I. Pathogenesis
Condyloma acuminatum is caused by the human papillomavirus (HPV), a DNA virus with a double-stranded DNA core.
The actual fact is that there are many different types of HPV, and there are more than 80 known subtypes of HPV, which can cause different clinical manifestations. CV is mainly caused by subtypes 6, 11 (low-risk), 16, 18, 31, 33 (high-risk), etc.
Clinical manifestations
It occurs in the genital and perianal areas of men and women. In men, it is most common in the coronal sulcus and prepuce, but also in the penis, prepuce, glans and urethral orifice. In women, it is most common in the posterior union and the inner labia minora, and can also be seen in the vaginal opening, vagina and cervical mucosa epithelium.
Most of the patients are young and middle-aged people who are sexually active. The age of prevalence is 16-35 years old, with the highest incidence in 20-34 years old, and it occurs in both men and women. Most of the patients have a history of unclean sexual contact or a history of infection in their spouse before the onset of the disease. The incubation period varies from 1 to 8 months, with an average of 3 months. Occasionally seen in children, generally through contact with contaminated utensils such as towels and other infections.
1. Typical damage.
The initial damage is a small, soft, light red papule, pin cap or rice grain in size. Patients usually have no conscious symptoms.
2. Subclinical infection.
It means that the epithelial cells have been infected by HPV, but no changes visible to the naked eye have appeared yet. Subclinical infection can be clearly shown by the vinegar white test. The vinegar white test is a simple and easy way to identify early condyloma damage and subclinical infection.
3. HPV carriers.
Using sensitive molecular biology techniques for polymerase chain reaction (PCR), DNA extracted from the vulva or vaginal swab specimens of the spouse or sexual partner of the patient with condyloma acuminata as a template for amplification, a significant percentage of spouses or sexual partners were found to be positive for HPV detection, and although he or she clinically had neither condyloma acuminata damage nor subclinical infection, it can be said to be an HPV carrier.
4, HPV infection in the epithelium of the genital area can show a rather wide spectrum of manifestations. From HPV carriers with no clinical and microscopic changes to subclinical infections with microscopic changes but no visible changes to acromegaly damage with typical clinical changes visible to the naked eye. In fact, only a small fraction of the HPV-infected population has typical clinical manifestations of condyloma acuminatum, with the vast majority being HPV carriers or subclinically infected.
5, several special parts of the condyloma acuminata
The actual Urethra is a very good place to get a good look at the Urethra. Sometimes the HPV virus can travel retrograde up the urethra, causing infection of the urethral epithelium, which requires urethroscopy.
The first is most of the papules, and then the warts grow. They can be large, cauliflower-shaped, or more often flat, with small papillary patches on the surface. If you are in the male perianal area, you should pay attention to the history of homosexuality and anal sex.
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6, huge type of condyloma acuminata
They are found on the mucosal surface of the foreskin and glans in men, and occasionally in the perianal area and vagina in women. The giant condyloma is essentially a verrucous carcinoma with pathological changes of low-grade squamous cell carcinoma.
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1, histopathological examination.
The typical condyloma acuminata microscopically seen as the epidermis is papillomatous hyperplasia, spiny layer hypertrophy, the surface has a mild hyperkeratosis and hyperkeratosis incomplete.
2.Vinegar white test.
With 3%-5% acetic acid soaked gauze or cotton swab on the surface of the lesion, 3-5 minutes after the affected area becomes and the surrounding normal tissue between the formation of obvious contrast, is a positive vinegar white swab test. It is a useful tool for detecting subclinical infections that have not yet developed visible changes to the naked eye. It appears as well-defined white patches or blotches. The vinegar white test is simple and easy to perform and should be used as a routine test for patients with acromegaly to correctly determine the extent of the lesion and thus guide treatment.
3. Colposcopy.
Colposcope is a special magnifying glass, mainly used for the observation of the mucous membrane of the cervicovaginal area, which can be used for the examination of vulvar and vaginal epithelium.
4. Cytology.
It is mainly used to check whether there is HPV infection in female vagina or cervical epithelium. Cells are scraped from the examined area and coated on a slide, fixed with 95% alcohol, and commonly used with Papanicolaou staining. The microscopic findings are divided into five grades: grade I: normal, grade II: inflammation, grade III: suspicious cancer, grade IV: highly suspicious cancer, and grade V: cancer. Grade Ⅱ is divided into Ⅱa and Ⅱb. Ⅱa is inflammatory cells, and Ⅱb smear contains a few mild nuclear heterogeneous cells in addition to inflammatory cells. Cases with smears showing IIb should be followed up and examined regularly. To determine whether there is HPV infection, specific anti-HPV antibodies, histochemical staining or in situ hybridization techniques should be used.
