Pilot study of cervical cytology screening in a sexually transmitted diseases clinic.

A pilot study of cervical cytology was carried out on 500 new patients at the women's sexually transmitted disease (STD) clinic at this hospital. The aim was to discover the incidence of abnormal smears in order to gauge the worth of cervical cytology as a routine clinic procedure. Information was also gathered on each patient's age, sexual history, method of contraception used, previous smears, and genital infection. Smears showing carcinoma in situ, dysplasia, or warty atypia were regarded as abnormal, and the relevant patients were referred for colposcopy. Seventy-three (14.6%) had abnormal smears. Eight women (1.6%), average age 29.7 years, had cervical intraepithelial neoplasia grade III (CIN III) confirmed by histology. One third of the patients with abnormal smears had genital warts, and the incidence of abnormal smears was greater in patients with genital warts than in those without warts. We concluded that STD clinics are useful places in which to carry out cervical cytology screening, and we noted a positive association between infection with genital warts and abnormal smears.     

Clinical features and outcome of first presentation anogenital warts in men and women

Objective Correlation of clinical features of patients on initial presentation of anogenital warts to outcome of treatment. Setting Outpatient genitourinary medicine clinic. Method Retrospective cohort analysis. Subjects Eighty-three male and 60 female patients attending the clinic with first episode anogenital warts within a 3-month period. Main outcome measures Relapse of warts following treatment. Total time for which treatment was given. Results Following one course of treatment, warts relapsed in 15% of the men, hut in only 37% of the women. After two courses, further relapse occurred in 31% of males and 18% of females (P < 0.001). Treatment for more than 6 months was required for 39% of men, but only 22% of women. Poorer outcome of treatment was related to larger size of warts at presentation. No significant relation was found between outcome and number, site or type of treatment used for warts, or for sexual behaviour or orientation of patients. A previously diagnosed sexually transmitted disease (STD) was reported by 34% of men and 28% of women: 28% of men and 23% of women had an STD diagnosed at the time of presentation with warts. No significant relation was found between outcome and STDs past or concurrent, including HIV. Female patients tended to have smaller warts than men but their better outcome remained significant after controlling for the size of warts. Conclusions Treatment outcome for genital warts is poor and significantly predicted by size of warts at presentation. Female patients have a better outcome from treatment of genital warts than male patients.     

Genital HPV infection not a local but a regional infection: experience from a female teenage group.

OBJECTIVES--To investigate the prevalence of human papillomavirus (HPV) infections in a group of female teenagers, and to analyse to what extent HPV DNA was also detectable, in urethra and cervix samples among the patients with macroscopic genital warts compared with those without. DESIGN--The patients were interviewed about their sexual habits and history of venereal diseases. They underwent a gynaecological health control examination, including macroscopic inspection for genital warts and collection of a cytological vaginal smear (Pap smear). Cell samples were also taken from endocervix and urethra and from vulva lesions, when found. These samples were tested for HPV DNA of the types 6, 11, 16, 18 and 33 using the polymerase chain reaction (PCR) technique. SETTING--An adolescence out-patient clinic in Malmö, Sweden. SUBJECTS--Forty-nine female teenagers consulting for gynaecological complaints, some of them for genital warts. RESULTS--Twenty patients had present and four had a history of genital warts (group A). The other 25 patients had no visible lesions (group B). In the first group (A) 18 of the 24 patients were positive for HPV DNA in one or more of the three locations studied. More patients were positive in urethra (17) than in cervix (15). In group B four of the 25 patients were positive for HPV DNA in urethra, three of these also in cervix. In the two groups 11 and four patients, respectively, showed pathological Pap smears. CONCLUSIONS--The finding of HPV DNA in urethra, both from women with and without visible genital warts, indicates that there is a high probability that the infection is also present in cervix, suggesting that the genital HPV infections are multifocal. Thus, patients with genital warts are most likely to have cervical HPV infections and will more often have pathological Pap smears than patients without warts.     

Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic.

INTRODUCTION--A recent study comparing heterosexual men with and without confirmed sexually transmitted diseases (STDs) in an urban STD clinic showed that uncircumcised men were less likely than circumcised men to have genital warts detectable by clinical examination (adjusted odds ratio 0.7, 95% confidence interval 0.4, 0.9). Based on these initial findings we hypothesised that the appearance and anatomic distribution of genital warts, and possibly treatment response, may be different for circumcised and uncircumcised men. METHODS--The anatomic location, appearance, number of warts, and response to treatment was investigated through review of medical records of 459 heterosexual men with genital warts detected in 1988. RESULTS--Age- and race-adjusted estimates indicated that among men with genital warts, warts were detected much more commonly on the distal penis--that is, the corona, frenulum, glans or urethral meatus-, among uncircumcised men (26%) than among circumcised men (3%) (OR 10.0, 95% CI 3.9, 25.7). Where the appearance was specified, warts were more often described as condylomatous in uncircumcised men and slightly more often as papular in circumcised men. No significant difference between circumcised and uncircumcised men was seen in the number of return visits to the clinic for persistent warts after treatment with liquid nitrogen: 2.2 visits for 19 uncircumcised men and 2.3 visits for 149 circumcised men. CONCLUSION--Circumcised men were more likely than uncircumcised men to have genital warts, but when present, warts were more often located on the distal portion of the penis among uncircumcised men. This paradox is not understood, but could reflect either nonspecific resistance to proximal penile warts conferred by the foreskin, or heightened susceptibility to various HPV types in uncircumcised men, some of which may confer subsequent immunity to genital warts.     

Increased incidence of cervical cytological abnormalities in women with genital warts or contact with genital warts: a need for increased vigilance?

OBJECTIVE--To determine whether women who have a history of genital warts or whose sexual partners have such a history were more likely to have borderline or dyskaryotic cervical smears than other women. DESIGN--Prospective study conducted over a five month period. SETTING--A genitourinary medicine clinic in Cambridge, UK. PATIENTS--One hundred and eighty five women who attended the clinic during the study period, on whom cervical cytology was performed. Ninety-seven had a history of genital warts and twenty had partners with genital warts. METHODS--Cervical cytology taken by standard methods. Demographic data and sexual history obtained by questionnaire. Colposcopy was performed on patients with a history of warts or wart contact. OUTCOME MEASURED--Relative incidence of cytological abnormalities in the various groups of patients. RESULTS--"Borderline" nuclear change was the most frequent abnormality reported in the wart contact group (six cases) whereas mild dyskaryosis was the most frequent abnormal finding in those women with a history of warts (21 cases). CONCLUSIONS--Women with warts or contact with genital warts were more likely to have borderline or dyskaryotic cervical smears than women without such a history. Recommendations for follow-up of these patients are made.     

Cervical signs of HPV infection in PAP-smear negative women with external genital warts

Forty-eight women with external genital warts, all with normal cervical cytological PAP smears, were examined by means of colposcopy. One cervical biopsy for histological evaluation was taken from each woman, irrespective of the colposcopic findings. Koilocytosis was detected in 18/48 (38%) and dysplasia (CIN-1) in 3/48 (6%) of the patients. The presence of aceto-white lesions on the cervix was significantly associated with abnormal histology; 12 of 17 (71%) aceto-white lesions and 8 to 31 (26%) normal-appearing cervices showed histological changes indicating HPV infection (p less than 0.01). Women with koilocytosis and dysplasia had genital warts for a mean of 201 days compared with 79 days in women with normal cervical histology (p less than 0.01). It is concluded that even the clinically normal appearing cervix frequently is a reservoir for HPV and that colposcopy should be a routine procedure in women with external genital warts, irrespective of the result of the PAP smear, to provide a basis for proper counselling and individual therapy.     

