The human papillomavirus (HPV), transmitted by physical contact with an area containing a wart, is the cause of condylomata accuminata (genital warts). There are more than 70 different types of HPV. Several types are associated with genital warts. Endocervical warts, caused by certain types of HPV, may be the cause of cervical intraepithelial neoplasia and cervical cancer. Other types are associated with common or flat warts elsewhere on the skin. HPV has an incubation period of 1 to 6 months and grows well in the moist genital area.

Several factors may increase one's risk for getting genital warts and other complications of HPV. These may include

• having multiple sexual partners,

• having sex with someone with an unknown infection,

• becoming sexually active at an early age,

• having receptive anal intercourse,

• being immunocompromised,

• tobacco and alcohol use,

• stress, and

• other viral infections occurring simultaneously with HPV.

Physical examination reveals soft, moist flesh-colored to white, flat or raised, single or clustered polyp-like lesions anywhere on the genitalia that may become pedunculated. These lesions may grow at varying rates and be influenced by pregnancy, immunosuppression, or maceration of the skin. Left untreated, warts may rapidly enlarge, taking on a "cauliflower-like" appearance.

Warts on the outer genitals are easily recognized. In men, warts may be found on the penis, within the urethral meatus, and the perianal region and rectum. In women, the vulva, vagina wall, cervix, and perineum may be affected. A pelvic examination may reveal growths on the vaginal walls or the cervix. These warts are flat and not easily visible without special procedures. Although HPV infection around the genitals is common, most people have no symptoms. When symptoms occur, there may be itching, increased vaginal discharge, or abnormal vaginal bleeding following sexual intercourse. Genital warts may be more severe in immunosuppressed individuals.

Genital warts, though usually identified by appearance, must be differentiated from warts of secondary syphilis (condylomata lata). Persistent and atypical warts may require biopsy to rule out carcinoma. Regular pap smears are necessary to detect HPV or other dysplasia related to this virus. Colposcopy is performed to detect endocervical warts. The tissue of the vagina and cervix may require an application of acetic acid to visualize the warts during a colposcopy.

Outbreaks of condylomata accuminata (genital warts) may be controlled with proper treatment from a physician, as over the counter remedies do not treat warts resulting from HPV. Applications of topical medications and treatments for the skin lesions applied several times per week over the course of weeks to months may be prescribed for home use. Interferon given intralesionally or intramuscular may be effective with intractable skin and genital lesions, though its long-term effects are uncertain. Surgical treatments include cryosurgery, electrocauterization, laser therapy, or surgical excision. Circumcision may prevent recurrence. Treatment with a resectoscope for removal of urethral lesions in men may be most effective.

Treatment to avoid complications and prevent spreading the condition to others must be implemented even if the individual is asymptomatic. Partners sexually exposed to an infected individual may be screened for evidence of lesions and treated accordingly.

Women with external genital warts do not require more frequent screening for cervical cytologic abnormalities because the HPV types that most commonly cause genital warts (HPV types 6 and 11) are not usually associated with cancer. High risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68) are associated with cervical cancer. Therefore, those women with cervical warts may require pap smears every 6 months if HPV DNA testing is positive. Follow up examinations are necessary to check for recurrences.

Genital warts may be more difficult to treat in immunosuppressed individuals.

• HPV can lead to cancerous and precancerous changes in the cervix, vulva, and anus.

• HPV and herpes virus together increases the risk for cervical cancer.

• The warts may become numerous and quite large, requiring more extensive treatment and follow-up procedures.

• Relapse is frequent requiring repetitive treatment.

• HPV may still be transmitted to other individuals when there are no visible warts or other symptoms, or after treatment regimens.

• Genital warts may not appear for months after having sexual contact with an infected person.

• Treatment of urethral lesions in men may result in urethral obstruction.

• Certain types of HPV genital lesions successfully treated with Interferon may reappear as invasive cancers.

Special Considerations

• When 38 CFR 4.118 offers variable methods to evaluate a skin condition, assign a single evaluation using the criteria that results in the highest rating. 

• Consider this condition pursuant to 38 CFR 4.27 and 38 CFR 4.20, when applicable. Analogous ratings are utilized when a specific disability is not listed in 38 CFR Part 4. Certain hyphenated codes do not necessarily denote analogous ratings – a hyphenated DC may also be used to identify the proper evaluation of a disability or a residual from disease. Diagnostic Codes (DCs) must be carefully selected as a condition specifically listed in the rating schedule may not be rated by analogy, unless otherwise directed (e.g., amyotrophic lateral sclerosis, multiple sclerosis).  When multiple DCs apply to a given disability, consider whether separate evaluations are warranted, and/or which DC will result in the most advantageous outcome for the claimant.

• Do not routinely award service connection for HPV infection as a medical nexus is required to establish an association between genital warts and in-service HPV infection.

Notes

• For the purposes of this section, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin.  

• Two or more skin conditions may be combined in accordance with 38 CFR 4.25 only if separate areas of skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used.