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ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 3  |  Page : 920-925

Effect of multiple genital and extragenital warts on quality of social life


Department of Dermatology, Andrology and STDs, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission20-Mar-2020
Date of Decision30-Apr-2020
Date of Acceptance10-May-2020
Date of Web Publication18-Oct-2021

Correspondence Address:
Marian S. R. Samaan
Nozha, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_96_20

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  Abstract 


Objective
The aim was to evaluate and analyze the effect of genital and extragenital warts (E-GWs) on social life.
Background
Genital warts (GWs) and E-GWs are common skin lesions caused by the human papillomavirus. GWs have been frequently reported to exhibit a strong negative effect on the quality of social life. Few studies have reported about E-GWs and their effect on life quality.
Patients and methods
This cross-sectional study investigated the effect of multiple GWs and E-GWs on quality of social life, including sexual life. This study involved 100 patients with multiple GWs (53 females and 47 males) and 100 patients with multiple E-GWs (45 females and 55 males).
Results
There was a significant statistical difference regarding age between the two groups (P < 0.001), which reflects the fact that GWs are more common in more sexually active younger age groups. There was a significant difference (P < 0.001) between the two groups regarding interference with personal relationships. There was a significant difference (P = 0.045) between the two groups regarding pain. There was a significant difference (P < 0.001) between the two groups regarding a decrease in sexual drive. There was a significant difference (P = 0.011) between the two groups regarding avoidance of sexual relations.
Conclusion
GWs and E-GWs can have a very strong negative effect on patients' daily life. They impair the quality of social life, including sexual life. Subsequently, we highly recommend the treating physicians the use of the 'bio-psycho-social' model when facing patients with multiple warts.

Keywords: extragenital, genital, life quality, wart


How to cite this article:
Samaan MS, Gaber MA. Effect of multiple genital and extragenital warts on quality of social life. Menoufia Med J 2021;34:920-5

How to cite this URL:
Samaan MS, Gaber MA. Effect of multiple genital and extragenital warts on quality of social life. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:920-5. Available from: http://www.mmj.eg.net/text.asp?2021/34/3/920/328355




  Introduction Top


Warts are common lesions caused by the human papillomavirus (HPV) that can affect the genital and extragenital sites. The appearance of warts is variable and depends to a certain extent on the type of HPV involved and the anatomical site, for example, warts on hands and feet (HPV 1, 2, 4, 27, and 57), plane warts (HPV 3 and 10), and genital warts (GWs; HPV 6, 11, 16, and 18) [1].

GWs can have four morphological features: condyloma accuminata, smooth or flat papular lesions, or keratotic warts. They often have no symptoms, except in some cases of vulvar warts, which can cause dyspareunia and discomfort; penile warts and pruritus; vaginal warts and vaginal discharge, bleeding, obstruction of the birth canal, and neonatal infection, which may result in juvenile-onset recurrent papillomatosis; and perianal and intra-anal warts, causing pain, bleeding during defecation, and pruritus [2].

GWs can have profound effects on the psychological well-being and quality of life of affected individuals in different populations. They can be a source of depression and anxiety, which can take a toll on sexual health [3].

Extragenital warts (E-GWs), usually present on fingers, hands, knees, and elbows, are caused by HPV 2, 4, 7, 26, 27, 28, 29, and 57. Other types of skin warts and their associated types of HPV include deep plantar warts (HPV 1 and 4), mainly on the underside of the feet; filiform warts (HPV 1, 2, and 7), occurring on the face, mouth, lips, eyelids, and nose; flat or plane warts (HPV 2, 3, 10, 26, 27, 28, 29, and 41), present throughout the body, including areas of the face, arms, hands, and knees exposed to the sun; and endophytic or punctuated warts (HPV 60, 63, and 65). Oral cavity warts are attributed to HPV 1, 2, 4, 6, 7, 11, and 13 [4].

Moreover, warts can be very painful depending on their location, socially unacceptable, especially on visible areas, and recalcitrant treatment with subsequent impairment of the patient's daily life [5].

This study aimed to evaluate and analyze the impact of GWs and E-GWs on social life.


