Anogenital warts are one of the most common sexually transmitted infections worldwide, caused by specific types of human papillomavirus (HPV). Recognizing symptoms early and undergoing proper diagnostic evaluation can help guide treatment decisions and reduce the risk of spreading the infection to others.

Introduction: Who Should Undergo Diagnostics

People who notice unusual lumps, bumps, or growths in their genital area should seek diagnostic evaluation as soon as possible. These small, flesh-colored or darker lesions can appear on the vulva, penis, scrotum, anus, or the skin surrounding these areas. Some people may also develop warts inside the vagina, on the cervix, within the urethra, or in the anal canal.^[1]

It’s important to understand that not everyone who carries the virus will develop visible warts. Many people have no symptoms at all, yet they can still transmit the infection to sexual partners. This makes diagnostic evaluation particularly important if you have been sexually active, especially if you have multiple partners or if a sexual partner has been diagnosed with genital warts.^[3]

Young adults between the ages of 15 and 30 are most commonly affected by anogenital warts, though anyone who is sexually active can develop them. If you notice any unusual symptoms such as itching, bleeding, discomfort during sex, or changes in your urination pattern, you should not delay seeking medical attention.^[2]

People who are immunocompromised, including those with HIV infection or those taking immunosuppressive medications, face a higher risk of developing anogenital warts and may experience more severe or persistent cases. For these individuals, regular screening and prompt diagnostic evaluation become even more critical.^[8]

Diagnostic Methods

Visual Inspection

The diagnosis of anogenital warts is usually made through visual inspection by a healthcare professional. During a physical examination, a doctor or nurse will carefully examine the genital area, including the external genitals, anus, and surrounding skin. In most cases, this simple visual examination is sufficient to identify genital warts.^[2]

Healthcare providers look for characteristic features of genital warts, which typically appear as small, skin-colored or whitish-grey bumps. The warts can be flat, raised, or have a distinctive cauliflower-like appearance, especially when several warts cluster together. Some warts may be as small as a few millimeters in diameter, while others can grow larger or form plaques when they join together.^[1]

For women, a speculum examination may be necessary to check for warts inside the vagina or on the cervix. For anyone with symptoms suggesting internal warts, such as bleeding from the anus or difficulty with urination, the healthcare provider may need to examine internal areas using specialized instruments.^[5]

Use of Magnification

Sometimes healthcare providers use a magnifying glass or similar device to get a better view of small or subtle lesions. This can help distinguish genital warts from other similar-looking conditions. The enhanced visualization allows the clinician to see details that might not be obvious to the naked eye, particularly when warts are very small or flat.^[4]

When Biopsy Is Needed

Most routine or typical cases of genital warts do not require a biopsy. However, there are specific circumstances when a healthcare provider may recommend taking a small tissue sample for laboratory examination. A biopsy becomes necessary when the diagnosis is uncertain or when the lesions look atypical.^[2]

Atypical features that might prompt a biopsy include warts that are pigmented, unusually hard or firm, attached to deeper tissues, bleeding, or ulcerated. Biopsy is also indicated if warts do not respond to standard treatment or if they worsen during therapy. This helps ensure that what appears to be a genital wart isn’t actually something more serious.^[11]

For patients who are immunocompromised, including those with HIV infection, biopsy may be more readily recommended. These patients have a higher risk of developing abnormal cell changes, and healthcare providers want to rule out more serious conditions such as high-grade squamous intraepithelial lesions (areas of abnormal cells that could potentially progress to cancer) or early cancer.^[2]

What Tests Are Not Recommended

HPV testing through laboratory analysis is not recommended for diagnosing anogenital warts. Test results for HPV would not confirm the diagnosis of visible warts and do not help guide how the warts should be managed or treated. HPV testing might show which type of virus is present, but this information doesn’t change the treatment approach for visible warts.^[2]

The acetic acid test, where vinegar solution is applied to the skin to look for “aceto-white” lesions (areas that turn white), is occasionally used but has significant limitations. This test has a high rate of false positive results, meaning it can make normal skin appear abnormal. It should not be used as a screening tool in people without symptoms, and it’s not recommended for routine diagnosis of genital warts.^[4]

Colposcopy, a procedure using a special magnifying instrument, is also not recommended for screening purposes. It may be used selectively when there’s concern about abnormal cell changes or to help target areas for biopsy, but it’s not a routine diagnostic tool for straightforward cases of genital warts.^[4]

Special Examinations

Proctoscopy, an examination of the inside of the rectum and anal canal, is not routinely recommended unless a patient has specific symptoms such as bleeding from the anus or significant irritation. However, if warts are discovered in the anal canal during proctoscopy performed for other reasons, the patient should be informed and offered treatment if desired.^[4]

Women who have genital warts do not necessarily need immediate cervical cytology testing beyond their regular screening schedule. However, women under 25 years of age should not undergo cervical cytology testing as a response to having genital warts, and women who are keeping up with their normal screening intervals don’t need additional tests just because they have warts.^[4]

Distinguishing From Other Conditions

Healthcare providers must distinguish anogenital warts from other conditions that can look similar. Several other skin conditions or infections can resemble genital warts, including molluscum contagiosum (another viral infection causing small bumps), skin tags, benign growths, or more serious conditions like condyloma lata (a manifestation of syphilis) or even cancer.^[2]

When syphilis is suspected, it can be diagnosed through blood tests or by examining fluid from the lesions. This is important because condyloma lata requires completely different treatment than genital warts caused by HPV.^[2]

Diagnostics for Clinical Trial Qualification

When patients are being considered for enrollment in clinical trials testing new treatments for anogenital warts, more detailed diagnostic procedures may be required beyond standard clinical care. Clinical trials often have specific inclusion and exclusion criteria that require documentation and confirmation of the diagnosis.^[2]

For clinical trial purposes, visual confirmation of external anogenital warts is typically required. Researchers need to document the number, size, and location of warts at baseline (before treatment begins) so they can accurately measure whether the experimental treatment is effective. Detailed measurements and sometimes photographic documentation of warts may be part of the screening process.^[14]

Some clinical trials may require biopsy confirmation before enrollment to ensure that participants truly have genital warts caused by HPV and not another condition. This is particularly important in trials testing new treatments, where researchers need absolute certainty about the diagnosis. The biopsy helps confirm the presence of characteristic cell changes associated with HPV infection.^[2]

Clinical trials may also include HPV typing as part of their diagnostic workup, even though this is not done in routine clinical practice. Researchers may want to know which specific HPV types are causing the warts, particularly to document whether participants have the most common types (HPV 6 and 11) or less common types. This information helps researchers understand how well the treatment works against different viral strains.^[2]

Patients with certain medical conditions or characteristics may be excluded from clinical trials. For example, some trials exclude pregnant women, people taking immunosuppressive medications, or those with certain other infections. Therefore, additional diagnostic tests may be required to screen for these conditions, such as pregnancy tests, blood tests to check immune function, or tests for other sexually transmitted infections.^[14]

For trials testing topical treatments applied by patients at home, researchers need to ensure that participants can correctly identify and reach the warts being treated. This may require detailed mapping of wart locations and patient education about proper application techniques. Follow-up examinations are scheduled at specific intervals to assess treatment response.^[11]

Clinical trials often require more frequent and more detailed follow-up examinations than standard care. Participants may need to return to the clinic weekly or biweekly for assessments, rather than the less frequent monitoring typical of routine treatment. These visits allow researchers to carefully track how quickly warts respond to treatment, whether new warts appear, and whether any side effects develop.^[12]