Dr. Hajaratu Umar Sulayman is currently a Consultant Obstetrician Gynaecologist as well as a Senior Lecturer at the Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State, Nigeria.
Condylomata acuminata seen in the anogenital region are usually caused by human papilloma virus (HPV) 6 and 11. In adults, transmission is usually via sexual transmission, but HPV and resulting anogenital warts in pediatric populations may be a result of perinatal vertical transmission, indirect transmission through contaminated objects or surfaces, autoinoculation, or sexual transmission [1].
Both sexes are affected equally, and the infection is usually transmitted by sexual intercourse, although spreading by autoinoculation from the hands may sometimes occur. Other forms of transmission include during vaginal delivery and intimate nonsexual contact with an infected individual [2].
Genital warts were initially associated with Sexually Transmitted Infections (STIs) like syphilis and gonorrhea, afterward with chronic irritation. Many of these are known to cause genital warts, skin warts, as well as oral and laryngeal papillomata although they all have distinct histology and immunology [3].
The peak incidence occurs in people in their twenties. Reports of Condylomata acuminata in children are rare, and the modes of transmission among children are said to be unclear. The proportion of children with genital warts who were proven to have been sexually abused ranges from 11 to 91 % as reported in some studies [4, 5].
Anogenital warts in children may contain either skin or genital wart virus type. Although the type of Human Papilloma Virus (HPV) present may give some indication of the likely mode of transmission, this can be interpreted only in conjunction with all available clinical and social information. The type of virus does not provide proof of the presence or the absence of sexual transmission [6].
We present here the cases of three children below the age of 5 years who presented to the gynecology clinics of the various hospitals in which I had worked in the last 5 years.
All the three cases presented with similar complaints of popular growth around the perineum noticed by their guardians.
Approximately from 10 to 20 % of children have common skin warts; vulval warts is, however, uncommon in the pediatric age group. When seen, it may be associated with sexual abuse, vertical transmission, immune-suppression, or poor hygiene [7, 8]. In Case 1, sexual abuse was likely due to the absence of the hymen, while in Case 2, there was poor hygiene; there was a possibility of autoinoculation in Case 3 as has been shown in some studies [1, 9]. Case 2 and Case 3 came from poor socioeconomic backgrounds. Parents and guardians usually do not volunteer information on sexual abuse freely even though they were aware of it due to social stigma and psychological trauma [10]. In Case 1, the mother denied any history of sexual abuse. They healthcare worker has to be sensitive and show empathy.
There has recently been a massive increase in the number of human papilloma virus types characterized by DNA technology, but some specific types are repeatedly found in certain sites and lesions. Thus, in adults, types 6 and 11 are found almost exclusively in anogenital warts, whereas types 1, 2, 3, and 4 are found in skin warts. This finding, in conjunction with epidemiological evidence, indicates that human papilloma virus types 6 and I1 are likely sexually transmitted. It has been suggested then that anogenital warts in a child may also be sexually transmitted and thus provide grounds for suspecting sexual abuse [6].
Management options include the use of topical agents like Podophylline, excision, or cautery. Podophylline was used in all the above cases although some lesions were initially excised for histological diagnosis. Genital warts can present as giant vestibular, vulval, and periurethral lesions of Condylomata acuminata, although these are very rare in children. When they occur, the treatment option is surgery [11, 12]. Although genital warts is a HIV-defining illness in adults, it is not so in the pediatric age group. However, the presence of anogenital warts in a child should heighten the suspicion of sexual abuse in the health professional, and hence, it should be ruled out.
M.S was a 4-year-old pupil who was seen in the gynecology clinic in Ahmadu Bello University Teaching Hospital Zaria in November 2007 in the company of her mother who had noticed a growth around her vulva a few days earlier. There was a history of the patient scratching the vulval region occasionally. There was no history of fever, painful urination, or sexual abuse.
On examination, the child was a well-preserved one; she had warty lesions around the labia majora and minora as well as the inner parts of the left thigh. The hymen was not intact, and no vaginal discharge was noticed. An impression of vulval wart with a history of probable sexual abuse was made. She was subsequently evaluated, and a sample was taken for histology which confirmed Condylomata acuminata (Vulval warts). See Fig. 1. She was managed with topical Podophylline over a 3-week period as well as antibiotics and multivitamins. She did recover well, and both mother and patient were counseled.
S.A was a 3-year-old child who was seen in our unit in General Hospital Minna in April 2010 with complaints of growth around the perineum by her mother who had noticed it during bathing of the child. There was history of intermittent mild bleeding per vaginum and no history of sexual abuse.
On examination, the child had features of poor nutrition and allergic conjunctivitis. Vulval examinations showed moderate-sized papules around the mons pubis, labia major, and minora. The hymen was intact. She was managed on antibiotic analgesics and antipruritic cream. Biopsy of one the lesions was taken for histology which confirmed vulval warts. She subsequently was managed with serial Podophylline application both in the hospital and at home as well as antibiotics and multivitamins. The lesion subsequently healed over a 4-week period. See Fig. 2.
F.A was a 3-year-old child who presented to the IBB Specialist Hospital in April 2012 with a 2-week history of some growth around the vulva. Her father had noticed it when bathing and dressing the child. There was no history of sexual abuse, fever, or vaginal discharge.
On examination, she was a well-preserved child whose general condition was stable. Vulval examination revealed few warty lesions around the mons pubis and labia minora. The hymen was intact with some reddish areas around the introitus probably due to scratching. She was subsequently evaluated and managed using topical Podophylline, antibiotics, and multivitamins after the tissue was sent for histology. She was examined once at follow-up 1 week later, and there was remarkable improvement. She was later lost to follow-up. See Fig. 3.
