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Comparing guidelines for the management of anogenital warts
  1. Raymond Maw
  1. Royal Victoria Hospital, Belfast BT12 6BA raymond.maw{at}royalhospitals.n-i.nhs.uk

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    What is the purpose of guidelines for management of clinical conditions? Implicit in the term guidelines is that they should provide a guide to diagnosis, treatment, and related management issues of a specific condition without being unduly prescriptive as that may alienate their use by those who do not always want to follow the “mantra.” Successful guidelines based on sound evidence should be seen to improve outcomes for patients and be adapted across the spectrum of services to which the particular condition presents. Two recently published evidence based guidelines—the national guidelines for the management of anogenital warts1 (AGW) and the European course on the HPV associated pathology: guidelines for the diagnosis and management of AGW,2 are efforts to accomplish these aims. Comparing these two, the most striking differences are ones of style and scope. The national guidelines is the work of a single author written to a brief which imposed a “house” style and concision to conform with the 22 other national guidelines on sexually transmitted infections jointly commissioned by the UK professional bodies, the Medical Society for the Study of Venereal Diseases, and the Association of Genitourinary Medicine. The European guidelines is the product of a multinational group of clinicians, pathologists, and virologists dedicated to teaching important principles for practice and management of HPV disease to physicians, gynaecologists, and other disciplines. As such, the European guidelines adopt a more didactic style with an expanded text which allows, among other things, for direction on how to perform procedures such as meatoscopy, the acetic acid test, differential diagnosis, and details of mechanism of action and outcomes of therapies. Both use the same guidelines to grading of evidence supporting treatment recommendations developed by the agency of Health Care Policy and Research.2 Of the treatments covered in both texts it is reassuring that identical conclusions as to the level of evidence available was reached. What is, of course, evident is that much yet remains to be done to provide a sound evidence base for all available treatments. The most striking difference on treatment is the exclusion for consideration by the European guidelines of the use of podophyllin and 5-fluorouracil, both being dismissed as no longer recommendable—a view which others would hold.3 In the United Kingdom podophyllin is still a widely used clinic based treatment and as such it would not have been possible to omit from the national guidelines. Certainly the days of indiscriminate application of podophyllin to all AGW should be over, but judicious use may still have its place for small numbers of soft poorly keratinised warts—for example, subpreputially. There are still no studies comparing different modalities depending on morphology, although differing responses are much quoted. With the wider use of home based therapies, podophyllin and imiquimod, it may well be time to consign podophyllin and 5-FU to the archives. Neither guideline attempts to tackle the problem of interpreting combination therapies. One omission from the national guidelines is that monopolar electrosurgery should not be used in pregnancy because of the risk of transmission of current to the uterine contents.

    Guidance as to the frequency of cervical cytology specimens for women with AGW is not given in the European guidelines, which may be because there are different national guidelines across Europe. Certainly as far as the United Kingdom is concerned, many women have cytology taken at too young an age, and too frequently if they have AGW. This is a hangover from the evolution of our understanding of the natural history of human papillomavirus infection of the cervix which needs correcting.

    Included in the national guidelines are reference to the use of the guidelines against which to audit practice. This is of particular importance with respect to clinical governance which is certainly to the forefront in United Kingdom medicine today. Also, treatments are costed in the national guidelines although, with different pricing structures, it would not have been possible to give figures for the European guidelines. Overall, the encouraging feature of these two guidelines is their concordance in almost all aspects of practice, with the greater detail making the European guidelines perhaps more of a teaching aid. Both help to highlight areas of deficiency in our practice and as such should be useful in pointing the way for areas of research.

    The greatest challenge as far as these and other guidelines are concerned is how they are going to be disseminated outside a relatively small group of specialists to many other practitioners who encounter these conditions in daily practice.

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