This review analyzes the results of existing literature on sexual dysfunction in women with GWs. Considering that the explanation of experiences and perceptions of patients is better achieved through qualitative studies, and quantitative measures are mostly inadequate in this regard, but generally there are few studies in this field, the research team decided to assess both qualitative and quantitative studies related to sexual impacts of GWs and HPV.
The findings of this review confirmed the hypothesis that GWs directly and/or indirectly cause sexual dysfunction and have negative psychosexual impacts in affected women. The present study also showed that women with GWs experience sexual dysfunction in all dimensions. In relation to the first research question, the findings of this study showed that there is a relatively high prevalence of sexual dysfunction in women with GWs. Regarding the second research question, the findings showed that women with GWs experience sexual dysfunction in all dimensions. The results of the studies were contradictory, and our findings are both consistent and different from previous studies. Some studies showed that GWs could cause sexual dysfunction in patients [16, 19,20,21]. The disorder was confirmed in all domains of sexual function, including libido, arousal, orgasm, pain, and sexual satisfaction. These changes were more severe in decreased sexual desire, and number of sexual intercourse [19, 20, 25]. In contrast, the results of Parkpinyo et al. study showed that GWs had significant effects on reducing arousal, orgasm, pain, and sexual satisfaction in women, while there was no significant reduction in libido [16]. The absence of a control group in this study and not comparing GWs patients with normal population can be one of the reasons for this different finding. The Tas et al. study, also confirmed GWs had no effect on the sexual function of refugees in Turkey [22], which may be due to the specific characteristics of the study population in this research (refugees), and the lack of knowledge of refugees about the disease, their difficult living conditions, and less significance of GWs for them.
The change in the frequency of sexual intercourse is one of the most obvious changes in the sexual behavior of patients. Sometimes, this decrease in the frequency of sexual intercourse occurred in the early stages of the disease, which improved over time. Lin et al. [31] reported that many participants reduced or eliminated the number of sexual intercourses after being diagnosed with HPV. A cross-sectional study by Escalas et al. [9] showed that 72% of patients reduced their sexual intercourse after being infected with HPV, and 71% stated that HPV diagnosis had a negative effect on establishing a relationship with a new sexual partner. Jeng et al.'s [24] study confirmed that traditional Chinese women after being infected with HPV, while trying to maintain their marital relationship, wanted to ensure that the disease did not affect their role as spouses. HPV infection caused a decrease in sexual desire and the number of sexual intercourse in these women, and finally had a negative effect on the quality of the couple's sexual relations [24]. Taberna et al. [33] also reported that only 38% of HPV patients expressed that their and their partner's sexual life were not affected by HPV, and most patients had less sexual intercourse after diagnosis.
Pain during intercourse is another dimension of sexual function that few patients experience and report. It seems that this pain has a psychological aspect because it is experienced by patients who, after the diagnosis of the disease especially in the first days, have a lot of stress and restlessness, while none of the patients complain of the lesions' pain, and they had not experienced this pain before the diagnosis of the disease [17]. El-esawy et al. [20], Nahidi et al. [19] and Parkpinyo et al. [16] reported that GWs can cause pain during sexual intercourse.
In comparison to other HPV related diseases, GWs have more negative effects on the sexual life of the patients, and only one study reported that the negative impacts of VIN2, 3 on sexual function were greater than GWs. One of the reasons for this finding may be the difference in the average age of the affected women in the 2 groups mentioned [27].
Regarding the psychosexual impacts of GWs, our findings showed that GWs cause many negative psychosexual impacts in women. Almost all studies have confirmed that patients with GWs experience more severe psychosocial and psychosexual impacts [10,11,12, 15, 26, 28, 29, 32, 34, 35] compared to general population. Women and men with GWs reported moderate to severe negative psychosocial and psychosexual impacts [32], but GWs' negative impacts are more common in women than in men [12, 15, 26]. This finding may be due to the different personalities of men and women, as women are more emotional, they show more reactions to occurring problems, and have a more negative body image because of the unpleasant appearance of GWs. It also seems that women search more information about the disease than men, and care more about their health. Therefore, this finding is to be expected.
The appearance of warts is unpleasant, and this appearance causes discomfort in patients, especially in women. Worrying about the appearance of genital warts in patients can reduce their mental body image. Following the change in the patient's mental image of her body, the patient's self-confidence during sex decreases due to the fear of the lesions being observed by her husband or sexual partner. Therefore, it indirectly affects sexual function negatively [17]. Women suffer more from negative self-image than men do, and as a result, GWs have greater negative impacts on their sexual life. Pineros et al. [12] reported that the self-esteem of 90% of women and 62% of men decreased after the diagnosis of genital warts. In addition, 77% of women and 46% of men mentioned the negative effects of genital warts on their sexual lives [12]. Qi et al. [15] reported that women with genital warts are more vulnerable in the two dimensions of mental body image, and sexual impacts. While men with genital warts are more vulnerable in the two dimensions of sexual impacts, and interaction with the doctor [15]. Drolet et al. [10] also reported that genital warts have the most negative effect on the mental image of the body, sexual activity, and fear of transmitting the disease to the sexual partner.
