The anal warts are due to infection of the anus by human papillomavirus (Human Papilloma Virus–HPV), the most common sexually transmitted disease. Warts affect the area around and inside the anus but can also develop on the skin of the genital area and perineum. They first appear as tiny spots, often as small as a pinhead. They can grow quite large and cover the entire area of the anus.
It is worth noting that when there are warts on the skin around the anus, there is a high possibility of coexistence of warts inside the anus as well. For this reason, in order to fully treat the problem, a person who has experienced perianal warts in the internal area of the anus should be checked with a high-definition proctoscopy. The warts extend to a distance of 5-7cm from the anus and no deeper, as it has been clarified by scientific studies; the HPV virus infects the cells of the anus but not the cells of the intestine.
The HPV virus, in addition to anal warts (causes in some people precancerous lesions in the anus called dysplasias. If these are not treated in time, there is a 10-15% chance within 3-5 years that they will develop into anal cancer. Most warts can be easily diagnosed with a simple proctoscopy, but rectal malformations are almost impossible to find in the same way because these lesions are flat, and their color is similar to that of the normal rectal mucosa.
For this reason, those patients who have warts in the anus must undergo a high-resolution anoscopy (High-Resolution Anoscopy) using acetic acid, i.e., a special liquid that colors the malformations and allows their identification with the microscope. Therefore, colonoscopy, rectoscopy, and simple proctoscopy have no place in the identification of lesions caused by HPV (warts and especially anal dysplasia).
It is of absolutely no importance to cauterize only perianal warts as intra-anal warts must always be looked for, as well as anal malformations with High Definition Proctoscopy because otherwise, untreated intra-anal lesions constitute a reservoir of the HPV virus, which continuously transmits the virus load outward causing frequent relapses. In addition, when there are warts in the anus, it is important to check for warts in the penis, vulva, and oropharynx.
The HPV virus
HPV (Human Papilloma Virus) infection is the most common sexually transmitted infection in the modern world and affects both men and women. There are about 150 types of HPV that affect different parts of the body. About 30 types of HPV (genital types) can affect the anus, genitals, mouth, pharynx, penis, scrotum, perineum, vulva, vagina and cervix.
These types are divided into two categories. The first category includes low-risk viruses that cause warts and low-grade intraepithelial lesions that are now considered not to develop into a malignancy. The second category includes the high-risk types, which cause high-grade intraepithelial lesions or dysplasias of the anus, which are considered precancerous as they can develop into anal cancer.
It is thought that approximately 80% of the sexually active population is at risk of contracting this infection at some point in their lives. The 15 or so types are considered “high risk,” and more specifically, two types (16 & 18) are found more often in cases of dysplasia or cancer of the anus.
The HPV virus is transmitted from person to person, usually through sexual contact. In particular, the HPV virus can be transmitted by having vaginal, anal, or oral sex with someone who has the virus. It is most often transmitted during vaginal or anal sex. It is also spread through close skin-to-skin contact during sex by simple skin or mucous membrane contact, contact with an infected person’s fluids, or even objects on which the virus is present (e.g., sexual aids). A person with HPV can pass the infection on to someone even when they have no signs or symptoms. For these reasons, condom use is essential but does not offer complete protection against HPV infection. Finally, the virus can be transmitted to the same person from one area to another (e.g., from the genitals to the anus and vice versa) by rubbing, scratching, or even wiping after a bowel movement. For the above reasons, when a man or a woman has warts on the genitals, they should also be examined in the anus by a specialist doctor. The partners of people who have developed warts should also always be examined in order to deal with the problem in a comprehensive way, with the aim of reducing recurrences. Otherwise, one partner who has not been treated acts as a source of transmission of the virus to the other partner, resulting in a risk of frequent reinfections.
Who is at risk of developing anal warts?
Anal warts, as well as HPV infection, are very common in both men and women. Men and women are more likely to develop anal warts who:
- They do not use a condom during sexual intercourse.