  Patients and methods Top


The study was approved by the Ethics Committee at Menoufia University. This cross-sectional study investigated the effect of multiple GWs and E-GWs on quality of social life including their effect on sexual life. This study involved 100 patients with multiple GWs (53 females and 47 males, aged 17–53 years) and 100 patients with multiple E-GWs (45 females and 55 males, aged 19–56 years) from Dermatology Outpatient Clinic, Menoufia University Hospital.

The exclusion criteria included any patient with other dermatological diseases and any patient with systemic diseases, for example, liver or kidney or heart disease.

Every participant was subjected to formal consent regarding that all patients freely accepted to participate in the interview and fill in the questionnaire. All participants were assured of confidentiality. Complete history taking, general examination, local examination of dermatological lesions, and filling out a questionnaire that consists of questions about the effect of GWs and E-GWs on quality of social life including sexual life were done.

Statistical analysis

Based on the past review of literature, Salah [6] reported that the difference in DLQI total scores between patients with E-GWs and those with multiple GWs was to be 1.8. The sample size has been calculated at α = 0.05, 1−β = 80%, and it will be 100 participants per group. Data were collected, tabulated, and statistically analyzed using an IBM personal computer with Statistical Package for the Social Sciences version 20 (2011; IBM Corporations, Armonk, New York, USA) and Epi Info 2000 programs (CDC) in Atlanta, Georgia (US), where the following statistics were applied.

Descriptive statistics: in which quantitative data were presented in the form of the mean and SD, range, and qualitative data were presented in the form numbers and percentages.

Analytical statistics: χ2 was used to study the association between two qualitative variables, and Mann–Whitney test is a test of significance used for comparison between two groups not normally distributed having quantitative variables. P less than 0.05 was set to be significant.


  Results Top


This cross-sectional study included 100 patients with multiple GWs (53 females and 47 males), and 100 patients with multiple E-GWs (45 females and 55 males). Both groups included immune-competent adult subjects without any cause of immune dysfunction. In the GW group, the age of the subjects ranged from 17 to 53 years, with a mean of 28.5 ± 8.8 years, whereas in the E-GW group, it ranged from 19 to 56 years, with a mean of 38 ± 13.3 years. There was a significant statistical difference regarding age between the two groups (P < 0.001), which reflects the fact that GWs are more common in more sexually active younger age groups. There was no significant difference between the two groups regarding sex, marital status, and occupation. There was a significant difference (P < 0.001) between the two groups regarding feeling embarrassed or self-conscious, as those in the GW group represented 95% whereas in the E-GW group represented 73%. There was a significant difference (P < 0.001) between the two groups regarding interference with personal relationships, as patients in the E-GW group represented 93%, whereas in the GW group represented 75%. There was a significant difference (P < 0.001) between the two groups regarding social or leisure activities affection, as patients in the E-GW group represented 67%, whereas the GW group represented 25%. There was a significant difference (P < 0.001) between the two groups regarding difficulty to do any sport, as patients in the E-GW group represented 68%, whereas in the GW group represented 20%. There was a significant difference (P < 0.001) between the two groups regarding prevention from working and studying, as patients in the E-GW group represented 65%, whereas the GW group represented 18%. There was no significant difference (P = 0.054) between the two groups regarding thinking of separation or divorce as patients in the GW group represented 6% whereas the E-GW group represented 1%, and there was no significant difference (P = 0.077) between the two groups regarding fear negative appraisal by others, as patients in the GW group represented 85%, whereas in the E-GW group represented 75% [Table 1].
Table 1: Social life affection regarding the site of warts

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There was a significant difference (P = 0.045) between the two groups regarding frustration by time spent on treatment of wart, as patients in the GW group represented 87%, whereas the E-GW group represented 76%. Frustration with past wart treatment, frustration with current wart treatment, frustration with the persistence of warts, frustration with recurrence of warts, and frustration with cost spent on treatment of warts affected both groups to a similar extent, without a significant statistical difference [Table 2].
Table 2: Social life affection regarding treatment with the site of warts

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There was a significant difference (P = 0.045) between the two groups regarding pain as patients in the E-GW group represented 87%, whereas in the GW group represented 76%. Discomfort and bleeding affected both groups to a similar extent, without a significant statistical difference [Table 3].
Table 3: Symptoms of warts regarding their site

