Anal warts, referred to as condyloma acuminata, are fleshy growths that can occur inside and outside the anus. Warts can also occur in the genital area. They are usually pale pink or brown in color. Warts usually start off as small growths and can grow over time. Small warts can spontaneously resolve in healthy individuals. Warts are contagious. They are caused by HPV the human papilloma virus, the most common STI. About 10% of sexually active adults have HPV and 1% have warts. The highest incidence is in men who have sex with men (MSM) at 10-15 %. A significant portion of warts in men who have sex with men (MSM) and are HIV positive have dysplasia. Anal warts may coexist with other common anal conditions such as hemorrhoids, anal fissures, skin tags, yeast infections, or infectious proctitis from other STI’s.

Small warts may cause no symptoms. There may be itching, burning, bleeding, irritation, pain, discharge, or feeling small bumps. They may be confused with skin tags or hemorrhoids.

Anyone exposed to HPV via intimate contact can develop warts, but many do not. Around 40% have latent HPV infection without symptoms. MSM, Multiple sex partners, anal intercourse, unprotected sex, or a weakened immune system increases the risk. Although rare, it is felt the virus can be spread through shared items such as towels or underwear.

Anal warts are caused by the human papilloma virus, HPV. It may be difficult to determine when you were infected. The warts may start 8-10 weeks after first contact. It is usually spread through intimate contact or intercourse. HPV may be able to spread through shared towels or bathroom facilities although this would be considered a rare cause.

Human Papilloma Virus, types 6 and 11, are the cause of most anal warts and felt to be non-oncogenic. HPV infection may also occur orally, vaginally/cervix, or on the penis. Chronic HPV infection, (especially types 16 & 18) can increase the risk of cancer. HPV can be spread from one person to another even if there are no visible warts. Condoms may help decrease the spread but are not 100% protective.

Most warts can be diagnosed with visual inspection. They appear as small fleshy growths around the anus. Over time they may become harder. The color may vary from skin color to pale pink or brown. They may be on skin tags or hemorrhoids. Size and number may vary. Warts may grow and multiply over time. A biopsy may done to determine if there is evidence of abnormal cells (dysplasia or cancer). This should be done in high-risk patients (HIV/MSM/other high risk HPV infections) or if the wart is suspicious for dysplasia or cancer such as hard, ulcerated, bleeding, or recurrent. Since people with one STI may have others, we recommend comprehensive sexual health screening. This may include HIV, Syphilis, Chlamydia, Gonorrhea, and Hepatitis B and C.

Untreated warts may enlarge, are contagious, or in some cases associated with dysplasia or cancer. They should be removed. OTC wart medication should not be used on anal or genital warts. Anoscopy should be done before treatment is started to look for internal warts. No one treatment is the clear best as the HPV virus persists after wart treatment and all treatments have some pain and recurrence. At home patient applied prescription Topical medications may be applied such as Podofilox (Condylox) or Imiquimod. Trichloroacetic acid (TCA) is usually applied by a specialist. These topicals are not for internal anal warts. They all take a while to work, require self-application, have local irritation or pain, and significant recurrence risk. Imiquimod is a patient applied cream that stimulates the immune system to fight HPV. It is applied three times per week for up to 16 weeks. It may cause a skin reaction, take months to work, and does not work well on larger warts. It is more expensive than other topicals. Podofilox is applied topically for smaller soft warts. It frequently irritates the area. It has a 40-80% initial success rate. It may work quicker than Imiquimod but have a higher recurrence rate. It is best for small warts on drier areas. Usually applied on the warts 1-2 x per day for 3-4 days then given 3-4 days rest. If it does not work within a month other methods should be tried. Recurrence rate is about 38-55%. It should not be used in pregnant or breast-feeding mothers, pediatric patients, or those with diabetes mellitus or poor circulation. Podophyllin resin is no longer approved because of toxicity. TCA is applied to small perianal warts weekly by a specialist. Local pain and irritation are common. Multiple treatments are required. Recurrence rate is 36%. It can not be used for intra-anal warts. Sinecatechins is a botanical from green leaves. Its long-term results are not yet known. Warts may be frozen with liquid nitrogen. It may be painful and require multiple visits. Initially successful in 80% of cases. Recurrence may occur in 39%. Usually done by a Dermatologist. Photodynamic therapy is not usually recommended because of the cost, time involved, lack of access to trained specialist, and possible side effects Warts can be excised, cauterized, or lasered. These office treatments may be quicker and more effective but are more expensive. They can be painful so will be done with topical and local anesthesia. Inside and outside warts can be treated this way. Recurrence may occur in 25-40% but have lower recurrence rate than topicals. Multiple treatments may be required. If there are many warts they may be divided into sections for multiple sessions to decrease pain and speed up healing.

