• Before information is given, an assessment must be made of the patient’s existing preconceptions and concerns
• Information should cover epidemiology, transmission, natural history, treatment and partner issues varying the order and pace of information delivery to suit the needs of the patient
• All patients should be given written information
  • NHS Inform Genital Warts
  • BASHH Patient Information Genital Warts
• For some patients the psychological impact of warts is the worst aspect of the disease. Where psychological distress is apparent, referral for counselling may be appropriate.
• Several treatment attempts are usually needed before warts subside

Epidemiology

• HPV infection is very common and most infections do not result in physical genital tract lesions, and resolve spontaneously within a year
• Gardasil® has been used in the HPV immunisation programme since Sept 2012. This is a Quadrivalent HPV vaccine (types 6,11,16,18). Types 6 & 11 account for approximately 90% of genital warts of genital warts. In Australia where the national HPV immunisation programme was implemented using Gardasil® there appears to have been a substantial effect in reducing the clinical burden of genital warts.

Transmission

• The majority of individuals infected with HPV have no visible warts
• The mode of transmission is most often by sexual contact but HPV may be transmitted prenatally and genital lesions resulting from infection from hand warts have been reported in children
• Transmission studies have quoted male to female transmission at 3 months of 54% and female to male transmission of 71%
• HPV transmission can occur from asymptomatic individuals 
• Consistent condom use has been shown to reduce the risk of acquisition of HPV infection and genital warts (in the order of about 30%). They may reduce the recurrence when both partners are infected, although the extent to which recurrence is due to reinfection is not known.

Natural History

• The infection is multicentric from the outset and the location of visible lesions does not accurately reflect the original site of inoculation. e.g. the presence of perianal warts does not imply anal intercourse has occurred
• The incubation period between HPV acquisition and the appearance of visible warts is very variable but generally in the range 3 weeks to 8 months, but can be as long as 18 months, with some evidence that it is longer in men
• Some apparently new infections will actually be recurrent disease
• Warts can appear at any time if immunity is impaired e.g. in pregnancy, HIV co-infection and smokers
• Treatment of sexual partners makes no significant impact on the natural history of genital warts
• Smokers may respond less well to treatment than non smokers
• About 30% of patients will experience spontaneous clearance of warts over a period of up to 6 months

Partner Attendance
Partners should be encouraged to attend if visible warts present.