Human Papillomavirus - Vulvovaginal Infections

HUMAN PAPILLOMAVIRUS

Human papillomavirus (HPV) infection is sexually transmitted and is the most common sexually transmitted disease (STD) among young, sexually active persons. An estimated 5.5 million people become infected with HPV each year in the United States (U.S. Surgeon General’s Report, 2001). More than 80 strains exist, some of which are associated with cervical abnormalities, includ-ing dysplasia and cancer. Infections can be latent (asymptomatic and detected only by DNA hybridization tests for HPV), subclin-ical (visualized only after application of acetic acid followed by in-spection under magnification), or clinical (visible condylomata acuminata). The most common strains, 6 and 11, usually cause condylomata (warty growths) on the vulva. These are often visi-ble or may be palpable by the patient. Condylomata are rarely pre-malignant but are an outward manifestation of the virus. Strains 6 and 11 are associated with a low risk for cervical cancer. Some strains may not cause condylomata but affect the cervix, resulting in abnormal Pap smear results. For example, strains 16, 18, 31, 33, 35, and 45 affect the cervix. Their effects are usually invisible on examination but may be seen on colposcopy. They may cause cer-vical changes that may appear as koilocytosis on Pap smear or ab-normal smear results. These strains are associated with a higher risk for cervical cancer (U.S. Surgeon General’s Report, 2001).

The incidence of HPV in young, sexually active women is high. Risk factors include being sexually active, having multiple sex partners, and having sex with a partner who has or has had multiple partners. Alcohol consumption and drug use are risk fac-tors, as both impair careful decision making, judgment, and self-care (Association of Reproductive Health Practitioners, 2001).

Medical Management

Treatment of external genital warts includes topical application of trichloroacetic acid, podophyllin (Podofin, Podocon), and chemotherapeutic agents. Interferon injections are also used in treatment. These agents are applied by the health care provider. Topical agents that can be applied by the patient to external le-sions include podofilox (Condylox) and imiquimod (Aldara). Be-cause the safety of podophyllin, imiquimod, and podofilox during pregnancy has not been determined, these agents should not be used to treat pregnant women. Electrocautery and laser therapy are alternative therapies that may be indicated for pa-tients with a large number or area of genital warts (Centers for Disease Control & Prevention, 2002).

Treatment usually eradicates perineal warts or condylomata. However, they may resolve spontaneously without treatment and may also recur even with treatment.

If the treatment includes application of the topical agent by the patient, she needs to be carefully instructed in the use of the agent prescribed and must be able to identify the warts and be able to apply the medication to them. The patient is instructed to anticipate mild pain or local irritation with the use of these agents (Centers for Disease Control & Prevention, 2002).

Patients with HPV should have regular Pap smears, possibly every 6 months for several years, because of the propensity of HPV to cause dysplasia (changes in cervical cells).

Much remains unknown about the subclinical disease and la-tent phase of the disease. Women are often exposed to this virus by a partner who is unknowingly a carrier. Condoms can prevent transmission, but transmission can also occur during skin-to-skin contact in areas not covered by condoms. In many cases, patients are angry about having warts or HPV and do not know who in-fected them because the incubation period can be long and part-ners may have no symptoms. Acknowledging the emotional distress that occurs when an STD is diagnosed and providing support and facts are important nursing actions.