In general, the most important psychosocial and psychosexual impacts in GWs affected women include negative sexual impacts, negative body image, worries, pain, discomfort, anxiety, depression, and limitation of social activities [10, 11, 26, 28, 29, 36].
Studies related to sexual dysfunction in HPV patients also reported that many HPV patients suffered from sexual dysfunction, which was more evident in the sexual desire, and intercourse frequency domains [9, 24, 31]. In addition, the results of qualitative studies that deeply explored the experiences and perceptions of HPV affected women, confirmed that patients experienced emotions including fear, anxiety, worry, anger, confusion, fear, worry, doubt, struggle, sadness, embarrassment, tension, regret, disappointment, and depression, which in most women decreased over a year, while in a third of women remained for a long time [9, 30, 31, 37].
After HPV diagnosis, some women denied it or reluctantly accepted it. A few women reported sexual routes as a source of infection, many of them suspected their husband or sexual partner as the source of infection. In some societies where men and women do not experience sex before marriage, contracting a sexually transmitted disease such as HPV or genital warts in one of the couples, can raise the suspicion of sexual infidelity. Despite the cultural differences in different societies, and the existence of different views among women about sexual infidelity, this issue is still important for women, and creates negative feelings in them. So that some patients consider their spouses' sexual infidelity as the main reason for their infection. Some patients only suspect that their spouse has committed sexual infidelity, and are not sure about it, but this doubt also disturbs the mental and psychological peace of the patients, and finally negatively affects their sexual function. In this regard, Lin et al. [31] and Mortensen et al. [38] confirmed that the suspicion of infidelity has always been one of the main concerns of women with genital warts and HPV. In addition, the fear of the husband's suspicion of the patient's infidelity was another concern expressed by the patients [31, 38]. In most quantitative studies, this aspect of psychosexual effects has been neglected, and only qualitative studies have addressed this issue.
The effects of demographic, cultural and social characteristics of women with GWs on their sexual function were also reported to be contradictory in several studies. The most important effective factors on sexual function included: age, duration of marriage, multiple marriages, level of education, place of residence, occupation, duration of illness, knowledge of HPV, number of warts, location and recurrence of warts, husband infection with GW, condom use, and type of treatment [12, 19, 20, 26, 34]. It seems that the cultural and social differences among the participants are the most important reasons for the different observed effective factors on sexual function in women with GWs.
Few studies assessed the concerns of women with GWs. The results of these studies showed that the most important concerns included fear of transmitting the disease to a sexual partner or husband, worsening of lesions, or recurrence of lesions through sexual intercourse [10, 11, 28]. In addition, the most important concerns of HPV infected women were fear of transmitting the disease, and fear of being judged by others [9, 32].
The fear of transmitting the disease to the husband or sexual partner causes anxiety. This stress reduces sexual desire and thus directly leads to sexual dysfunction [39]. Anxiety and worry about the spread or recurrence of lesions were reported in many studies, the severity of which was directly related to the number of lesions, rate of recurrence, and women's awareness of the disease. Women who had more lesions, or experienced frequent lesions reported more anxiety and worry. Women who had more information about the disease also experienced more anxiety. Another concern of women was the fear of transmitting the disease to their husbands. This concern was especially more profound among women whose husbands had no lesions, because they believed that their husbands were not infected, and they could transmit the disease to their husbands during sex [17]. The findings of some studies are also consistent with this finding [10, 11, 34, 39].
Faced with this fear and worry of disease transmission, many patients tried to have protected sex with a condom [31]. While the results of Daley et al.'s [30] study contradict this finding, Daley reported that 39.2% of HPV patients rarely use condoms. 16.9% of patients reported occasional use of condoms and only 12.8% of them used condoms regularly. However, most participants considered condoms to be an appropriate method of preventing disease transmission [30]. The authors found no studies investigating the rate of condom use among GWs affected women, or their attitudes in this regard. Therefore, it is not possible to comment on the role of condom use in the sexual intercourse of these patients.
Regarding the effects of genital warts on men's sexual function, different findings have been reported. Adeli et al. [17] reported that unlike the high percentage of women with GWs who suffered from sexual dysfunction, their husbands' sexual function was not affected in most cases. Few men reported lower sexual satisfaction due to a change in the type of intercourse (elimination or reduction of vaginal, oral, or anal intercourse) [17], while Chew et al. [40] reported an association between sexual dysfunction in men partnered with women with FSD, especially in the domains of erectile and ejaculatory function. Differences in the study population, and socio-cultural backgrounds may be the reasons for these observed differences in the findings, in the way that Adeli et al. evaluated the husbands of women with GWs, while Chew et al. evaluated the sexual partners of women with sexual dysfunction.
According to the objectives of the present study, the studies addressing cervical cancer, cervical intraepithelial neoplasia, men, and non-heterosexuals were excluded. This issue was a limitation of the present study. Therefore, it is suggested that these cases be examined in future studies.
