What to expect when getting genital warts removed
Receiving a diagnosis of genital warts can be distressing, and no doubt you will have a lot of questions you want to ask. First and foremost will be ‘How do I get rid of them?’. The answer to this isn’t necessarily hugely comforting, as even after removal genital warts can recur. However, for most people the virus that causes warts is completely eliminated from your body within 1-2 years, so while it is daunting to get a diagnosis, the prospects are good, and there are lots of ways to remove them when they appear. First things first though — what even is a genital wart?
What are genital warts?
Genital warts are small single or multiple bumps or growths on the skin, varying in size, colour, and shape. They can occur in the vulva, perineum, anal area, vagina, cervix, and urethra.
Genital warts are caused by the Human Papilloma Virus (HPV), which is the most common sexually transmitted viral infection in the world.1 Incidence is highest between the ages of 15-29, and the prevalence of genital warts is thought to be around 4% in women aged between 16-44 years.2 The prevalence of HPV infection is much higher (around 50-80%), as most people are asymptomatic.3 There are over 100 different types of HPV, but most genital warts are caused by HPV 6 and 11.
Treatment will only be offered if you have visible warts, as there is no cure for the virus itself, and therefore nothing to treat if the skin is clear and no warts are visible.
Diagnosis of genital warts is usually made by a doctor or nurse examining the skin. However, it is not possible to tell when you may have contracted the virus. Treatment will only be offered if you have visible warts, as there is no cure for the virus itself, and therefore nothing to treat if the skin is clear and no warts are visible. This is why it is possible that the warts will recur, as treatments only remove visible warts and not the virus itself. The type of treatment is dependent on the size, quantity, and distribution of the wart(s).
Topical treatments to remove genital warts: Podophyllotoxin gel
Podophyllotoxin gel or cream, also known by the brand names Wartec or Warticon, causes the breakdown and death of the wart cells after 3-5 days of application. To get the gel you will need a prescription from your GP or a sexual health clinic. You will normally be expected to apply this to your warts yourself, for three consecutive days a week, for a maximum of four weeks. You apply it to the warts specifically, avoiding the healthy skin around the wart — using a mirror can help you apply the cream accurately. It can cause mild side effects such as redness, itching, and burning, which affect around one in ten people, and it is is usually prescribed for anal or vaginal lesions, with clearance rates ranging from 45-77%.4 Rates of recurrence with podophyllotoxin gel appear to be approximately 38%,5 and warts that do not go away after four courses need to be treated by an alternative option.
Imiquimod cream is another patient-applied treatment that goes under the brand name Aldara, and also requires a prescription from a medical professional. It is thought to work by activating immune cells to promote an inflammatory response to clear warts. It is usually applied at night, by the person affected, three times a week to warts that are external or perianal, and the area should be washed 6-8 hours after application. Side effects of imiquimod include burning, itching, redness, tenderness, ulceration, and pain, which affect around 25% of users.6 Very occasionally there can be systemic side effects such as headaches or general malaise. Clearance takes roughly eight weeks, and a low recurrence rate of 13% has been found.7
Sinecatechins is another type of patient applied ointment to external warts. It is usually applied to each wart three times daily for up to 16 weeks, and can be used in immunocompromised patients. If no improvement is seen within a few weeks, this treatment is usually abandoned and an alternative is sought. Clearance rates are approximately 58% with recurrence rates lying between 6-9% at 12 weeks follow up.8 Safety in pregnancy has not yet been established, and side effects can include redness, itching, burning, pain and ulceration. As with the other topical treatments, it requires a prescription from a doctor, and you can either see your GP or attend a sexual health clinic.
Trichloroacetic acid is an acid that burns and erodes the skin, and so needs to be applied by a doctor in an outpatient clinic setting. It is usually applied to external warts, and while there have been cases where warts have disappeared with a single dose, for most people several applications are usually required, which can be up to three times weekly. The main side effects include pain or burning. It is safe to use during pregnancy and clearance rates are high at 70-80%.9 However, recurrence rates are also somewhat high at 36%. Treatment periods can range from 2-5 months.
Destructive and surgical therapies to remove genital warts: Cryotherapy
Cryotherapy involves freezing the abnormal wart tissue using a cooling agent such as nitrogen. This leads to a bodily response, whereby your body clears the destroyed cells. This treatment is most effective for multiple small warts on the vulva, growing in a small area. Clearance rates are between 79-88% within the first three treatments.10 Cryotherapy is generally used when topical therapy has failed, or if patients know they won’t be able to comply with the topical regimen.
During your appointment, you will have a doctor and a chaperone present. You will have to expose the area affected and will be required to remove your underwear, but will be given a gown or cover, similar as to when you attend the doctors for a smear test or other gynaecological appointment. The doctor will then apply liquid nitrogen to and around the warts for around 10-20 seconds using either a cotton tipped applicator or a device called a cryoprobe. Sometimes a magnifying instrument is used to better see the skin. The tissue is then allowed to thaw and is frozen again if needed. The frequency of the freeze/thaw cycles is dependent on the size and thickness of the warts.
Cryotherapy involves freezing the abnormal wart tissue using a cooling agent such as nitrogen. This leads to a bodily response, whereby your body clears the destroyed cells. This treatment is most effective for multiple small warts on the vulva, growing in a small area.
