Anal condylomata

Condyloma Acuminatum (anal wart)

• Caused by HPV, especially subtypes 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 82 (90% of condyloma are from subtypes 6 and 11, which are typically benign lesions; serotypes 16 and 18 are more commonly seen with dysplasia and malignancy)
• Generally regarded as premalignant
• Presentation
  • Larger disease burden can have pruritis, bleeding, burning, tenderness, discharge, pain
  • Application of 5% acetic acid causes lesions to turn white - can aid in identification
  • Giant condyloma acuminata - size definitions vary, but very big lesions need total excision with 1cm margin as they likely harbour SCC
• Differential diagnosis
  • Benign skin tags
  • Hypertrophic anal papillae
  • Molluscum contagiosium
  • Seborrheic keratoses
  • Hypertrophied sebaceous glands
  • Conyloma lata (secondary syphilis)
  • Dysplastic nevi
  • Anal cancer
• Histopathology
  • Verrucous architecture composed of papillary excrescences and hyperkeratosis, with koilocytic changes within a maturing squamous epithelium
• Workup
  • Large lesions (1-2cm at base) should be referred to a surgeon
  • Women should have a pap smear too
  • Check for chlamydia, gonorrhoea, HIV
• Intervention - most patients require intervention
  • Goal of treatment is complete destruction of all condyloma
  • Approach:
    • <1cm warts: anything will work well, but cryotherapy or electrosurgical excision are the quickest and easiest, whereas patient-applied topical things will be slower
    • >1cm:
      • Probably best with surgical excision
      • EUA with excisional biopsies and fulguration of remaining lesions
      • If carpeting is present with minimal intervening normal skin, better to stage treatment to minimise anal scarring and stenosis
      • Treat individual recurrences in clinic with topical therapy
      • 20-50% recurrence regardless of modality
  • Topical
    • Response rates ~50%, better with smaller lesions
    • Podophyllotoxin
      • Rarely used - local toxicity
    • Imiquinod
    • 5-flourouacil - patient-applied
    • Trichloroacetic acid - physician-applied
    • Sinecatechins

Verrucous carcinoma (Buschke-Lowenstein tumour or giant condyloma)

• • Rare, slow-growing
  • Intermediate form between the above and SCC
  • Tend to local invasion rather that metastasis
  • Can complicate with abscess or fistula
  • If involving sphincter: most likely APR
  • If not involving sphincter: wide local excision +/- flap closure