Condyloma acuminatum (CA) is a sexually transmitted disease (STD) caused by infection with low-risk human papillomavirus (HPV), leading to wart-like proliferation of the skin and mucosa.
Related Factors for Disease Onset
HPV is a non-enveloped, double-stranded DNA virus. More than 90% of clinical cases of condyloma acuminatum are caused by HPV types 6 or 11, though co-infection with high-risk types such as HPV 16, 18, 31, 33, or 35 may also occur. Risk factors include early sexual activity, multiple sexual partners, and other unsafe sexual practices.
Modes of Transmission
The primary mode of transmission is sexual contact. Genital tract infections in pregnant women can be vertically transmitted to newborns via the placenta or the birth canal. In rare cases, transmission may occur through oral, manual, or genital contact.
Effects on Mother and Child
Lesions tend to grow rapidly during pregnancy. Large condylomas acuminata may obstruct the birth canal. There is a risk of vertical transmission of HPV during pregnancy. Neonatal infection with HPV types 6 and 11 can lead to respiratory papillomatosis.
Clinical Manifestations
Symptoms are generally absent, though itching, burning pain, or a foreign body sensation in the vulva may occasionally occur. Lesions may be solitary or multiple. Initially, they appear as small, scattered, pale-red papules, which gradually increase in number and size. These lesions may coalesce and take on a papilliform, cauliflower-like, or cockscomb-like appearance. The surface of the lesions is prone to erosion, exudation, maceration, and ulceration, with possible bleeding or secondary infection. Lesions are commonly located at sites of trauma during sexual activity, such as the posterior commissure of the labia, the inner sides of the labia minora, the vaginal vestibule, the external urethral opening, or the perianal area. The vagina, cervix, or urethra may also be involved.
Diagnosis and Differential Diagnosis
Diagnosis can be made based on typical clinical lesions and patient history. Laboratory tests include:
- Acetic acid testing: While this test has low predictive value for diagnostic purposes, it may be useful in distinguishing suspicious lesions during treatment.
- Dermatoscopy and colposcopy: These tools can aid in the identification of small lesions.
- Histopathological biopsy: Biopsy is not routinely required for typical lesions but should be considered in cases of atypical lesions, diagnostic uncertainty, or disease progression.
- HPV testing: Routine HPV testing of lesions is generally not necessary for diagnosis.
The condition requires differentiation from:
- Benign papular dermatoses such as squamous papilloma, pseudo-condyloma, ectopic sebaceous glands, lichen nitidus, and lichen planus.
- Other STDs, including molluscum contagiosum and syphilis.
- Premalignant or malignant lesions of the genital tract.
Treatment
The primary goal of treatment is the local removal of warty lesions, while also addressing subclinical and latent infections around the lesions to reduce recurrence. Treatment includes topical medications, physical therapies, or surgical options, with an individualized approach based on the patient's condition.
Topical Medication
Small or localized lesions can be treated with 5% imiquimod cream, 0.5% podophyllotoxin solution, or 5% fluorouracil cream. Local adverse reactions should be monitored and managed. These treatments are not suitable during pregnancy.
Physical Therapies
These therapies are appropriate for extensive or multiple lesions and include cryoablation, laser ablation, microwave therapy, or photodynamic therapy.
Surgical Treatment
Lesions that are pedunculated, large, or refractory to other treatments may require excision.
Treatment During Pregnancy
For small vulvar lesions, 80–90% trichloroacetic acid can be applied locally. For large, pedunculated lesions, physical therapies may be considered. Giant lesions may require surgical excision.
Management During Delivery
Pregnancy with condyloma acuminatum is not an indication for cesarean delivery. If the lesions are limited to the vulva, vaginal delivery is feasible. However, extensive lesions that obstruct the birth canal may lead to soft tissue trauma and significant bleeding during vaginal delivery, in which case cesarean section is advised.
Follow-Up and Prevention
Most recurrence or intractable lesions arise within the first three months after treatment. Follow-up during this period should be conducted every two weeks. After three months, the follow-up intervals may be extended until 6–9 months after the last treatment. Sexual partners should undergo evaluation and treatment for condyloma acuminatum. The use of condoms is recommended to block transmission routes. In non-pregnant individuals, vaccination with the quadrivalent or nine-valent HPV vaccine effectively prevents HPV infection and reduces the incidence of condyloma acuminatum.