A 28-year-old woman from Delhi presents with multiple genital warts of 6 months duration. She is asymptomatic and has no history of abnormal Pap smears. On examination, she has visible condylomata acuminata on the vulva. What is the most appropriate next step in management?

Explanation

## Clinical Assessment of Genital HPV Infection **Key Point:** Any patient presenting with genital warts requires cervical cytology screening and HPV genotyping to exclude concurrent high-risk HPV infection and cervical dysplasia, regardless of symptom status. ### Rationale for Liquid-Based Cytology and HPV Genotyping Liquid-based cytology (LBC) is the gold standard for cervical cancer screening in women with genital warts. HPV genotyping is essential because: 1. **Risk stratification**: Low-risk HPV types (6, 11) cause ~90% of benign warts but do not cause cervical cancer 2. **High-risk types (16, 18, 31, 33, etc.)** are oncogenic and require closer surveillance and more aggressive management 3. **Concurrent infection**: A woman with visible warts may harbor high-risk HPV simultaneously, necessitating cervical assessment **High-Yield:** HPV types 16 and 18 account for ~70% of cervical cancers; types 6 and 11 are responsible for >90% of benign genital warts but carry minimal malignant potential. ### Management Algorithm for Genital Warts ```mermaid flowchart TD A[Genital warts diagnosed]:::outcome --> B[Perform Pap smear + HPV genotyping]:::action B --> C{HPV type & cytology results?}:::decision C -->|Low-risk HPV + normal cytology| D[Topical therapy or observation]:::action C -->|High-risk HPV or abnormal cytology| E[Colposcopy + biopsy]:::urgent D --> F[Follow-up Pap in 1 year]:::action E --> G[Manage dysplasia per grade]:::action ``` **Clinical Pearl:** Asymptomatic women with genital warts are at risk of harboring oncogenic HPV; cytology screening is non-negotiable before deciding on treatment strategy. ### Treatment Considerations (After Screening) Once cervical pathology is excluded or managed: - **Topical agents**: Imiquimod, podophyllotoxin, sinecatechins (for low-risk, small warts) - **Ablative**: Cryotherapy, laser, electrocautery (for extensive lesions) - **Observation**: Acceptable if low-risk HPV and patient preference, as spontaneous regression occurs in 30–50% over 2–3 years **Warning:** Immediate surgical excision without prior cervical assessment risks missing dysplasia or malignancy.