Investigation of patients with genital warts presenting to dermatological and to genito-urinary departments

Although many patients with genital warts attend a genito-urinary clinic, a number are referred by their general practitioners directly to a dermatologist. Studies from genito-urinary clinics have suggested that a high proportion of patients have other genital infections. A recent study has suggested that patients with genital warts referred to dermatologists are similar (Fairris, Statham & Waugh, 1984).
Fifty male patients with anogenital warts referred to the Skin Hospital were studied. Details of sexual history, contact with anogenital or other viral warts, and history of previous or concomitant sexually transmitted disease were obtained. Patients were examined for urethral discharge, and for proctitis in the case of perianal warts. Urethral swabs for Gram stain, gonococcal culture and Chlamydia culture were taken from all patients, with rectal swabs for gonococcal culture from patients with perianal warts. Serological tests for syphilis were performed.
Clinical evidence of genital infections other than warts was found in only one patient with a urethral discharge, who was found to have gonococcal urethritis. Genital infections were detected in three patients. Urethral swabs from two grew Gonococcus , and from one grew Chlamydia.
Of 50 male patients presenting with anogenital warts to the genito-urinary department of the Manchester Royal Infirmary, eight had other genital infections. These included one with gonococcal urethritis, five with non-specific urethritis and two Chlamydia infections.
A similar study of female patients is being undertaken and preliminary results suggest a higher rate of genital infections than in men.     

Human papillomavirus DNA detection in primary anogenital warts and cervical low-grade intraepithelial neoplasias in adults by in situ hybridization.

In this study, 58 consecutive patients with primary anogenital warts were selected from patients attending a genitourinary clinic. Patients were grouped on the basis of clinical lesion site, i.e. patients with genital warts only, patients with perianal or anal canal warts only, and patients with concurrent perianal and genital warts. Of these patients, 38% of the men (12/31) and 33.3% of the women (9/27) had other anogenital infections, such as nonspecific urethritis (NSU) or nonspecific genital infection, which were the most common. Of the patients who had perianal warts, 37% of the men (7/19) and 25% of the women (4/16) also had warts in the anal canal. Of the women who had anogenital warts, 63% (17/27) had concurrent subclinical low-grade cervical intraepithelial neoplasia (CIN) lesions. Human papilloma virus (HPV) DNA (either 6 or 11, 16 or 18, or 31 or 33 or 35) was detected in 53.3% (40/75) of the anogenital wart biopsy samples, and in 35.2% (6/17) of the low-grade CIN lesions. HPV types 6 or 11 were the most common types in anogenital warts (45.3%); and in CIN lesions HPV types 6 or 11 and 16 or 18 were found with equal frequency (17.6% each). There were no significant differences in HPV types between patients with genital warts and patients with perianal and anal canal warts. Anogenital infection with HPV is multicentric; external anogenital warts and subclinical CIN lesions often exist concurrently. The low prevalence of HPV DNA detected in anogenital warts and CIN biopsy samples may be due to insensitivity of the in situ hybridization technique used in this study.     

Pattern of sexually transmitted diseases and risk factors among women attending an STD referral clinic in Nairobi, Kenya

BACKGROUND: In Kenya, sexually transmitted disease (STD) clinics care for large numbers of patients with STD-related signs and symptoms. Yet, the etiologic fraction of the different STD pathogens remains to be determined, particularly in women. GOAL: The aim of the study was to determine the prevalence of STDs and of cervical dysplasia and their risk markers among women attending the STD clinic in Nairobi. STUDY DESIGN: A cross-section of women were interviewed and examined; samples were taken. RESULTS: The mean age of 520 women was 26 years, 54% had a stable relationship, 38% were pregnant, 47% had ever used condoms (1% as a method of contraception), 11% reported multiple partners in the previous 3 months, and 32% had a history of STDs. The prevalence of STDs was 29% for HIV type 1, 35% for candidiasis, 25% for trichomoniasis, 16% for bacterial vaginosis, 6% for gonorrhea, 4% for chlamydia, 6% for a positive syphilis serology, 6% for genital warts, 12% for genital ulcers, and 13% for cervical dysplasia. Factors related to sexual behavior, especially the number of sex partners, were associated with several STDs. Gonorrhea, bacterial vaginosis, cervical dysplasia, and genital warts or ulcers were independently associated with HIV infection. Partners of circumcised men had less-prevalent HIV infection. CONCLUSION: Most women reported low-risk sexual behavior and were likely to be infected by their regular partner. HIV and STD prevention campaigns will not have a significant impact if the transmission between partners is not addressed.     

