Approach

Diagnosis of genital warts is made based on the clinical presentation of lesions located on the genital area, perianal region, or adjacent areas such as the mons pubis, with a tendency for genital wart formation to occur on areas of high friction.[3][17][40][41] Biopsy is generally not performed for the diagnosis of genital warts.

Clinical presentation

Genital warts are usually 1 to 3 mm, discrete, sessile, smooth-surfaced exophytic papillomas or they may coalesce into larger plaques. These plaques may be extensive, with expansion into the urethra, or into the anal or vaginal canals.[3][Figure caption and citation for the preceding image starts]: Venereal warts in the anal region of the perineumCDC/Dr Wiesner [Citation ends].com.bmj.content.model.Caption@61dc3527 Colour varies from flesh-coloured to whitish to hyperpigmented. Maceration may occur, particularly in moist areas lacking the thick horny cell layer found in cutaneous warts.[5][Figure caption and citation for the preceding image starts]: Wart on shaft of penisFrom Dr Tyring's personal collection; used with permission [Citation ends].com.bmj.content.model.Caption@45f3f506[Figure caption and citation for the preceding image starts]: Close-up of penile wartFrom Dr Tyring's personal collection; used with permission [Citation ends].com.bmj.content.model.Caption@5b7f7c7d External genital warts may be diagnosed using direct visual inspection aided by bright light and magnification.[3] Lesions are generally asymptomatic, but may be painful, friable, or pruritic.[5][6]​​​ Bleeding may occur due to local trauma or maceration of the area. Urinary symptoms such as terminal haematuria or abnormal stream of urine may be present.

Investigations

A biopsy may be indicated if the genital warts appear fixed to underlying structures or are refractory to standard therapy.[42] Additional indications for biopsy include ulceration of the lesions or an individual wart larger than 1 cm.[6]​ Should a biopsy be indicated, the following histological features are seen: epidermal hyperplasia, parakeratosis, koilocytosis, and papillomatosis.[17] Compared with common warts, the papillomatosis seen in genital warts tends to be more rounded. Not all of these histological features are necessarily seen in every genital wart. In patients with recurrent perianal warts, evaluation for intra-anal warts by anoscopy is recommended.[6]​ Urinary symptoms such as terminal haematuria or abnormal stream of urine should prompt a referral for urethroscopy to evaluate the distal urethra and meatus.​[6]​

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