Anal Warts (HPV)

What are Anal Warts (HPV)?

Warts are small lumps resembling lentils or cauliflower that appear in the genital and anal areas. They are caused by infection with the human papillomavirus (HPV).

HPV is a very common virus transmitted from person to person, usually through sexual contact or direct touch. 70% of women and 24% of straight men have the virus in the anal area. Among homosexual men, 60% are infected, and the percentage reaches 90% in HIV-positive homosexual men.

Anal Warts (HPV) – Causes & Risk Factors

Having multiple sexual partners, engaging in anal sex, not using condoms, sexual toys, douching, smoking, anal touching, the use of corticosteroid creams, and immunosuppression increase the likelihood of HPV infection in the anus.

Anal Warts (HPV) – Symptoms

Anal warts are often noticed by patients as small palpable lumps, or they may secrete fluids and cause itching. Warts can grow significantly and be felt as large irregular surfaces. Precancerous dysplasias, also caused by HPV, do not cause any symptoms and cannot be felt by hand as they are soft and flat.

Dysplasias are detected only with acetic acid application and high-resolution anoscopy. This examination should be performed in all high-risk groups. These include HIV-positive individuals, people on immunosuppressive therapy (e.g. for autoimmune diseases or transplants), women with dysplasia or cancer of the external genitalia, homosexual men, and individuals with multiple sexual partners.

Other diagnostic methods include anal cytology, which unfortunately misses a significant percentage of cases, and HPV testing. Dysplasias progress to anal cancer in approximately 15% of cases.

Anal Warts (HPV) – Diagnosis with Anoscopy

HPV causes not only warts but also dysplasias (precancerous conditions) and cancers in the female genital organs, penis, anus, mouth, and tonsils. There are about 40 types of HPV. In the anus, some types cause warts, while others cause dysplasias and cancer. Anal warts are not limited to the external skin but are also found inside the anus. Inside the anus, HPV infects only the skin cells and not the intestinal cells, which is why it does not extend beyond 5-7 cm from the anal skin.

If someone has visible warts on the external skin, they should also be examined internally with anoscopy and acetic acid application. Warts are easily diagnosed by visual inspection and anoscopy.

However, not all lumps around the anus are warts and should not cause unnecessary concern. They are often hemorrhoids, skin tags, thromboses, sebaceous cysts, or molluscum contagiosum (another sexually transmitted disease). Acetic acid application helps distinguish HPV lesions from other conditions.

Colonoscopy does not aid in the diagnosis of anal warts or dysplasias because HPV only infects squamous skin cells and never the columnar cells of the intestine.

Anal Warts & Prevention: The Importance of HPV Vaccination

Vaccination is crucial in preventing HPV infection. The 9-valent vaccine covers nine HPV types, including about 95% of all infections, protecting against the most common types and those causing cancer. Vaccination prevents cancers of the anus, cervix, and mouth.

In developed countries, vaccination is routine for both men and women up to 26 years old, and up to 45 years for homosexuals and HIV-positive individuals. Vaccination is not only preventive but also treats existing HPV infections (anal warts, dysplasias) by significantly enhancing humoral immunity in addition to the local cellular immunity triggered by HPV infection.

Anal Warts (HPV): Immediate Treatment – Definitive Removal with Laser

Small anal warts are treated with medical creams or cryotherapy. For extensive perianal warts, laser CO2 is used as a non-traumatic method. Internal anal warts are removed simultaneously during anoscopy.

In 95% of cases, removal is done at the time of diagnosis in the doctor’s office without hospitalisation or general anaesthesia. Simple local anaesthesia, like that used by dentists, is sufficient. However, warts and dysplasias can recur after any treatment. Follow-up after 5-6 weeks is essential. Whenever cauterisation or laser is used, smoke evacuation is necessary because of the risk of the treating physician developing throat cancer from inhaling viral particles.

Corticosteroid creams should be avoided because they weaken the immune system and thus activate HPV.

Anal Warts (HPV): Frequently Asked Questions

HPV is transmitted to the anus through direct sexual contact, objects, or touching the genital area with hands. Condom use is essential but does not completely protect against anal warts. HPV infection, anal warts, dysplasias, and anal cancer are more common in individuals with multiple sexual partners or those engaging in anal sex. Women with genital dysplasias or cancer are also at higher risk.

Reduced immunity is a major risk factor for anal warts. This occurs in HIV infection or long-term corticosteroid or immunosuppressive therapy (e.g. after transplants, in autoimmune diseases, or inflammatory bowel diseases). Smoking further increases the risk of anal warts, their recurrence, and progression to cancer. The frequency of anal cancer in homosexual men is similar to cervical cancer rates before the introduction of the Pap smear.

HPV often exists in the anus without symptoms. Benign types cause warts resembling cauliflower-like lumps. Other types cause flat precancerous lesions: low-grade (LGAIN) which are harmless, and high-grade (HGAIN) which can develop into anal cancer in 9-15% of cases within 3-5 years.

Vaccination should ideally occur between ages 12-26, but older age is not a contraindication. The European Medicines Agency notes vaccine benefits even in those over 26, especially high-risk groups (homosexual men, immunosuppressed, HIV-positive individuals).

HPV vaccines, like all vaccines, have been extensively tested, and their side effects are recorded and continuously monitored. Both the World Health Organization and the European Medicines Agency confirm HPV vaccines are safe.

HPV only infects skin cells, not intestinal cells. Skin cells extend up to 5-7 millimeters from the anal entrance, so deeper intestinal examination is not required for HPV infection.

Anal HPV infection occurs in 60% of homosexual men, and when HIV is also present, the infection rate rises to 90%.

High-resolution anoscopy is performed on patients suspected of HPV infection and at high risk for dysplasia. It is mandatory if cytology results are suspicious and is repeated to cauterise any dysplastic lesions found.