Vulval Warts (Condylomata acuminata)

Vulval warts are caused by a papilloma virus, commonly transmitted by sexual contact. The warts are pinhead in size when they first appear, typically at the posterior fourchette and adjacent labia minora. They may occur singly or in clusters, often growing rapidly and coalescing to form large masses in the vulvar, vaginal, perineal, or anal areas.

The diagnosis of external genital warts is usually made on clinical grounds and necessitates a thorough gynaecological examination. The patient should be assessed for a secondary bacterial vaginosis which is commonly seen. Appropriate swabs and serology should also be undertaken to screen for concomittant sexually transmitted infections.

Treatment methods include physical diathermy or chemical diathermy using podophyllin, cryotherapy with liquid nitrogen, imiquimod 5% cream, trichlora-cetic acid, and surgical removal. Therapeutic techniques result in clearing of the exophytic lesions rather than eradication of the virus and accordingly recurrence often occurs.

The photograph shows massive condylomatous warts present on clinical examination of a 36-year-old woman who was 6 months pregnant. Such proliferation of the warts, as seen here, is usually restricted to the pregnant state and reflects the lowered immune response in this condition. Additional presenting fea tures of a foul-smelling purulent discharge are suggestive of a secondary bacterial infection. If left untreated, bacterial vaginosis has the potential to cause preterm delivery and so appropriate diagnostic testing and therapy is imperative. Treatment of the warts, however, can be postponed until postpartum and podophyllin treatment during pregnancy is definitely contraindicated.

Vaginal delivery may present a problem due to obstruction of labour and haemorrhage. A further possible complication is that of laryngeal papillomatosis in the infant. Delivery by caesarean section is therefore recommended in a case such as this.

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