Anogenital warts guide: Screening and diagnostic testing
This guide focuses on the assessment and management of external anogenital warts (AGW) caused by human papillomaviruses (HPV). HPV vaccination and HPV-related cancer screening recommendations are beyond the scope of this guide.
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Screening and diagnostic testing
Screening
Screening for anogenital warts is not recommendedFootnote 1.
A clinical encounter for anogenital warts (AGW) is an opportunity to discuss comprehensive screening for other sexually transmitted and blood-borne infections (STBBI) and cancer screeningFootnote 1.
Cancer screening
Routine cervical and other cancer screening should be conducted as indicated, regardless of AGW diagnosis or HPV vaccination statusFootnote 1Footnote 2. Consult provincial or territorial cervical cancer screening guidelines and recommendations.
Currently, there is no consensus about the use of screening methods, including digital anorectal exam, high resolution anoscopy, anal cytology and/or HPV testing for screening those at higher risk of anal cancer, including gay, bisexual and other men who have sex with men (gbMSM) and people living with HIVFootnote 3Footnote 4. Some guidelines recommend digital anorectal exams for people living with HIV and gbMSM without HIV who have a history of receptive anal intercourse to detect early anal cancersFootnote 4. Access to anal cytology and high resolution anoscopy may vary by jurisdiction. Consult local practice or consensus guidelines for recommendations about screening and follow-up of abnormal results.
Other sexually transmitted and blood-borne infections
STBBI screening varies by age, sex, gender, medical and sexual history. Screen anyone with STBBI risk factors and treat as appropriate to prevent transmission and reinfection.
People being evaluated or treated for AGW should be screened for:
- chlamydia
- gonorrhea
- syphilis
- HIV, as per the recommendations in the HIV Screening and Testing Guide.
If risk factors are present and if clinically indicated, consider screening for:
Offer vaccination for hepatitis B (HBV), hepatitis A (HAV), human papillomavirus (HPV) and mpox as per the Canadian Immunization Guide. Refer to provincial or territorial vaccination schedules for more information.
Diagnosis of anogenital warts
Visual inspection is the usual means of diagnosing anogenital warts (AGW)Footnote 1Footnote 4Footnote 5Footnote 6Footnote 7.
HPV testing is not recommended as results would not alter clinical diagnosis, management, or treatment of external AGWFootnote 4.
Differential diagnosis
Consider the following differential diagnosis and confirm with biopsy if diagnosis is uncertainFootnote 1Footnote 5Footnote 6:
- Non-pathological variations in sebaceous glands:
- Fordyce spots and Tyson's glands
- vestibular papillae or micropapillomatosis labialis
- pearly penile papules on the coronal sulcus
- sebaceous cysts
- Pathological entities caused by non-infectious diseases of the skin and mucosa:
- intradermal nevi
- lichen planus
- lymphangioma
- psoriasis
- skin tags or acrochorda
- seborrheic keratosis
- squamous cell carcinoma
- Pathological entities caused by infectious agents:
- Buschke–Löwenstein tumours (giant condylomata acuminata that may proceed to cancer)
- molluscum contagiosum
- condyloma lata of secondary syphilis
- intraepithelial neoplasia (predominantly caused by HPV)
- mpox (formerly Monkeypox)
Physical examination
Physical examination is strongly recommended when an STBBI is suspected. The physical examination for AGW should include a visual inspection of the external genitalia.
As applicable, offer a speculum examination of the vagina and cervix to identify any lesions and to obtain a sample for cervical cancer screening per provincial or territorial guidelines. Refer individuals with vaginal or cervical lesions for colposcopy in accordance with provincial or territorial guidelinesFootnote 1.
Consider anoscopy for individuals with perianal or intra-anal wartsFootnote 1.
Refer individuals with urinary flow problems that may be the result of AGW of the distal urethra or urethral meatus for urological assessment.
References
References
- Footnote 1
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Steben M, Garland SM. Genital warts. Best Pract Res Clin Obstet Gynaecol 2014;28(7):1063-1073.
- Footnote 2
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Public Health Agency of Canada. Human papillomavirus (HPV) vaccines: Canadian Immunization Guide For health professionals. 2017. Available at: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-9-human-papillomavirus-vaccine.html.
- Footnote 3
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Palefsky JM, Rubin M. The Epidemiology of Anal Human Papillomavirus and Related Neoplasia. Obstet Gynecol Clin North Am 2009;36(1):187-200.
- Footnote 4
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021 07 23;70(4):1-187.
- Footnote 5
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Karnes JB, Usatine RP. Management of external genital warts. Am Fam Phys 2014;90(5):312-318.
- Footnote 6
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O'Mahony C, Gomberg M, Skerlev M, Alraddadi A, de las Heras-Alonso ME, Majewski S, et al. Position statement for the diagnosis and management of anogenital warts. J Eur Acad Dermatol Venereol 2019;33(6):1006-1019.
- Footnote 7
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Yanofsky VR, Patel RV, Goldenberg G. Genital warts: A comprehensive review. J Clin Aesthetic Dermatol 2012;5(6):25-36.
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