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Anal Condylomata

Condyloma acuminata (anal and perianal warts) are caused by certain types of Human Papiloma Virus (HPV). A total of 68 different types (or serotypes) of HPV have been identified; only a subset can grow in the anal region. In a minority of patients, if the warts are left untreated, anal condylomata can degenerate or turn into a squamous cell invasive cancer. If anal warts are destroyed upon discovery and patients are examined frequently for recurrences after the initial treatment then squamous cell cancers will not have the opportunity to develop. The majority of perianal and anal condylomata are caused by HPV types 6 and 11 (low risk) which rarely lead to a squamous cell cancer. Patients with anal warts caused by HPV types 16 and 18 are at higher risk for the development of a cancer and are usually reexamined more frequently after initial treatment. Regardless of the specific serotype, it is necessary to remove or otherwise destroy anal warts when they are discovered.

It is thought that condylomata accuminatum are most often sexually transmitted, however, transmission by close (non-sexual) contact with infected individuals has been reported and described. Anal and genital warts can be found in both heterosexual and homosexual men and woman. Anal warts are also more commonly found in immune suppressed individuals and patients on immunosuppressive medications. For example, they are more commonly seen in renal transplant patients.


Condylomas in the anal region are most commonly found on the anoderm of the anal canal (the external part of the anal canal that has a thin skin lining) and also on the perianal skin which surrounds the anus. In some patients, however, these warts can be found growing internally on the most distal rectal mucosa (intestinal lining of the rectum that is in the anal canal). The lesions are usually pink or white in color. These lesions can be flat or polyp like lesions (cauliflower-like) that extend from the skin. The warts can be single lesions or groups or clumps of lesions. They range in size from a few millimeters to much larger lesions that surround the anal canal (very rare). Warts can also be found on/in the penis, scrotum, labia or vagina. All warts, regardless of location, must be treated.


Although perianal/anal condylomata may be asymptomatic, most patients have minor symptoms and complaints associated with the lesions. The symptoms include: 1) minor bleeding (usually at the time of cleaning of the perianal region after a bowel movement), 2) anal itching (related to inflammation or to difficulties cleaning the anal area), 3) minor discomfort and pain, and 4) anal discharge, and 5) anal wetness. These lesions are not uncommonly discovered when the patient notes a lump, protrusion, or lesion when cleaning the area.


In most cases, the presence of anal warts can be determined by a thorough external perianal and perineal examination. In some patients the diagnosis may not be obvious in which case a biopsy is necessary to establish the diagnosis. It is critical that the anal canal be thoroughly examined for internal warts with an anoscope. A thorough external and internal anorectal examination is necessary at the time of follow up visits.


There are both surgical and non-surgical treatments. Patients with limited external anal warts can be treated with topical creams/ointments in the office or home. Surgical treatment is most often reserved for patients with both internal and external lesions and in those with many lesions or with large lesions. Internal lesions require surgery for their destruction because the topical treatments used to destroy warts externally, when used internally, can burn and destroy the adjacent normal rectal lining. The topical agents used include: 1) bichloroacetic (or trichloroacetic) acid, 2) podophyllin, 3) 5-fluorouracil cream, 4) Aldara cream, 5) Thiotepa, 6) Bleomycin, and 7) Interferon. The latter 3 treatments are rarely used today. Of note, interferon therapy is associated with serious side effects including fevers, chills, myalgia, headache, and fatigue in some patients.

The bichloroacetic acid treatment is the chemical agent that is commonly used to treat external lesions. The acid is placed directly onto the warts with an applicator in the doctor’s office. The surrounding skin is protected from the acid by petrolatum jelly which is placed on the unaffected nearby skin. The patient is instructed to take a thorough shower, bath, or sitz bath in 3 to 4 hours. In the author’s office, the treatment is repeated every 3 to 4 weeks until the external lesions are destroyed.

In a hospital operating room or outpatient operating suite a variety of approaches can be used including: 1) surgical excision of wart and small rim of normal skin/lining, 2) electroagulation (burning of the wart down to the dermis or subcutaneous fat), 3) cryotherapy (freezing of the warts), and 4) laser therapy. The most commonly used combination is surgical excision of some lesions to establish the diagnosis and then electrocoagulation to destroy the other warts (at the same time). It should be noted that anesthesia is required prior to surgical treatment. Dr. Whelan utilizes surgical excision and electrocoagulation in the operating room for the treatment of anal warts.

Another approach, seldom if ever used today, is to make an autologous vaccine from each patient’s anal wart tissue that is surgically excised. The patient is then repeatedly injected with the vaccine that was prepared from their own wart tissue. A large amount of wart tissue is needed for this (5 grams advised). The results have been disappointing. In one study, a good response was observed in only 11 % of patients. Dr. Whelan’s office is not capable of making or administering this type of vaccine.


No anesthesia is usually given for office treatments such as bi-cloroacetic acid or podophyllin. Patients may experience a burning sensation from the acid after it is applied. This is usually a minor discomfort that does not require narcotic pain medication in the majority of patients. If requested, local anesthesia (usually lidocaine or marcaine) can be given in the office, however, the injections required to administer the lidocaine or marcaine are a bit painful as well.

In the operating room, local anesthesia that is injected subcutaneously is often used in combination with intravenous pain medications and anti-anxiety medications that are administered by an anesthesiologist. An alternative is to administer a spinal anesthetic block that knocks out all pain and sensation below the waist for several hours. If requested, general anesthesia can also be administered. Regardless of the anesthetic method used, at the end of the operation local anesthesia is administered to the area to decrease the postoperative pain.

Recurrence and Surveillance

Regardless of which type of treatment is used, there is a high rate of recurrence. The medical literature in this area is not ideal because the follow up periods for many of the papers is relatively short and, not infrequently, incomplete. Also, for the more esoteric methods there are only a few published papers and limited results available. Although the recurrence rate varies from series to series a realistic range of rates is between 25 and 35 %, regardless of the method used. Immunosuppressed patients may have a higher recurrence rate.

It is crucial that close surveillance via external inspection of the anorectal area and anoscopy (to view the inner anal lining) be carried out every 3 to 4 months for at least the first several years after the warts have been completely destroyed. After 2 years of surveillance every 3-4 months the interval between examinations can be extended to 6 months for at least 2-3 years further. Unfortunately, in some patients, warts can recur many years later. If recurrent or new warts are found at any time then they must be destroyed and the close surveillance resumed.

What Our Patient’s Say…

Our family wishes to express our heartfelt appreciation for the kindness, excellent care and wisdom our mother, Jean Broussard, received during her hospitalization.

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