WHAT ARE ANAL WARTS?
Anal warts or condyloma are lesions that affect the lining around and inside the anus. They may also affect the skin on or around the genital region. They tend to first appear as flesh colored tiny growths as small as a pencil tip. They may grow quite large and cover the entire anal area. Usually, they are not painful but can sometimes be itchy or uncomfortable. Some patients may also experience bleeding or mucus discharge.
WHAT ARE CAUSES AND RISK FACTORS FOR ANAL WARTS?
Anal warts are usually associated with an HPV infection, which is the most common sexually transmitted disease. Certain variants of HPV are more likely to be associated with development of anal warts than others. It is important to note that anal intercourse is not necessary to contracting HPV. Exposure to the virus likely occurred many years ago or from prior sexual partners, and you may have just recently developed the actual warts.
Other risk factors include:
- Anoreceptive intercourse – Unprotected sex and multiple sexual partners increases this risk. However, anal warts are not always associated with anal intercourse.
- Smoking – This introduces harmful chemicals increases the risk anal warts.
- Immunosuppression – Certain patients with autoimmune diseases or transplant patients require immunosuppressive medications. Cancer patients may also require drugs that suppress their immune system. HIV patients with low CD4 counts have acquired immunodeficiency putting them at increased risk as well for anal warts.
WHAT ARE SYMPTOMS OF ANAL WARTS?
Most patients will experience one or more of the following: anal itching, anal bleeding, anal pain, discomfort, or mucous discharge.
HOW ARE ANAL WARTS DIAGNOSED?
Although potentially sensitive and difficult to talk about, your doctor may ask about risk factors including a history of anoreceptive intercourse, HIV status, or a chronically weakened immune system (medications for organ transplant patients, inflammatory bowel disease, rheumatoid arthritis, etc).
Your doctor will perform an anorectal examination to evaluate the skin around the anus. Digital rectal examination and possibly an anoscopy will likely be performed to assess the anal canal and rule out mass. Anoscopy involves inserting a small instrument slightly larger than the size of a finger into your anus to help visualize the area.
DO ANAL WARTS NEED TO BE REMOVED?
Yes. If they remain, the warts can grow larger and multiply. Untreated warts may lead to an increased risk of anal cancer in the affected area. Fortunately, the risk of anal cancer is very low.
WHAT ARE MY TREATMENT OPTIONS?
- Topical Medications: Certain warts may be treated with topical medication if there are no concerns for cancerous or pre-cancerous lesions. These lesions also must be very small and only located on the skin around the anus. These medications include Imiquimod or 5-fluorouracial (5-FU). How well they work to eliminate anal warts completely is unknown. These medications must be applied for several weeks and side effects include skin irritation, burning, and painful ulcerations of the skin.
- Surgical treatment: Surgery provides immediate results but must be performed using a local anesthetic in addition to light sedation. This can usually be performed at an outpatient surgical center. Surgery includes excision (removal) as well as fulguration (burning) of any external and internal anal warts.
WHAT IS MY RECOVERY LIKE AFTER SURGERY?
Most patients experience moderate discomfort for a few days after surgery, and pain medication may be prescribed. Return to work depends on the extent of the disease. Some people return to work after a couple of days, while others may remain out of work for several days to weeks. Postoperative pain, discomfort, and slight bleeding are expected and may last at some level for several weeks. Clear, yellowish or blood tinged drainage is to be expected for days to weeks after the procedure. Absorptive pads such as gauze or sanitary napkins (feminine pads) may be used to absorb moisture and itching associated with the drainage.
WHY AM I GETTING RECURRENT WARTS?
Warts may recur repeatedly after successful removal. This is because the virus that causes the warts often persists in a dormant state and has not been eradicated.
To prevent spread of HPV, safe sex practices are recommended which include abstinence, condom protection, or limiting sexual contact to single partner. As a precaution, sexual partners ought to be checked for warts and other sexual transmitted diseases (STD), even if they have no symptoms. Your physician may recommend testing for other STDs depending on signs and symptoms.
WHAT IS ANAL DYSPLASIA?
