Abstract

Human Papillomavirus (HPV) infection is the most common sexually transmitted disease worldwide, affecting up to 80% of sexually active women throughout their lifetime. Although most infections are transient and asymptomatic, high-risk genotypes such as HPV 16 and 18 are strongly associated with high-grade squamous intraepithelial lesions and cancers of the cervix, vulva, vagina, and anal canal. Genital warts (condyloma acuminata), typically caused by low-risk types HPV 6 and 11, may coexist with high-risk genotypes. We report a case of a 42-year-old woman who presented to primary care with no recent medical follow-up. During an opportunistic cervical cancer screening, large perianal and vulvar condylomas were noted. Symptoms had been present for two years and previously self-attributed to hemorrhoids. Cytology revealed high-risk HPV infection with ASC-H morphology. Vulvar and perianal biopsies confirmed low-grade intraepithelial lesions. Multidisciplinary management with gynecology and general surgery included trichloroacetic acid, topical imiquimod, and electrosurgical excision. This case highlights the pivotal role of primary care in HPV prevention, early detection, and integrated care coordination.

Keywords: HPV; Genital warts; Primary care; Opportunistic screening; Cervical cytology; ASC-H; Women’s health.

Abbreviations: HPV: Human papillomavirus: ASC-H: Atypical squamous cells – cannot exclude high-grade lesion.

Citation: Belo Vieira L, Fernandes J. How opportunistic screening uncovered extensive HPV lesions. J Clin Images Med Case Rep. 2025; 6(5): 3583.

Introduction

Human Papillomavirus (HPV) is the most prevalent sexually transmitted infection globally. Although the majority of infections are transient and asymptomatic [1], persistent infection with high-risk genotypes is a major cause of anogenital malignancies [2,5]. Opportunistic screening during primary care visits provides critical opportunities for early detection and intervention, particularly in individuals not enrolled in organized screening programs. This case underscores the importance of vigilance in sexual and reproductive health evaluations within primary care [3,4].

Case presentation

A 42-year-old woman with no recent medical follow-up presented for her first family medicine consultation. Her past medical history included chronic venous insufficiency. She was a smoker (5 pack-years), null alcoholic consumption, and was using a hormonal implant with amenorrhea. She had not received HPV vaccination and her cervical cancer screening was overdue. During the visit, she agreed to opportunistic cytological screening. Physical examination revealed bulky vulvar and perianal condylomas, which she had noticed two years earlier and initially self-attributed to hemorrhoids. She described pruritus, pain, and occasional bleeding. Previously, she had visited the emergency department without follow-up. Cytology showed high-risk HPV infection with ASC-H morphology. Colposcopy showed a type 3 transformation zone with no feasible cervical biopsy. Vulvar and perianal biopsies revealed low-grade HPVpositive intraepithelial lesions. Treatment included trichloroacetic acid 85%, daily topical imiquimod, and electrosurgical removal due to persistence of large lesions.

Figure 1: Extensive perianal and vulvar condylomas observed during the initial primary care consultation.

Discussion and conclusion

This case illustrates the essential role of primary care in the prevention, detection, and management of HPV-related conditions. Opportunistic screening allowed for the identification of significant pathology that had been neglected and misinterpreted for years. Through coordinated care between family medicine, gynecology, and general surgery, effective diagnosis and treatment were achieved. This highlights the potential impact of integrating preventive care, sexual health literacy, and cross-specialty collaboration in improving patient outcomes and reducing HPV-related morbidity.

References

1. World Health Organization. Human Papillomavirus (HPV) and cervical cancer. 2023.
2. Centers for Disease Control and Prevention. HPV Infection - CDC Fact Sheet. 2023.
3. Direção-Geral da Saúde. Norma n.º 002/2023 - Programa Nacional de Rastreio do Cancro do Colo do Útero.
4. European Centre for Disease Prevention and Control. Introduction of HPV vaccines in EU countries-2022.
5. Bosch FX, et al. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002.