Cervical epithelial abnormalities are significantly associated with non-HPV lower genital tract infection in female contacts of warts*

Objectives

• 1 To assess the prevalence of cervical epithelial abnormalities in female sexual partners of men with anogenital warts.
• 2 To examine the possible association between non-HPV lower genital tract infection, and cervical epithelial abnormalities.

Design Retrospective review of the medical records of all female sexual partners of men with anogenital warts attending the GUM clinic in 1990. Setting and patients The department of Genito-Urinary Medicine (GUM), Royal Victoria Hospital, Belfast. Sixty-two female sexual partners of men with anogenital warts. Methods Cervical cytology and colposcopy was performed on all patients. Biopsies were taken of colposcopically identified cervical epithelial abnormalities, Non-HPV lower genital tract infection was detected by routine genito-urinary screening. Demographic data and sexual history were obtained by questionnaire. Outcome measured Overall prevalence of cervical epithelial abnormalities and correlation to the presence of non-HPV lower genital tract infection in the female. Results The overall prevalence of cervical epithelial abnormalities detected with colposcopy and biopsy was 46.8%. The prevalence of koilocytosis and cervical intraepithelial neoplasia (CIN) was 69.6% when non-HPV lower genital tract infection was detected by routine genito-urinary screening. When no infection was detected the prevalence was 33.3% (P < 0.05).     

Topical anaesthesia with local anaesthetic (lidocaine and prilocaine, EMLA) cream for cautery of genital warts.

Removal of genital warts by thermocautery was performed in 108 patients (57 men and 51 women) under topical anaesthesia with a local anaesthetic cream, lidocaine and prilocaine (EMLA). Most men had warts in the preputial cavity, most women had warts situated on the mucous membranes of the vulva, and warts at multiple sites were common. About 1 ml of cream per lesion was applied to the warts for 20 to 105 minutes before the operation. Plastic film (Glad, Union Carbide) was applied over the cream when natural occlusion, such as under the prepuce or on the introitus, was not present. Local pallor was seen in 30% of the patients, redness in 53%, and oedema in 15%, but did not cause any discomfort and were clinically insignificant. Analgesia was sufficient in 96% of the men and in 40% of the women. Additional local infiltration was given to 60% of the women, but was not as painful as injections generally are in the genital area. The analgesic efficacy on women may be further improved by optimising the application time on the genital mucosa.     

Relation between information and advice provision to male GUM clinic attendees and sexual orientation and ethnic group

OBJECTIVES: To examine whether the provision of advice and information to male genitourinary medicine (GUM) clinic attendees was related to their reasons for attendance, ethnicity, or sexual orientation. METHOD: Cross sectional survey of men attending a large city centre GUM clinic. Data were collected using an anonymous subject completed questionnaire. RESULTS: Of the 302 men recruited, 72% described themselves as white and 85% reported only female sexual partners. Information and advice provision were generally found to reflect reason for attendance--for example, those attending with a concern about "an STD or urinary problem" were more likely to report advice and information on NSU/chlamydia, herpes, gonorrhoea, or syphilis than those attending without such concerns. For those attending with a concern about HIV less than half (42%) reported receiving advice and information about HIV. The reasons for attendance were found to vary with ethnicity (black men were more likely to attend for a "check up," and less likely to attend about HIV or with genital warts than white men) and sexual orientation (those with male partners were more likely to attend about HIV or hepatitis B than those with only female partners); there were corresponding variations in the provision of advice and information. CONCLUSIONS: The clinic was generally providing advice and information appropriate to the reasons for attendance and this reflected variations in such needs with ethnicity and sexual orientation. The provision of advice and information about HIV could be more comprehensive.     