A pathologist may detect that some warts have abnormal changes called “dysplasia”. Dysplasia is classified based on how advanced it appears under the microscope. Low grade anal intraepithelial neoplasia (LGAIN) can sometimes become high grade but the vast majority of LGAIN do not turn into cancer. High grade anal intraepithelial neoplasia (HGAIN) contain cells that are “premalignant” or pre-cancerous. These cells are not invasive, but have the potential to become cancerous if the tissue is not completely excised. Patients with HGAIN and high risk patients with any dysplasia need close follow up determined by their physician. A gynecologic examination is also recommended in females, as the presence of HGAIN puts a female patient at risk for having cervical dysplasia.
HOW IS ANAL DYSPLASIA DIAGNOSED?
Anal dysplasia is usually found within anal wart or sometimes these cells are found incidentally at the time of unrelated anal surgery such as hemorrhoid surgery.
Screening procedures can detect anal dysplasia, however, they are not universally performed and their role in prevention is unclear at this time. Screening procedures include:
- Anal Papanicolaou (Pap) smear – Anal swabs are used to collect a sample of cells from the anal canal. Anal Pap can be used for both screening patients considered high-risk and as follow up after anal dysplasia has been treated. Unfortunately, this test is highly inaccurate and up to 50% of patients will have a false-positive test.
- High Resolution Anoscopy (HRA) – This is a specialized exam that uses high magnification and application of temporary stains to assess for precancerous or cancerous cells in the anus. This is very similar to colposcopy (examination of the cervix) in women who have cervical dysplasia. Directed biopsies are performed for any questionable areas to identify areas that may need further treatment.
HOW IS ANAL DYSPLASIA TREATED?
There has been much debate over the optimal treatment for anal dyplasia, and unfortunately there is yet to be a consensus. Observation alone with clinical follow-up may be considered for low grade anal dysplasia. Even with treatment, there is a high risk of recurrence so physicians may recommend close observation depending on your risk factors. Treatment options include:
- Topical 5% imiquimod (Aldara) cream or 5% 5-fluorouracil (5-FU) cream may be applied to areas of anal dysplasia. These creams usually need to be applied for several months. Side effects include skin irritation, burning, painful ulcerations, and hypo-pigmentation (loss of color around the anus).
- Wide local excision. This surgical technique involves removal of all affected areas. Total removal of all disease is often difficult and can still result in high rate of recurrence. Complications include narrowing of the anal opening and fecal incontinence.
- Targeted therapy using high-resolution anoscopy (HRA). HRA is effective to identify, biopsy and destroy anal dysplasia without the long recovery and complications associated with wide local excision. There is still a high risk of persistent or recurrent disease, reported in up to 20-80%. Complications such as incontinence and narrowing are generally not seen with HRA.
Both wide local excision and targeted destruction by HRA have been shown to prevent progression from anal dysplasia to anal cancer.
AFTER TREATMENT, WHAT IS MY FOLLOW-UP?
High risk patients with any dysplasia or any patient with HGAIN should usually be closely followed long term to detect recurrence and avoid progression to anal cancer. Physical examinations may be performed at periodic intervals as determined by your docor. Follow-up generally includes digital rectal examination, anoscopic examination. Depending on risk factors, it may include repeated HRA and/or Pap smear. Discuss your surveillance plan with your doctor to see what type of surveillance is right for you.
ABOUT COLON AND RECTAL SPECIALISTS
Colon and rectal specialists was founded in 1913. We are a group of dedicated fellowship trained colorectal surgeons. We are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. Our surgeons have all completed advanced surgical training in the treatment of these diseases in addition to full general surgical training. We are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.
ABOUT C.A.R.E.S. CENTER
Colon and Rectal Endoscopy and Surgery (CARES) Center is our state-of-the-art Ambulatory Surgery Center. Our center has been accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) and has been given Medicare Deemed Status by CMS. We perform a variety of services including: screening colonoscopies, anal biopsies, high resolution anoscopy (HRA), hemorrhoidectomy, abscess and fistula surgery, fissure surgery, pilonidal surgery, and surgery to treat fecal incontinence. Learn more about us at www.crspecialists.com.