- They have multiple love partners.
- They have anal sex
- They have or have had sexual contact with a person infected with the virus.
- They started having sex at an early age.
- They do not have a strong immune system (HIV positive, transplant recipients, patients who take immunosuppressants or cortisone for various diseases on a chronic basis, etc.)
- They smoke
Also, all women with dysplasia or cancer of the lower genital system (cervix, vagina, or vulva) have an increased chance of developing HPV lesions in the anus as well. Finally, warts, as well as anal malformations, are a serious problem for HIV-positive homosexuals as in this group; there is an increased rate of HPV infection and immunosuppression which gives the DNA of the virus the opportunity to integrate into the DNA of the anal epithelium and cause cell damage.
What do anal warts look like?
Anal warts look like small moles that can appear in a variety of colors, usually skin-colored or brown, white, and pink. Their shape can be compared to that of papillomas, while their size ranges from tiny, just a few millimeters (undetectable), up to 10 to 12 centimeters. In the case where the volume of anal warts has increased excessively, partial obstruction of the anal area is possible, creating significant problems for the patient that require immediate treatment.
Anal warts usually develop in clusters and may spread to other places adjacent to the anal area (vagina, urethra, penis, etc.). They often cause itching and a burning sensation in the anus area, and, in some cases, skin lesions can lead to bleeding.
What are the symptoms of anal warts?
Anal warts are found in and around the anus area. They start as small bumps that may be no bigger than the head of a pin. Initially, they are too small to be noticed. They can develop a cauliflower-like appearance as they grow or when clustered together. Sometimes they can grow large enough to cover the entire surface of the anus and perianal skin.
Anal warts often appear without pain or discomfort. Other symptoms of anal warts are relatively rare but may include itching, bleeding, or fluid discharge from the anus. A person with anal warts may also feel like they have a lump in their anal area, as well as a feeling of fullness in the anus and a feeling of incomplete emptying.
Warts can appear on other parts of your body at the same time you have anal warts. Genital warts in women can appear on the vulva, vagina or cervix. Genital warts in men can develop on the penis, scrotum, thighs or groin. Warts can also develop in the mouth or throat of someone with an HPV infection. Oral sex with a person who has genital warts or deep kissing of a person with neck warts can also lead to infection.
Another very important element that should not be overlooked in any case is that HPV also causes malformations in the anus. These lesions are high-grade intraepithelial lesions and are considered precancerous. These lesions usually do not cause symptoms and are difficult to find because they are flat, have the same color as the normal rectal epithelium, and are soft to the touch. These lesions, if not treated, will develop into malignancy at a rate of approximately 10-15% within 3-5 years. Therefore, the only way to find them and treat them properly is by high-resolution proctoscopy using a microscope and acetic acid. This examination should be performed on all patients who present with perianal or intraanal warts in order to carry out a comprehensive treatment.
How are anal warts diagnosed?
The most appropriate doctor who can make a valid and responsible diagnosis of both intra-anal and perianal warts is the specialized surgeon-proctologist. All people with anal warts should undergo the following diagnostic tests:
- Overview of perianal country. This specific examination is short, and with it, the specialized proctologist can very easily diagnose warts found in the perianal region but also differentiate them from other conditions whose clinical picture shows some similarities to that of warts, such as hemorrhoids, anal papillomas, ring fissure, perianal fistula, hidradenitis anal diary, anal herpes, anal syphilis, and perianal skin ulcers. It is now preferred to inspect the perianal region using a microscope so that even the smallest HPV lesions can be detected.
- Cytological examination of the anus (Rectal Pap Test). This is a similar test to the Pap Test that women do to prevent cervical cancer. All people who develop perianal or intraanal warts (men and women) should have a rectal Pap test to prevent rectal cancer. The rectal Pap Test is a simple procedure, short (takes about 2 minutes) and painless, that can diagnose precancerous lesions of the anus (dysplasias) in high-risk groups of people.