Nitrogen may cause the sensation of burning or stinging during the treatment, but healing should occur between 1-3 weeks. Some swelling or soreness may occur and during this time the dead tissue usually sheds off. After the treatment you can continue to shower as normal, but don’t scrub vigorously around the affected area, and it is best to avoid intercourse until the treated area has healed and the soreness gone. If you have had cryotherapy in the vagina you should use sanitary pads instead of tampons and avoid intercourse and douching until the vagina heals, usually in 2-3 weeks. Cryotherapy can be used safely during pregnancy.
Electrocautery is the use of electrical currents to burn and destroy the warts. The wart is then removed by scraping away the dead tissue. This technique is used for small warts on the vulva, generally on patients who have few warts, and is not used for large warts as it can lead to permanent scarring. It is a very effective treatment, with clearance rates of 94% six weeks post treatment.11
Prior to getting the treatment done, a local anaesthetic can be administered for pain control. A grounding pad is placed on your body to protect you from any effects of the electric current, and then a small probe with an electric current is used to burn the wart tissue. The current does not enter your body; only the tip of the probe is in touch with your body, where it is placed on the wart tissue.
After the procedure, you may experience mild bleeding, and some pain or discomfort, and the area needs to be kept clean to prevent any infection. In some cases, general anaesthesia will be used if there are many warts that require removal as this can be quite painful. Simple pain relief such as paracetamol or ibuprofen can help with any discomfort or pain after the procedure.
If you have a cardiac pacemaker or any other cardiac devices you shouldn’t have electrocautery as a treatment as it can interfere with the vital functioning of these devices.
Surgery is one of the oldest treatments for the removal of genital warts. It involves removing the wart tissue with a scalpel, and is associated with a 72% clearance rate.12 It is now considered to be outdated, but is suitable for very large warts that, for example, block the urethra, or for warts that have been unresponsive to other treatments.
Surgery is also the best option for warts that look suspicious, so that the tissue can be sent to the laboratory for examination. Like electrocautery, surgery can be painful. Prior to the procedure, local anaesthetic is applied to the areas affected, but general anaesthetic is usually used if multiple large warts need to be removed. For large incisions you may require stitches, and recovery from the process depends on the location and number of warts removed.
Sex should be avoided until the warts have gone not only to prevent the spread of HPV, but to allow your skin to heal from treatment, as the friction from sex can prevent the skin from healing well.
Healing tends to take two to four weeks, but patients can return to normal activities within one to three days. The incision sites will need to be kept clean to avoid infection, and, again, simple over the counter pain relief can help with any discomfort you experience after the process.
Laser surgery is used for larger warts that cannot be treated with other methods due to the location of the warts. The laser vaporizes the affected tissue with clearance rates between 23 to 52%, and is generally the treatment for immunosuppressed patients or pregnant women who are not responding to trichloroacetic acid or cryotherapy.13 Laser is not used often as it requires special training to use the equipment, and is an expensive and complicated procedure.
Can I have sex before or during treatment for genital warts?
The HPV virus can be passed on during sexual contact, and you do not need to have penetrative sex to pass it on as it can also occur with close genital contact. Condoms are very good at preventing HPV transmission, but as condoms don’t cover the whole genital area, HPV can still be passed on.
The virus is active when warts are present, and is therefore more likely to be passed on when you have visible warts, although it can still be passed on even if warts are not present. Sex should be avoided until the warts have gone not only to prevent the spread of HPV, but to allow your skin to heal from treatment, as the friction from sex can prevent the skin from healing well. Condoms should be used for the first three months after the warts have gone, but you cannot pass on the virus by sharing the same towels or baths.
Where should I go for treatment?
All the above treatments can be done at a sexual health clinic. There are many private clinics who also provide the same treatment. However, at a sexual health clinic, all prescriptions and treatments are free of charge. If a doctor feels general anaesthesia may be required, then the procedure will have to be done in hospital. You can choose to have a female doctor if that makes you more comfortable, but you may have to wait longer than usual until one becomes available.
It is totally understandable to feel embarrassed, or fear you may be judged. However, this will not be the case. Doctors and nurses have seen warts time and time again as they are very common. You do not need to have multiple warts to attend a clinic. If you happen to find a lump or growth and are unsure if it is a wart, please attend a clinic anyway. The earlier you attend a clinic, the earlier you can be treated.
It is possible to have multiple treatments, but the warts still return. This could be due to a new HPV infection rather than the old one, but there is no telling whether or not this is the case. If your warts to recur, go back to your doctor and they will offer another form of treatment.
- H. Patel et al., ‘Systematic review of the incidence and prevalence of genital warts’, BMC Infectious Diseases, Vol. 13, No.39, 2013.
- K. A. Fenton et al., ‘Sexual behaviour in Britain: reported sexually transmitted infections and prevalent genital chlamydia trachomatis infection’, Lancet, Vol. 358, No. 9296, 2001, pp.1851-1854.
- H. Cubie, ‘Diseases associated with human papillomavirus infection’, Virology, Vol. 445, No.1-2, 2013, pp. 21-34.
- V. Yanofsky et al., ‘Genital Warts: A comprehensive review’, Journal of Clinical and Aesthetic Dermatology, Vol. 5, nN. 6, 2012, pp. 25-36.