples
- Diagnosis of Recurrent Genital Eruptions
- Identifying Herpes Simplex Virus as a Risk Factor for Human Immunodeficiency
Virus Transmission

45. Genital Herpes Simplex
Counseling Patients with Genital Herpes
Explain the natural history of the disease, with emphasis on potential for recurrent episodes, asymptomatic viral
shedding, and sexual transmission
Abstain from sexual activity when lesions or prodromal symptoms are present and inform sexual partners that you
have been diagnosed with genital herpes. The use of condoms during all sexual exposures with new or uninfected sex
partners should be encouraged.
Sexual transmission of HSV can occur during asymptomatic periods. Asymptomatic viral shedding occurs more
frequently in patients who have genital HSV-2 infection than HSV-1 infection and in patients who have had genital
herpes for ,12 months.
Child-bearing–aged women who have genital herpes should inform health care providers caring for them during
pregnancy about the HSV infection
Episodic antiviral therapy during recurrent episodes might shorten the duration of lesions
Suppressive antiviral therapy can ameliorate or prevent recurrent outbreaks and prevent asymptomatic transmission

46. Genital Herpes Simplex
 Treatment

47. Genital Herpes Simplex
 Other Treatment Methods
•Treated with cool water, silver nitrate 0.5%, or Burow’s
compresses applied for 20 minutes several times daily
•Reduces edema and inflammation, macerates and
debrides crust and purulent material, and relieves pain
Cool Compresses
• Based on the frequency and severity of recurrences
•Continuous daily suppressive therapy significantly reduces, but does
not completely suppresses
• After 1 year suppressive therapy, discontinuation of therapy should
be discussed
Daily Suppressive
Therapy
•Occlusive ointments such as petroleum jelly should
not be applied to eroded lesions
•Light lubricating body lotions are soothing when
inflammation subsides and tissues become dry.
Lubrication

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