Ano-Genital Warts in Children: Sexual Abuse or Not?

Gail Hornor, RNC, MS, CPNP

Disclosures

J Pediatr Health Care. 2004;18(4) 

In This Article

Mode of Transmission of HPV

Studies indicate that in adults, genital HPV infections are primarily sexually transmitted (Gutman, Herman-Giddens, & Phelps, 1993; Stevens-Simon, Nelligan, Breese, Jenny, & Douglas, 2000). In children, the mode of transmission of HPV infection is not as straightforward (see Box 1). Sexual transmission is recognized as a possibility in children, but other possible modes of transmission have been documented (Adams, 2001; de Jesus et al., 2003; Hadlich & Kohl, 1998).

Vertical transmission of the HPV virus from infected mother to her infant can occur (de Jesus et al., 2003; Frazier, 1998; Hadlich & Kohl, 1998). Adams' (2001) classification scale for evaluating medical findings of suspected sexual abuse lists ano-genital warts/condyloma in a child younger than 2 years of age as a nonspecific finding for sexual abuse—perinatal transmission must be considered. Vertical transmission can occur through the bloodstream prior to birth, or at the time of birth, as the infant passes through the infected birth canal (Frazier, 1998). Delivery via caesarean section does not eliminate the possibility of vertical transmission of HPV; there are reports of congenital condyloma after caesarean section without premature rupture of membranes (Syrjanen & Puranen, 2000). Syrjanen and Puranen state that HPV transmission can occur in utero through semen, ascending infection from the mother's genital tract, or transplacentally. Vertical transmission of the HPV virus does not mean that warts must be present at birth or shortly after birth. HPV is a latent virus and can reside in the skin and mucous membranes without causing warts. The warts may not appear until months or even years after birth (Frazier).

It is important to understand that the absence of visible ano-genital warts in the mother during pregnancy does not eliminate the possibility of vertical transmission to the child (Frazier, 1998). HPV can cause subclinical infection, meaning the virus can be present on the cervix or in the vagina without causing warts (Frazier).

Ano-genital warts (HPV) also can be transmitted via autoinoculation (Cohen, 1997; Syrjanen & Puranen, 2000). Children with a common wart on their hands or elsewhere on their body can transmit the virus by touching their warts and then touching their own genitals.

HPV can be transmitted nonsexually from direct contact with caretaker contaminated with genital HPV or common warts (Cohen, 1997; Syrjanen & Puranen, 2000). For example, caretakers with genital warts who touch or scratch their genitals and then without washing their hands change a baby's diaper or assist a child with toileting/bathing may transmit the virus to the child's genitals. A caretaker with common warts of the hands could transmit HPV in the same manner. HPV transmission via contact with contaminated objects or surfaces is possible (Syrjanen & Puranen). Evidence exists that HPV can be transmitted on small water droplets called foamites (Frazier, 1998). Foamites have been found in the underwear of people with HPV, and Savin (2001) proposes that foamites may be a source of initial infection or reinfection with HPV. Re-innoculation may occur in people who do not change their underwear frequently (Savin).

Sexual abuse must never be eliminated when considering possible modes of transmission for ano-genital HPV. Many forms of sexual abuse can result in transmission of HPV, including genital-genital contact, genital-anal contact, oral-genital contact, fondling, and digital anal/genital penetration.

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