Cervical cytology screening in sexually transmitted diseases clinics in the United Kingdom. British Co-operative Clinical Group.

During a three month prospective study in 116 sexually transmitted disease (STD) clinics throughout the United Kingdom, out of 17,261 women who underwent cervical cytology, 1167 had dysplastic smears and 115 had positive smears. Positive smears were more prevalent in women attending Welsh clinics than elsewhere in the United Kingdom and increased in incidence with rising patient age. Of all cytological abnormalities reported, 56% of dysplastic smears and 33% of positive smears were found in women aged under 25 years. A subsequent retrospective study in 10 teaching hospitals suggested that past or present genital warts were associated with these cytological abnormalities of the cervix, especially in younger women.     

Immunotherapy of genital warts with inosine pranobex (Imunovir): preliminary study.

One hundred and sixty five heterosexual men and women with genital warts were treated with inosine pranobex (Imunovir) or conventional treatment, or both. Inosine pranobex was found to be more effective in lesions of longer duration, whereas conventional treatment was more effective in genital warts of a shorter duration. Supplementation of conventional treatment with inosine pranobex increased the success rate from 41% to 94%. Immunological studies in 134 patients with genital warts showed an increased number of B cells in 21% of peripheral blood samples. Absence of major defects among circulating lymphocytes suggested that patients with genital warts may have a local immune reaction.     

Cryotherapy Versus Podophyllin in the Treatment of Genital Warts

Abstract: 572 patients with solitary or multiple genital warts attending the Department of Genitourinary Medicine at the Royal Victoria Hospital, Bournemouth, U.K. between lanuary 1981 and December 1981 were allocated to either pedophilic or cryotherapy for the treatment of their warts. Of 350 patients successfully treated for their warts and returned for a follow-up examination 6 weeks or more after completing their treatment, 206 (139 men and 67 women) were treated with pedophilic, and 144 (86 men and 58 women) with cry therapy. One hundred five (51 %) of those treated with pedophilic and 114 (79%) treated with cryotherapy were free of warts at their follow-up examination. Patients treated with podophyllin required a mean of 6,7 SD 3.5 treatments over a mean of 4.7 SD 2.4 weeks, whereas those receiving cryotherapy required a mean of 2.6 SD 2.0 applications over a mean of 2.3 SD 1.2 weeks.     

Cryotherapy Versus Podophyllin in the Treatment of Genital Warts

572 patients with solitary or multiple genital warts attending the Department of Genitourinary Medicine at the Royal Victoria Hospital, Bournemouth, U.K. between January 1981 and December 1981 were allocated to either podophyllin or cryotherapy for the treatment of their warts. Of 350 patients successfully treated for their warts and returned for a follow-up examination 6 weeks or more after completing their treatment, 206 (139 men and 67 women) were treated with podophyllin, and 144 (86 men and 58 women) with cryotherapy. One hundred five (51%) of those treated with podophyllin and 114 (79%) treated with cryotherapy were free of warts at their follow-up examination. Patients treated with podophyllin required a mean of 6.7 +/- SD 3.5 treatments over a mean of 4.7 +/- SD 2.4 weeks, whereas those receiving cryotherapy required a mean of 2.6 +/- SD 2.0 applications over a mean of 2.3 +/- SD 1.2 weeks.     

Cervical cytology: are national guidelines adequate for women attending genitourinary medicine clinics?

