Anal Warts – Should you be worried?

Anal warts are surely not a topic you want to hear in your routine conversation, let alone having it. In general, warts may affect any area of the skin and it may occur in both men and women. But what if it occurs around the anus? Most people tend to hide this problem due to its stigmatism, appearance, intimate or sexual relationship, and health issues. 

What are anal warts?

Anal warts are an abnormal skin growth that occurs around or inside the anal canal which comes in all kind of shapes and sizes – as small as a pinhead to big cauliflower-like lesions covering the whole anal area. Anal warts are benign tumours  (growths) that are most commonly caused by Human Papilloma Virus similar to other genital warts that occur on the vulva, vagina or penile area. However, patients often find it difficult to notice since it’s at the back of their bum, thus they can only feel and assume it. Thus they tend to ignore it since it is usually painless. 

What is HPV?

HPV is a common sexually transmitted infection (STI). It is usually categorised based on their associated risk for cancer into low risk and high risk. More than 90% of anal warts are caused by low-risk types of HPV. HPV is passed from one person to another during contact with an infected part of the body. Anal HPV warts are commonly acquired through sexual contact especially penetrative anal sex with someone who is infected with HPV – in both men and women.

Anal warts vs anal cancer

Anal warts are only caused by Low-risk types of HPV ( Types 6,11,42,43 and 44) and these types of HPV do not usually develop into malignant cancer. However, anal cancers are caused by High-risk types of HPV which is one the reasons why we encourage not only women by also men to take HPV vaccine. Usually, anal cancer is more ill-looking, aggressive and sometimes ulcerative thus it’s better to get yourself checked by a doctor.

How to diagnose anal warts?

It’s typically diagnosed by a thorough history and physical examination at the doctor’s bedside office. In most cases, anal warts do not require a biopsy for diagnosis. 

 Furthermore, HPV screening for asymptomatic individual is not recommended since there are no approved HPV tests to find HPV on the anus and the laboratories only test for high-risk types of HPV and not the low-risk types (which causes anal warts).

How are anal warts removed?

Although anal warts do resolve by itself, it usually takes months or even years for it to heal itself and you may try over-the-counter wart treatments. However, if it’s on the anal area, it’s very difficult for you to apply it yourself. Furthermore, it can also occur in the anal mucosa (in between anal and rectum) which you can miss since it can only be visualised using a proctoscope (this can be quite a way in from the anus per say). Also remember that the faster you remove the wart, the less likely it will spread since all warts can be “mother” warts that give rise to additional warts to its surroundings. Hence they are a couple of methods that are available for the removal of the warts.

1.      Lotions and Creams

1a)     Aldara (imiquimod)

Imiquimod is in a class of medications called immune response modifiers. It acts by increasing the activity of the body’s immune system on the genital and anal warts. 

Most likely you will need your partner’s help if you want to use this method. It will be given in the form of sachet. It’s best to use it at night after a shower since it will moisten up the warts and make sure to dry the lesion first before applying the cream. To apply it, take a very small amount of the cream using a cotton bud and apply it on top of the warts. Try not to spread it to the surrounding healthy skins. Once it has been applied, Imiquimod cream should be left on the skin for 6 to 10 hours and try not to wash it during this time. That’s why it’s best to use it before you go to sleep. Continue using imiquimod until all of the warts are healed, up to a maximum of 16 weeks.

Furthermore, you will probably need to apply it once a day for 3 days a week – ie once every other day (e.g., Tuesday, Thursday, and Saturday OR Monday, Wednesday, and Friday). 

1b)   Duo/Podofilm Painting – Acid painting

 Duofilm paint is a keratolytic (breaking down keratin – a protein that forms parts of the skin structure) liquid containing salicylic acid and lactic acid. 

The paint is applied on top of the warts that will cause it to soften and shed by time. For the warts to be removed completely, it can take up to three months of treatment for the affected or maybe less. Once the warts are successfully removed, the new skin that grows underneath will be healthy.

The warty growths can recur though. 

2)   Radiofrequency Surgery

This is a type of radiosurgery which is also known as radio wave or radiofrequency surgery where it will cut the tissue with high frequency alternating current. It’s one the methods that we will typically do here since it is safe, rapid and effective. The difference between other types of traditional electrocautery is that radiofrequency surgery can simultaneously cut and coagulate tissue without applying any physical pressure. This in turn gives us better precision, versatility and surgical control. Thus resulting in lower risk of scarring, minimal bleeding, minimal damage to the surrounding tissues and with the application of local anaesthesia will result in a minimal or painless procedure.

3)   Liquid nitrogen / Freezing

This type of method requires a special device that releases liquid nitrogen into your skin. This will freeze the wart and later it will peel off by itself. More often than not, patients will see improvement after 2-3 treatments over a month. This method doesn’t require any local anaesthesia prior since it’s painless.

Can genital warts be prevented or avoided?

To prevent it, the only sure way is abstinence. Thus, if you are sexually active, having sex only with a partner who isn’t infected with HPV is the only way to prevent it. However, male circumcision and the use of condoms have shown a significant protective effect against HPV transmission although they are not 100% effective since they do not cover all the affected skin.

They are vaccines that can prevent HPV. The most recent of which is Gardasil 9. As the names tell, it covers 9 HPV strains and out of the 9 HPV strains in the vaccine, two are for wart prevention (HPV 16 and 18) and the remaining seven are for cancer prevention (HPV 16, 18, 31, 33, 45, 52, 58).

In Malaysia, starting from 2010, all females (only) age 13 and above are given HPV vaccine but most of them are given Cervarix vaccine. Cervarix gives you protection only against the commonest cancer-causing HPV 16 and 18. There is no wart protection with Cervarix. 

Unlike Australia, HPV vaccination was introduced in their National Immunization Programs that include vaccinating boys aged 12-13. This is because vaccination in boys or young men helps to prevent this increased risk of anal cancers regardless of sexual preferences in the future. Even men who do not engage in receptive anal sex can still benefit from the vaccine. So we should also encourage our boys and men to get vaccinated with GARDASIL 9 to reduce the overall risk and incidence of HPV related cancers and warts. 

Next read: What is HPV?

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