- Digital examination of the anus. During the digital examination, the specialist proctologist looks for lesions that can be felt in the anus area. It is very important that all quadrants of the anal canal be inspected in detail. Additionally, with the digital examination, the tonicity of the sphincter mechanism and the prostate gland in men are checked.
- High Definition Proctoscopy (High-Resolution Anoscopy – HRA). This particular test is very specialized and is performed by very few doctors around the world. It is used to find precancerous lesions and warts inside the anus. During it, precancerous lesions are looked for using a special microscope. If such lesions are found, a biopsy is taken from all of them for histological confirmation of the diagnosis. If any biopsy is positive for dysplasia, high-definition rectaloscopy is repeated to perform laser cauterization of the histologically confirmed dysplasias of the anus and perianal region. Also important is the fact that through high-definition proctoscopy, even the smallest warts are found and cauterized, which are impossible to find with other tests.
Treatment for anal warts
The treatment of anal warts to be effective should include the treatment of both perianal and intraanal warts, as well as the detection and treatment of precancerous malformations of the anus and perianal region. All the above lesions have a common causative agent, the HPV virus, and therefore, their treatment must be uniform by a specialized proctologist. The treatment of lesions due to HPV infection (warts and malformations) must be done with High-Resolution Anoscopy (HRA). It is a process that requires training, expertise, and experience. Proctologist Dr. Ioannis Dontas is one of the first doctors to apply it in Greece after training in the United States of America.
In particular, treatment options include:
- Topical medication: These creams usually work best if the warts are very small and only on the skin around the anus.
- Topical medications that will freeze the warts (liquid nitrogen).
- Topical medications that will burn off the warts (trichloroacetic acid, podophyllin).
- Surgery: When warts are either too large for the above treatments or are internal, surgery is considered. During the operation, the warts are surgically removed. The patient will be anesthetized for the procedure. The type of anesthetic depends on the number, size, and exact location of the warts being removed. When there are many warts, the surgeon may perform the surgery in stages. An internal examination will also be done to identify and treat any damage to the inside of the anal canal.
- Cauterization of warts with a surgical carbon dioxide laser (Laser CO2). A modern technique that offers a safe and effective treatment for warts. Through the use of the hyperpulse CO Laser2 in combination with a special microscope, even the smallest lesions are identified and sublimated, thus minimizing the possibility of recurrence of warts. This particular technique is one of the safest, painless, and bloodless that exists and is the technique par excellence performed by Dr. Ioannis Dontas, always under the guidance of a microscope. The process of destroying warts usually requires some type of anesthesia. Local anesthesia is sufficient in 95% of cases. However, in patients with extensive lesions, spinal anesthesia combined with intoxication or even general anesthesia may be needed. The advantages of this technique are many. In particular, it is a painless, bloodless, simple, and short, safe technique, which has a reasonable cost, does not require the taking of analgesics, there are minimal recurrence rates, and the patient can return to his daily habits by the very next day. Finally, this is a technique that offers an excellent aesthetic result as large incisions and misshapen scars are avoided.
Anal warts and prevention
As mentioned above, anal warts are due to HPV infection. Consequently, the vaccine against the specific virus, if carried out in time, significantly reduces the chances of warts appearing. Vaccination is recommended for men and women up to 45 years of age and, ideally, should be carried out before the start of sexual contact in order to immunize the body against the strains of the virus contained in the vaccine. The vaccine has been tested in thousands of patients and found to be safe and effective in preventing warts and anal cancer as well as other malignancies such as cervical cancer.
Other ways to prevent the transmission of HPV and anal warts include:
- abstinence from sexual intercourse
- using barrier methods such as condoms
- limiting the number of sexual partners
- smoking cessation
However, barrier methods do not fully protect against HPV as HPV can also be transmitted by direct physical contact or even by contact with other objects.