Because these warts can grow or lead to anal cancer you should see a qualified specialist who performs anoscopy on a regular basis. Anal warts can be diagnosed and treated by colorectal surgeons, proctologists, general surgeons, dermatologists, or other specialist with additional experience and training. Anal warts with dysplasia or those with weakened immune systems should be cared for by trained specialists and if possible, who have access to high resolution anoscopy (HRA).

Yes, they can come back (30-70% chance) because the virus persists after wart removal. Frequent follow up visits are required. New warts are easier to treat when they are small. HPV vaccine may decrease chances of recurrence. Stop smoking and strengthen your immune system through diet, exercise, proper sleep, and stress management.

HPV vaccination, Ghardasil-9, should be given to boys and girls ages 9 and up. It is highly effective but not 100%. Why not 100%? Some are already infected with HPV before vaccination. There are 200 types of HPV, and not all are covered by the vaccine. Nevertheless, vaccination before exposure protects over 90% of individuals from HPV related cancers. Other measures include avoiding intimate contact with individuals of unknown STI status. Avoid smoking. Condoms may be helpful. Follow guidelines for PAP smears. Other risk factors include unprotected sex, anal intercourse, multiple partners, MSM, HIV, and weakened immune system. Starting sex at a young age increases the risk HPV infection. People in high-risk groups should have regular testing for STI.

Anal Pap is a simple test done with a small circular brush that is placed in the anal canal. The laboratory examines the brushed cells for any evidence of pre-cancerous cells usually caused by HPV. We recommend most Anal Pap test include testing for high-risk (HR) Human Papillomavirus (HPV). Anal Pap with HR-HPV can help decide who needs high-resolution anoscopy (HRA). Patients who are at increased risk for developing anal dysplasia and then cancer and should have anal Pap include: Those with HIV, anal intercourse, solid organ transplant patients, genital warts, high-grade cervical, vaginal, or vulvar dysplasia or cancer, chronic immunosuppression. Men who have sex with men and transgender women who have HIV should start anal Pap at age 35 and this group who are HIV negative at 45.

Biopsy is done for suspicious lesions that may be ulcerated, painful, bleeding, pigmented, hard, do not respond to treatment, or in immunocompromised patients. Biopsy is done in the office quickly and safely with minimal pain.

Indications for HRA screening for anal cancer are a positive anal Pap or anal wart biopsy showing pre-cancerous cells (dysplasia). An anal Pap with high-risk HPV testing (HR-HPV) that shows mild dysplasia (ASCUS) but no high-risk HPV, may be recommended to continue with annual PAP without HRA unless there is a change in the PAP results. HRA is also used to treat and monitor precancerous anal lesions. HRA is a 20–30-minute office procedure done through a special lighted anoscope. High definition magnified and color recording video system allows suspicious areas to be biopsied or removed.

Anal dysplasia is a precancerous condition where abnormal cells develop in the lining of the anus. It is classified as low grade (usually benign) or high grade (may become cancerous). It is associated with HPV infection (frequently Types 16 & 18) and HIV. Anal dysplasia is not common in the general population. In those with other genital area dysplasia (cervical, vulvar, vaginal) it is present in about 15% and those with HIV up to 30%. Weakened immune system, MSM, HIV all increase the risk of anal dysplasia and cancer. Close following of anal dysplasia with HRA can help prevent anal cancer or diagnose it at an earlier stage leading to a 90% cure rate. HRA can help prevent anal cancer even in high-risk HIV positive groups by 57%.

Anal cancer is relatively uncommon with 10,500 cases per year. The incidence is increasing 2.7% per year because of HPV and cigarette smoking. 90% of anal cancers are related to HPV (type 16 and less likely 18) and in HIV patients it may be 100%. There may be pain, bleeding, and a mass around the anus. Many have a history of HPV infection. Squamous cell cancer is the most common type. Treatment may include chemotherapy, radiation, and surgery. Following high risk patients with rectal exam and HRA can help with an early diagnosis. Early-stage anal cancer has a 90% cure rate. Follow up should include high-resolution anoscopy.

Partners should be informed they may have been exposed to HPV, and they may elect to have a physical examination. There may or may not be any visible warts in someone with an HPV infection. It may take 8-10 weeks after exposure to develop Clinical signs of HPV.

Topical therapies are not proven safe during pregnancy and should be avoided. Anogenital warts can rarely cause respiratory papillomatosis among infants. C-section is not required in most cases. Careful Anal Wart treatment may be done during pregnancy, but results may vary till after delivery. Gardasil vaccination is not recommended during pregnancy.