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Anogenital warts
Background
Overview
Definition
Anogenital warts, also known as condylomata acuminata, are an STI caused by certain strains of the HPV, primarily HPV genotypes 6 and 11.
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Pathophysiology
The pathophysiology of anogenital warts involves the transmission of HPV through sexual contact, leading to the infection of squamous epithelial cells in the anogenital region. The virus causes these cells to proliferate excessively, resulting in the formation of warts.
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Epidemiology
The incidence of anogenital warts is estimated at 160-289 per 100,000 person-years worldwide.
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Risk factors
Risk factors for anogenital warts include engaging in sexual activity, especially with multiple partners, and having unprotected intercourse. Additional risk factors include immunosuppression and concurrent infection with other STDs. Transmission of HPV, although less frequent, can also occur through non-sexual routes.
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Disease course
Anogenital warts present as fleshy growths on the skin or mucous membranes of the anogenital area, often in the perianal region, and can be painless or tender. They can vary in size and shape, ranging from flat to raised, small to large, and singular to multiple. Anogenital warts are usually asymptomatic, but some can cause itching, discomfort, tenderness, or bleeding.
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Prognosis and risk of recurrence
The prognosis of anogenital warts is generally good as they are usually benign. However, they can recur after treatment, and certain high-risk HPV strains can lead to malignancies, such as SCC.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of anogenital warts are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2025), the European Association of Urology (EAU 2025), the British Association for Sexual Health and HIV (BASHH 2024), the World Health Organization (WHO 2024), the Center for Disease Control (CDC 2021,2019), ...
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Diagnostic investigations
Physical examination: as per BASHH 2024 guidelines, perform a thorough examination of the entire external anogenital area and urethral meatus with adequate illumination in patients presenting with new or recurrent warts.
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consider performing a speculum examination in patients with warts at the introitus where the upper limit cannot be visualized, or in patients with external warts and additional vulvovaginal symptoms, such as irritation, bleeding, or discharge. B
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Screening for STIs
Screening for cervical cancer
Assessment of sexual partners
Diagnostic procedures
Biopsy: as per AAFP 2025 guidelines, diagnose genital warts based on clinical assessment. Perform a biopsy in cases of uncertain diagnosis, lack of response to standard therapy, worsening of the condition during therapy, or presence of atypical lesions such as pigmented, indurated, affixed to underlying tissue, bleeding, or ulcerated lesions.
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Medical management
Imiquimod: as per EAU 2025 guidelines, offer self-administered imiquimod 5% cream, applied to all external warts overnight thrice weekly for 16 weeks, for the treatment of anogenital warts.
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Podophyllotoxin
Sinecatechins
Trichloroacetic acid
5-FU
Other topical agents
Management of internal involvement (intra-anal)
Management of internal involvement (urethral)
Management of internal involvement (vaginal)
Management of internal involvement (cervical)
Nonpharmacologic interventions
Therapeutic procedures
Intralesional interferon injection: as per IUSTI 2020 guidelines, consider offering intralesional interferon injections in patients with refractory anogenital warts.
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Cryotherapy
Photodynamic therapy
Laser therapy
Perioperative care
Surgical interventions
Surgical excision: as per EAU 2025 guidelines, offer surgical management (excision, electrosurgery, electrocautery, or laser therapy) of anogenital warts based on an informed discussion with the patient.
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Electrosurgery (indications)
Electrosurgery (technical considerations)
Male circumcision