VOL: 97, ISSUE: 06, PAGE NO: 37
Mary Pleavin, RGN, is a senior staff nurse at the Countess of Chester Hospital NHS Trust.Mary Pleavin, RGN, is a senior staff nurse at the Countess of Chester Hospital NHS Trust.
Each year, more than 110,000 cases of anogenital warts are reported in the UK, and the number of sufferers is increasing (Lamagmi et al, 1998). Most cases present to genitourinary medicine clinics.
With the aim of coping with demand for treatment and meeting patients' expectations of care, staff in the genitourinary medicine department at the Countess of Chester Hospital NHS Trust have established a treatment protocol that has evolved into a nurse-led home treatment model. The model is consistent with the recommendations of the recently published European guidelines for the diagnosis and management of anogenital warts (Von-Krogh et al, 2000) and represents the future not only for clinics but for patients with a condition that is often stigmatised.
Anogenital warts (condyloma accuminata) are the visible lesions caused by the human papillomavirus (HPV). More than 70 different sub-types of HPV have been identified by molecular typing, but only about 20 are implicated in the development of anogenital warts. Of these, sub-types 6 and 11 are the most common cause, being found in more than 90% of cases. They appear as small, often fleshy, growths on the skin of the genitals and around the anus. The warts are often felt as gritty, hard bumps before they are seen. HPV also causes skin warts and verrucae and has been implicated in the development of cervical intraepithelial neoplasia (CIN), which will be discussed later.
Following infection - which need only involve genital-to-genital contact with an infected person - it can take between two weeks and a year or more for lesions to appear. Following infection with HPV, some people become carriers without any visible lesions; they may be able to infect others who will go on to develop warts.
Although most patients with anogenital warts are treated in genitourinary medicine clinics, the organisation of the clinic can vary greatly between hospitals. The genitourinary medicine department at the Countess of Chester Hospital NHS Trust is a single consultant unit in a busy district general hospital. It has an open-access policy from Monday to Friday and with a total of seven clinics, patients can be seen without a prior appointment or referral.
In 1999, 6,000 attendances were recorded. Of these, 47% were attending of their 'own accord', while 26% came via a GP's referral. The remaining 27% came through a variety of sources such as the referral of another health professional - for example, a midwife, practice nurse or school nurse - or were advised to attend by their partner. Among new attenders who presented with a diagnosed infection, 10.26% presented with anogenital warts. Interestingly, the majority of 3,247 new attenders came for sexual health screening and their results showed no infections.
Chester care sequence
When dealing with this disease, it is important to remember that anogenital warts are disfiguring and can impact upon the sufferer's sex life. The physical symptoms, which may include inflammation, itching, bleeding, dyspareunia and fissuring, are unpleasant. Furthermore, warts may cause feelings of anxiety, guilt, anger and loss of self-esteem. Therefore, patients attending the genitourinary medicine clinic will usually do so only after much thought; many will be worried (perhaps about future fertility and the risk of cancer) and often acutely embarrassed. It is important that all clinic staff are sympathetic and endeavour to make patients feel as comfortable as possible.
Clinical evaluation at the clinic is undertaken by the doctor. The goal of the investigation is to ensure appropriate diagnosis and treatment and to minimise psychosexual sequelae.
Because HPV sub-types 16 and 18 have been found to be associated with the development of cervical cancer, all women with anogenital warts should be encouraged to comply with the national cervical cytology screening programme. Our female patients are asked to attend their GP for a smear test three to four months after wart clearance. In line with national guidelines, we do not routinely take cervical smears from women under 20 years of age (NHS Cervical Screening Programme, 1997).
Once anogenital warts have been diagnosed by the doctor, the clinic nurses take over patient management. 'Managed' patients attend nurse-led sessions, which take place before the main clinic sessions, often covering the lunch period for patients' convenience. Since each of the clinic's three nurses sees her own patients, continuity of care is maintained until the warts have cleared and the patient is discharged from the clinic.
Treatment options for anogenital warts
A range of treatments is available for the management of anogenital warts (see Box 1). However, treatment decisions need to reflect a number of considerations. The nurse discusses the possible treatment options with each patient. She or he always attempts to develop a relationship with the patient to help understand their sexual history, relationships, occupation and where they work. Such factors may affect whether a patient is treated at home or in the clinic.
Unsurprisingly, given the intimate nature of the condition, many patients prefer to treat themselves. An international survey of patients with genital warts found that patients expressed a preference for products that could be self-applied in the privacy of their own homes because this lessens the discomfort, anxiety and embarrassment associated with clinic-based treatments (Maw et al, 1998).
Clearly, cost is also a consideration, not only in terms of the acquisition cost of each therapy, but the cost of clinic time. Our own patient survey among patients with genital warts revealed that up to 42% had had to take time off work to keep their appointment. The reasons they gave their employers to explain their absence from work varied from 'clinic appointment', 'visit to the doctor' or simply going out for different reasons. The treatment options are (See Box 1 for details):
Podophyllin solution requires a twice-weekly application regimen which needs to be washed off four hours after application. This might prove difficult in the work environment. Furthermore, podophyllin is associated with a variable response rate and is not appropriate for use during pregnancy (Peterson and Weisman, 1995). It is therefore no longer regularly used in the clinic.
Cryotherapy and podophyllotoxin cream
A recent review of the clinic's caseload shows 80% of newly presenting patients with anogenital warts are offered initial treatment with cryotherapy. Patients are then given the option to treat themselves at home using 0.15% podophyllotoxin cream (Warticon), provided the nurse is satisfied that the patient is able to undertake self-treatment. Podophyllotoxin cream is also offered to clients who decline cryotherapy, because the discomfort is unacceptable or the weekly visits are not convenient. However, this treatment is also not appropriate for use during pregnancy.
Removal by cautery
Occasionally, a pedunculated wart may be removed by cautery under local anaesthesia. This procedure has the advantage over cryotherapy in producing an instant result; however, many patients are often unhappy at the prospect of having a wart burnt off their genital area. Very large areas of warts may require surgical removal, and these patients are referred to a plastic surgeon or gynaecologist.
Our survey showed that 48% of the patients in our clinic were given podophyllotoxin cream. When asked to describe their treatment, 69% used the words 'easy, modern, and effective'. Of those who answered the question about the time taken to attend clinic, including travel, waiting and appointment, nearly 70% said this was less than one hour.
Such results have led us to conclude that we are right to move treatment of anogenital warts away from frequent clinic visits and into the patient's home. Our experience suggests that this results in greater patient satisfaction, presumably due to:
- Less frequent visits to the clinic;
- Reduced waiting time when attending the clinic;
- Allowing a sense of personal empowerment from direct involvement in their own care.
Of course, this model also reduces clinic overheads, freeing staff for other duties rather than undertaking a task that can be effectively undertaken by the patient. It is in recognition of such factors that the authors of the European guidelines on the diagnosis and management of anogenital warts also recommend the use of home therapy for those patients who are able to undertake it.