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There was a significant difference (P < 0.001) between the two groups regarding a decrease in sexual drive, as patients in the GW group represented 78%, whereas in the E-GW group represented 19%. There was a significant difference (P = 0.011) between the two groups regarding avoidance of sexual relations, as patients in the GW group represented 81%, whereas in the E-GW group represented 65%. There was a significant difference (P < 0.001) between the two groups regarding feeling worried from vaginal delivery, as patients in the GW group represented 100%, whereas in the E-GW group represented 0%. Feeling worried during act and decrease in quality and/or frequency of sexual relations affected both groups to a similar extent without a significant statistical difference [Table 4].
Table 4: Sexual life affection in all patients regarding the site of warts

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  Discussion Top


GWs are well known to negatively affect emotional well-being and life quality among the affected patients. Intimacy problems and sense of guilt or shame have been repeatedly reported among patients with GWs [7].

GWs are not always benign as E-GWs because they are associated with increased cervical cancer risk, especially in immunocompromised patients, which adds more dysfunction to quality of life [8].

E-GWs are caused by HPV. They are extremely common and benign. E-GWs can resolve spontaneously by natural immunity but this might take months or years to happen [9].

E-GWs represent the benign pathway for HPV in comparison to GWs that carry a potential malignant risk [6].

The present study aimed to evaluate and analyze the effect of GWs and E-GWs on the quality of social life. A cross-sectional study was conducted that included 100 patients with multiple GWs (53 females and 47 males) and 100 patients with multiple E-GWs (45 females and 55 males). Both groups included immune-competent adult subjects without any cause for immune dysfunction.

Regarding social life affection, the present study revealed that 95% of GW group felt embarrassed or self-conscious about their warts and 85% felt fear of negative appraisal by others. One of the patients quoted: 'it is embarrassing even if people do not tell you in the face, you can see that look, I feel they think that I am filthy.' This correlates with the study of Sénécal et al. [10], who reported that the high psychosocial effect of GW may be because they are visible and distressing and associated with discomfort and feelings of anxiety, depression, anger, fear of contagiousness, shame, and embarrassment. Qi et al. [11] had emphasized the importance to establish psychosocial support systems for patients experiencing GWs by re-directing our approach toward a 'bio-psycho-social' model instead of just a 'biomedical' one. Dominiak-Felden et al. [3] indicated that women with GWs suffered most in the three domains of sexual effect (63.2), self-image (62.7), and partner issues and transmission (58.7).

Regarding symptoms of warts, this study revealed that 98% of GW group felt discomfort because of their warts and 76% felt pain. This correlates with the study of Franceschi et al. [12], who reported that although GWs are not life-threatening, they are associated with anxiety, fear of rejection, discomfort, pain, and emotional stress, and treatment is usually lengthy and painful. Shi et al. [13] conducted a similar study in mainland China and found that 56.4% of patients reported some problems in the 'anxiety and depression' dimension (highest), followed by 'pain and discomfort' (24.7%) and 'mobility' (3.5%). It has been evidenced that patients with GWs experience loss of quality of life and had a significantly heavy psychosocial burden. Woodhall et al. [14] also reported that the 'pain and discomfort' and 'depression and anxiety' dimensions were the two most affected domains.

Regarding social life affection in the GW group with treatment, the present study revealed that 85% of GW group patients were frustrated with past wart treatment, and 87% of GW group patients were frustrated with time spent to apply the treatment of warts. One of the patients quoted: 'I want to be treated from my GWs as soon as possible to prevent my wife from being infected and regain my normal life.' This correlates with the results of Lacey et al. [15], who showed that treatment of GWs is long, painful, and often unsatisfactory, with high recurrence rates. Stanley [16] reported that HPV genital lesions' treatment may be long and painful and can cause sexual impairments. Worry associated with repeated examinations, consultations, invasive and painful treatments, which increase in case of recurrences, adds further vulnerability to the woman's emotional and sexual well-being. The higher the number of interventions, the more painful the technique and the severity of the scarring, the more severe is the potential psychosexual effect.