5. Polymerase chain reaction (PCR)
IV. Diagnosis
The diagnosis of condyloma acuminata is not difficult for typical warts or cauliflower-like swellings occurring in the vulva and perianal area. For early and subclinical infections, colposcopy (for women) or urethroscopy (for men) should be performed on the basis of the vinegar white test, and further histopathological examination of the lesions should be taken to confirm the diagnosis. If the diagnosis is still difficult, specific histochemical examination, in situ hybridization technique or PCR can be performed to find the pathogen and confirm the diagnosis.
Five, differential diagnosis
1, flat warts.
This is the characteristic clinical sight of stage II syphilis, manifested as perianal or vulvar flat papules, surface moist, about 0.5cm in size, no tip, and the surface is not papillary or granular. The rash is visible on the trunk and palmoplantar areas of the patient. The serologic test for syphilis is positive. The actual surface of the flat warts is examined under a dark-field microscope, and most of the active syphilis spirochetes are visible.
2, penile pearl-like papules.
The first thing you need to do is to get a good idea of what you are getting into. They are arranged in one or two rows along the coronal sulcus. They are normal and do not require treatment. The pearly papules of the penis do not change in form and do not increase in size if the diagnosis cannot be confirmed by a negative vinegar white test. In many men’s foreskin tether two then, visible one or two such as pin cap large white papules, slightly elevated skin surface, the surface is smooth, this is also normal to see, no need to treat.
3, female vaginal pseudomonal warts.
The histopathological examination is free of empty cells, which can be distinguished.
The relationship between HPV infection and genital cancer
1. A lot of evidence shows that there is a clear relationship between HPV infection and genital cancer, especially cervical cancer in women. In women with cervical epithelial infection with HPV type 16 or 18, moderate to severe atypical hyperplasia occurs in about 2/3 of patients within two years.
2. Bowen-like papulosis is a squamous carcinoma in situ that occurs in the vulva. A significant percentage of patients have a history of condyloma acuminata, and some patients can be accompanied by condyloma acuminata.
3, huge type of condyloma acuminata, which is a warty carcinoma occurring in the genital area, histopathologically low degree of squamous carcinoma changes, the lesion is based on the original condyloma acuminata, without treatment, long-term chronic stimulation evolved.
Seven, treatment
1, topical drug treatment.
(1) 0.5% tincture of ghosts: for the number of small, small warts, individual warts less than 2 centimeters in diameter, 0.5% tincture of ghosts is the drug of choice. The actual fact is that you can find a lot of people who are not able to get a good deal on a lot of things. The main adverse reactions are local pain, redness and swelling, no systemic adverse reactions were found. It is contraindicated for pregnant women. In patients with circumcision, local redness and swelling are often prominent after topical application, individual patients can be highly edematous penis and foreskin, at this time the drug should be suspended, and 0.9% saline or high saline for wet compresses.
(2) 10%-25% tincture of bamboo leaf resin: because of its greater toxicity, large area use can produce systemic toxic reactions, so it has been gradually replaced by its purified product 0.5% tincture of onychomycetin. The use of 10%-25% tincture of diclofenac should not exceed 0.5 ml per dose, and the solution should be washed off after 1-4 hours. It is prohibited for pregnant women.
(3) trichloroacetic acid solution; concentration varies from 30%-80%, this is a chemical erosion agent, should be used by experienced medical personnel, should not be handed over to the patient himself. The solution will be applied directly to the lesions, if the warts are not corroded off, then it can be repeated after a week. When using the drug should pay attention to protect the surrounding normal skin to avoid burns.
(4) 2.5%-5% 5-fluorouracil ointment: external use 1-2 times a day, until the warts fall off, if the surrounding normal skin mucous membrane appears red, swollen, erosion, then should be suspended.
(5) Interferon: can be injected locally or made into an ointment for topical use. The local injection is more painful and requires multiple treatments, not easy for patients to accept. The topical alpha 2 b interferon gel can be used topically to stimulate T cells and suppress the virus, and is effective for small warts. The advantage is that the drug is non-irritating and there are no local adverse reactions such as redness, swelling and pain, but the disadvantage is that the onset of action is slow, requiring 4-6 weeks of continuous topical application. The results of clinical trials have shown that the topical application of alpha 2 b interferon gel has the effect of preventing recurrence after the condyloma acuminata is treated with freezing and laser.