OBJECTIVES: To study whether all women attending a genitourinary medicine (GUM) clinic warrant a cervical smear as part of a routine screen for infection, or whether this "at risk" population is adequately covered by the national screening programme. METHODS: A cervical smear and a screen for sexually transmitted infections (STI) were taken from 900 women attending a GUM clinic between May 1996 and April 1997. RESULTS: Of 812 smears available for analysis, 613 (75.5%) were normal, 176 (21.7%) were mildly abnormal, and 23 (2.8%) were moderately or severely abnormal. In the absence of an STI there was a 14% (37/273) risk of having an abnormal cervical smear. In the presence of cervicitis the risk was 26% (22/84) and with genital warts the risk was 34% (75/215). CONCLUSION: The national screening programme guidelines for cervical cytology should be followed in the GUM clinic. There is no benefit in performing extra smears outside the programme nor in adopting a policy of universal screening.     

Cervical cytology screening in a sexually transmitted diseases clinic for the first time in Sri Lanka.

A prospective study of cervical cytology was carried out on 350 consecutive female patients attending the central venereal diseases clinic (CVDC) in Colombo, Sri Lanka. The main objective was to assess the proportion of abnormal cervical smears to emphasise the need to introduce routine cervical cytology screening in the sexually transmitted diseases (STD) clinics in Sri Lanka. Data about each woman's age, sexual history, method of contraception, number of pregnancies, genital infections, and previous cervical smears were collected to compare the findings in patients with normal smears with findings in those with abnormal smears. Smears reported as showing koilocytic atypia, dyskaryosis, carcinoma in situ, or invasive carcinoma were considered to be abnormal. Forty seven (13.4%) women in the study sample had abnormal smears, and 32 of these were aged under 35. None of the 350 patients had had a cervical smear taken previously. Women who had had five or more pregnancies, compared with those who had had four or fewer pregnancies, and women with trichomoniasis, compared with no genital infection, had significantly higher incidences of abnormal than normal smears. Higher proportions of abnormal than normal smears were also found in women whose sexual partners had been surgically sterilised. These findings suggest a serious need for cervical cytology screening in STD clinics.     

Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study

OBJECTIVE: The objective of this study was to determine the prevalence, incidence, and risk factors for genital and anal warts in HIV-negative homosexual men in Sydney. STUDY DESIGN: The authors conducted a prospective cohort study. Participants were asked whether they had had genital and anal warts at each interview. Details of lifetime sexual contacts and sexual behaviors in the last 6 months were collected. RESULTS: Among 1,427 men recruited, 8.9% and 19.6% reported a history of genital and anal warts at baseline, respectively. Incidence rates for genital and anal warts were 0.94 and 1.92 per 100 person-years, respectively. In multivariate analysis, both incident genital and anal warts were associated with younger age. In addition, incident genital warts was associated with insertive fingering (P trend = 0.018), whereas incident anal warts was associated with insertive fingering (P trend = 0.007) and insertive fisting (P trend = 0.039). CONCLUSIONS: Anal warts were twice as common as genital warts. Fingering and other manual sexual practices may be an important transmission route for both.     

Detection of human papillomavirus DNA on the fingers of patients with genital warts

OBJECTIVE: To determine whether patients with genital warts carry human papillomavirus (HPV) DNA on their fingers. METHODS: 14 men and eight women with genital warts had cytobrush samples taken from genital lesions, finger tips, and tips of finger nails. Samples were examined for the presence of HPV DNA by the polymerase chain reaction. RESULTS: HPV DNA was detected in all female genital samples and in 13/14 male genital samples. HPV DNA was detected in the finger brush samples of three women and nine men. The same HPV type was identified in genital and hand samples in one woman and five men. CONCLUSION: This study has identified hand carriage of genital HPV types in patients with genital warts. Although sexual intercourse is considered the usual mode of transmitting genital HPV infection, our findings raise the possibility of transmission by finger-genital contact.