Additionally, the present study revealed that 87% of GW group patients were frustrated with the persistence of warts and 85% were frustrated with the recurrence of warts. This is in agreement with the study of Stanley [16], who reported that early and late recurrences of the infection and related pathologies are frequent. GWs may have a very different effect from the psychosexual point of view, according to the severity of lesions, aggressiveness of related treatments and their adverse effects, frequency of recurrences and their severity, and quality of psychosexual support from relatives and health care providers.

Regarding sexual life affection, the current study revealed that among 78% of GWs group patients, their sexual drive had decreased, 88% of them felt worried during the act, and 87% felt their sexual relations had decreased in quality or frequency. This agrees with Graziottin and Serafini [17], who reported that clinical correlates include loss of sexual desire, more difficult mental and genital arousal, less frequent intercourse, dyspareunia, and a qualitative and quantitative reduction of the repertoire of sexual behaviors. After HPV genital infection, many women refused passive oral sex for fear of infecting their partner.

Regarding social life affection, the present study revealed that 67% of the E-GWs group patients felt their warts affected social activities. A male patient quoted: 'Imagine that it was my wedding and I was waiting to have the best pictures with my wife and all that I can think about is my facial warts!'. A female patient quoted: 'I was very happy to be engaged! So, I captured a picture for my hand and the shining ring to post on Facebook, but I had to edit the photo to “virtually” remove my ugly warts.'

Furthermore, the present study revealed that 68% of E-GW group patients felt their warts prevent them from doing any sport. One of the patients quoted: 'I was afraid of infecting others when I was swimming.' Another patient quoted: 'I like playing football but when I am playing it hurts me and leads me to stop playing.'

Additionally, the present study revealed that 65% of E-GW group patients felt their warts prevented them from working or studying. Many patients with E-GWs experienced skipping some days from work for different reasons such as pain or psychological frustrations about treatment ineffectiveness. One of the patients quoted: 'I work in a bakery and its part of my job to use gloves; however, I am afraid if my boss may kick me out because of warts in my hands. So, I always keep my gloves to be safe.' This in agreement with the study of Salah [9], who reported that E-GWs can have a very strong negative effect on patients' daily life. Subsequently, we highly recommend considering and acknowledging the harmful effects of E-GWs on patients' life quality. As a start, the treating physicians should use the 'bio-psycho-social' model when facing patients with E-GWs in an attempt to secure the best quality of life for the patients keeping in mind that we should treat patients as a whole, not just warts. The present study also revealed that 93% of E-GW group patients felt their warts interfered with personal relationships. E-GWs exhibited significant impairment of personal relationships such as hand shaking or kissing/cuddling of their kids. One of the patients quoted: 'You know, after having warts on my face, I decided to be careful when playing with my kid! That hurts!'. Another patient quoted: 'My friend seemed very suspicious when he asked about the pumps on my hands as I told him those are just “warts”! Then I was just struggling when he asked, are these not infectious???'. This correlates with the study of Finlay and Khan [18], who reported that patients with viral warts recorded a more severe negative effect on the quality of life than patients with other dermatoses, like acne vulgaris.

Regarding symptoms of warts, the current study revealed that E-GWs are more symptomatic and annoying to patients. Overall, 87% of this group have pain due to wart. Plantar wart lesions were associated with pain or burning in most patients. Many cases with plantar warts avoid walking or standing for long times and to use more comfortable footwear because of pain. One of the patients quoted: 'Doc, I hope you can help me to get rid of my warts. I am a teacher and when I am standing, it hurts as if I am standing on a punch of stones for hours!!'. Some patients reported onset of pain after aggressive surgical excisions, which may be explained by disturbed healing and innervation. This is in agreement with the study of Ciconte et al. [19], who showed that however, the search for a cure, cosmetic disfigurement, social stigmatization and prevention of HPV transmission in the community, symptoms as disabling pain are logical justifications for treating cutaneous warts.

Regarding sexual life affection, this study revealed that 87% of E-GW group patients felt worried during the act, 78% of their sexual relations had decreased in quality or frequency, and 65% of them avoided sexual relations. This correlates with the study of Salah [9], who reported that E-GWs also affected love partners and their sexual relations, for example, patients with facial warts were worried about infection transmission by touching or kissing, and patients with hand or feet warts also were concerned about infecting their partners during sexual and nonsexual activities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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