External Genital Warts: An Update

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Mayeaux Key Points • Human papillomavirus (HPV) infection can cause a spectrum of diseases ranging from nonmalignant skin growths to epithelial dysplasias and cancers. • HPV infects the nuclei basal layer of epithelial cells, where it usually exists for about 3 months in a latent state. • The majority of anogenital HPV infections are subclinical. • There are no readily available clinical diagnostic methods to identify subclinical infections. • Imiquimod, podophyllin, and podofilox are contraindicated in pregnancy. • Interferon therapy is not recommended as a primary modality because it is inconvenient, ineffective, and associated with a high frequency of systemic adverse effects. • Cesarean delivery should not be performed solely to prevent HPV transmission to the newborn. • The use of a cryoprobe in the vagina is not recommended because of the risk of vaginal perforation and fistula formation. • Patients with warts on the anal mucosa should undergo digital rectal examination or anoscopy to detect rectal warts. Genital warts in women may develop anywhere in the squamous epithelium of the lower genital tract, and multiple sites are found in about 50% of patients. 3 Although such warts are often asymptomatic, some patients may experience anogenital pruritus, burning, vaginal discharge, and/or bleeding. Rarely, dyspareunia or obstruction of the urethra, vagina, or rectum may occur. Human papillomavirus primarily infects the basal layer of epithelial cells. It usually exists in a latent state for about 3 months. The virus replicates in dividing epithelial cells, eventually producing genital warts. The majority of anogenital HPV infections are subclinical, and are identified only by whitening on application of 5% acetic acid (acetowhite effect), or a finding of HPV DNA without associated epithelial abnormalities. There are no readily available, specific clinical diagnostic methods for identifying subclinical infections. TRANSMISSION Prior or coexisting HPV infection does not affect the risk of acquiring new HPV infections. Risk is most strongly associated with sex with a new partner—ie, exposure to new strains. 4 Although vaginal intercourse is the predominant mode of transmission, HPV may also be transmitted through nonpenetrative sexual contact (eg, in virgins). 4 Contrary to traditional thinking, male condom use can reduce the risk of maleto-female transmission by 70%. 5 Other risk factors include current smoking and oral contraceptive (OC) use, which may be surrogate markers for other sexual behaviors. 4 Use of the quadrivalent HPV vaccine may decrease the risk of external HPV lesions when administered prior to exposure. VIRAL TYPES The majority of anogenital HPV infections are subclinical, and are identified only by whitening on application of 5% acetic acid (acetowhite effect), or a finding of HPV DNA without associated epithelial abnormalities. More than 30 HPV types can infect the human genital area. 6 Anogenital HPV types are subdivided based on oncogenic risk. High-risk types (eg, 16, 18, 31, 33, 35) are strongly associated with cervical neoplasia. They usually cause flat lesions that are only identified on Papanicolaou smear or The Female Patient VOL. 32 DECEMBER 2007 39
CME External Genital Warts application of acetic acid. Persistent infection with high-risk HPV types is the most important risk factor for cervical neoplasia. More than 90% of anogenital warts result from low-risk HPV types 6 or 11. Some 66% of affected individuals have a transient infection that is subsequently cleared without treatment. 7 Among adolescent women, the average HPV infection lasts a median of 5.6 months, although high-risk HPV types tend to be more persistent. 8 Clinical warts may present as cauliflower-like, flesh- to pink-colored lesions (condylomata acuminate); dome-shaped, flesh-colored, smooth papules; flat papules; or keratotic warts that may be confused with cancer. 9,10 Typical exophytic condylomata are more likely to occur on keratinized skin. Multiple lesions may coalesce, producing large condylomata. Genital HPV infections can be associated with warts in the urethra, meatus, cervix, vagina, anus, and/or oral cavity. Cervical warts are especially worrisome, as they may lead to high-grade dysplasia or cancers. 9 Anal infection is also troubling, as intromissive anal intercourse confers an increased risk of anal dysplasias and cancer. Coding for Benign External Genital Warts Philip N. Eskew, Jr, MD When patients present with external genital warts as a chief complaint, the physician should apply the following codes from the International Classification of Diseases, 9th ed (ICD-9). • 078—Other diseases due to viruses and chlamydia 078.0—Molluscum contagiosum 078.1— Viral warts; viral warts due to human papillomavirus (HPV) 078.10— Viral warts, unspecified; condyloma not otherwise specified (NOS); verruca NOS; verruca vulgaris; warts (infectious) 078.11—Condyloma acuminatum 078.19— Other specified genital viral warts; genital warts NOS; verruca; verruca plana; verruca plantaris Therapy is covered by Current Procedural Terminology (CPT) codes, as opposed to evaluation-andmanagement codes: • 56501— Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) • 56515—extensive (same modalities) • 56820—Vulvar colposcopy • 56821—Colposcopy with biopsy • 57061— Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) • 57065—extensive (same modalities) Preventive vaccination involves age-appropriate physical evaluation, which need not include a pelvic examination. Applicable CPT codes are: • 99384— Initial comprehensive preventive medicine; adolescent (aged 12 through 17 years) • 99385— Initial comprehensive preventive medicine, 18-39 years Codes for vaccination alone are: • 90649— HPV vaccine, types 6, 11, 16, 18 (quadrivalent); 3-dose schedule for intramuscular use • 90471— Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular); one vaccine (single or combination vaccine/toxoid) The ICD-9 codes are: • V04— Prophylactic vaccination; inoculation against certain diseases V04.89—Other viral diseases Philip N. Eskew, Jr, MD, is Past Member, Current Procedural Terminology (CPT) Editorial Panel; Past Member, CPT Advisory Committee; Past chair, ACOG Coding and Nomenclature Committee; and Instructor, CPT coding and documentation courses and seminars. 40 The Female Patient VOL. 32 DECEMBER 2007
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External Genital Warts: An Update

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