(6) 5% Imiquimod cream: It is an immunomodulatory agent. Topical application, wash the affected area before use, squeeze a sachet (250mg) of the drug on a cotton stick, apply to the lesions and massage lightly several times, 3 times a week (once a week on Monday, Wednesday and Friday or two, four and six nights), for a course of 8 weeks. Adverse effects are mainly local irritation, including erythema, edema, erosion, burning and pain. The recurrence rate after treatment with this drug is low.
(7) Other: there are many topical drugs for the treatment of condyloma acuminata, either through the corrosive and destructive effect on the tissue, or through the inhibition of DNA or RNA, and the therapeutic effect.
2, physical therapy.
(1) liquid nitrogen freezing: the general use of cotton swab method, using cotton swabs dipped in liquid nitrogen, slightly pressurized placed on the lesions for a few seconds, so repeatedly many times. For large damage, cotton balls or gauze dipped in liquid nitrogen, pressed on the affected area, frozen and rewarmed several times a week, generally need several treatments. The side effects are local edema, which can last for several days.
(2) carbon dioxide laser: suitable for warts smaller cases, in the female cervical mouth, male urethra warts difficult to external medicine, can use carbon dioxide laser treatment.
（The actual fact is that you can find a lot of people who are not able to get a good deal on a lot of things.
(4) photodynamic therapy (PDT): applicable to the occurrence of warts in the urethra, PDT is the joint application of photosensitizers (commonly δ-aminoketovaleric acid) and the corresponding light source (helium-neon laser) through photodynamic reaction selective action on the target tissue caused by the destruction of warts tissue and not damage the surrounding normal tissue a treatment method. The advantages of this treatment method are small side effects, non-invasive, high cure rate, and low recurrence rate.
3, system treatment.
(1) Interferon: 1 million U to 3 million U subcutaneous or intramuscular injections, every other day or twice a week. The efficacy of each report varies greatly, in general, do not have to use, for immune function low acromegaly patients, can be selected.
(2) Levamisole: It has immunomodulatory effects and can enhance the function of lymphocytes.
(3) Other immunomodulators, such as transfer factor, etc.
4, surgery: suitable for large condyloma acuminata, to surgical methods to remove the main body of the wart, to be wound healing after the use of local drugs or freezing and other methods. Some patients have long foreskin, in the foreskin there are most of the condyloma acuminata damage, it is recommended to circumcision.
5, in the treatment of several issues should be noted.
（The actual fact is that you can find a lot of people who are not able to get a good deal on a lot of things. As mentioned earlier, subclinical infection means that HPV has invaded the epithelium, causing histological changes, but there are no visible clinical changes, so the treatment is often “missed”.
(2) reinfection: the patient’s spouse or sexual partner should be examined, such as suffering from condyloma acuminata, while treatment. Otherwise, it can cause the patient to be reinfected.
(3) male urethral warts treatment: this part of the treatment is more difficult, and easy to recur. The actual fact is that you can find a lot of people who are not able to get a good deal on this.
(4) For female patients with warts, a speculum should be used with a vinegar white test to check if the cervical epithelium is infected. Since chronic infection with HPV types 16 and 18 can lead to atypical hyperplasia of the cervical epithelium and even the development of cervical cancer, cervical warts, including damage from subclinical infection, need to be treated promptly.
(5) For patients who have been basically cured, it is recommended to use topical alpha 2 b interferon gel, which is a drug with little local irritation and no significant adverse effects. 2.5% 5-fluorouracil ointment can also be used topically. To avoid the local irritating effect of this drug, it can be applied topically once a day in the afternoon and washed off before bedtime. The above topical medications can be applied once a day or every other day for 2-3 months.
Eight, follow up
Patients with condyloma acuminata should be followed up regularly after cure, usually once every 2-4 weeks for 3 months. The actual fact is that you can find a lot of people who have been in the marketplace for a long time, and they’ve got a lot of people who have been in the marketplace for a long time. Before complete cure, patients should be instructed to avoid sexual life.
Nine, prevention
1, cleanliness and self-love, avoid extramarital sex.
2, advocate the use of condoms.
3, with condyloma acuminata should be treated in a timely manner, sexual partners or spouses should go to the hospital at the same time for examination.
4, the patient’s underwear, bath towels, etc. should be used separately, and should pay attention to disinfection.