Diagnostic Assessment — Genital Warts
Example 1 of 1 · fictitious patient
Diagnostic Assessment Genital Warts BOP Code: 8 of 2023 (Warts) RH Code: 7 of 2023 (Warts)
ADF History
The veteran, date of birth [withheld], Royal Australian Navy, Boatswain's Mate, 20 March 1980 to 4 January 1987
Occupational History
Sexually transmitted infections, including genital warts (condylomata acuminata), are recognised as conditions that can be acquired during military service.
The communal living environment, postings and sea service away from home, and the social circumstances of naval service are associated with increased risk of sexually transmitted infections
History
The veteran had genital warts (penile warts) during ADF service.
The warts were present for 6 months and enlarging at the time of surgical referral on 17 June 1984.
He was referred from a patrol boat to the treating doctor.
Brown, Consultant General Surgeon, for surgical treatment.
Diathermy of multiple penile warts was performed under general anaesthetic at RANH a patrol boat on 20 June 1984
Timeline
17 Jun 1984 — Surgical referral to the treating doctor.
Brown, Consultant General Surgeon, from a patrol boat.
Multiple warts on the shaft of the penis, present for 6 months and enlarging. "Penile warts, 6 months, enlarging" 20 Jun 1984 — Diathermy of multiple penile warts performed under general anaesthetic at RANH a patrol boat by the treating doctor.
Betadine paint applied to diathermy wounds post-operatively.
Uneventful recovery. "Diathermy multiple penile warts"
Symptoms
The veteran had multiple visible and enlarging warts on the shaft of the penis that had been present for approximately 6 months prior to surgical treatment
Imaging
No imaging related to this condition
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Genital Warts / Condylomata Acuminata (ICD-10: A63.0).
Genital warts are caused by human papillomavirus (HPV) infection, typically types 6 and 11, and are transmitted through sexual contact
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Approximately January 1984 (6 months prior to referral on 17 June 1984) [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 17 June 1984 When was the condition confirmed / formally diagnosed? 17 June 1984 When did the veteran first present to you (or your practice) for this condition? 31 July 2021
3. How was this diagnosis confirmed?
The diagnosis was confirmed on clinical grounds by the treating doctor.
Brown, Consultant General Surgeon.
Multiple warts were visible on the shaft of the penis.
Definitive treatment was by diathermy under general anaesthetic [ [CHART REVIEW document], pages 112 114]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 17 June 2000 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Warts, No.
8 of 2023) Factor 9(1): having direct physical contact with another person s cutaneous warts, within the 12 months before the clinical onset of warts — MET - This factor is not confined to cutaneous warts in the person affected.
In the 12 months before about January 1984 the veteran lived and worked in close quarters with other sailors at a patrol boat and, from August 1983, in a patrol boat, whose sick bay held a wart clinic in October 1983, which suggests that cutaneous warts were common around him.
Direct skin contact with shipmates is routine in that setting, and although none is recorded, it is reasonable to infer direct physical contact with another person's cutaneous warts in that period.
Cutaneous wart virus types occasionally cause anogenital warts, usually carried on the hands, although sexual contact is the more likely route of his genital warts.
Factor 9(2): for warts affecting the cervix uteri only, having penetrative sexual intercourse with a person with genital warts within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the cervix uteri and cannot apply to the veteran, who is a man.
Factor 9(3): for warts affecting the anogenital region only, having contact with the anogenital warts of another person within the 12 months before the clinical onset of warts — MET - the veteran's genital warts, multiple warts on the shaft of the penis, affected the anogenital region.
Anogenital warts are usually acquired through intimate skin-to-skin contact with the anogenital warts of another person, which may be small, flat or unnoticed, and they usually appear about three weeks to eight months after that contact.
The warts had been present for about six months when he was referred on 17 June 1984, placing their onset in about January 1984 and the contact from which they arose in the preceding months, well within the 12- month window.
The record does not identify the source, but the lack of a record is not evidence that the contact did not occur.
Factor 9(4): for warts affecting the oral cavity or the larynx only, having oral sex with a person with anogenital warts within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the oral cavity or larynx; the veteran's warts in this assessment affected the shaft of the penis.
Factor 9(5): for plantar warts only, using communal showering or bathing facilities within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to plantar warts; the veteran's warts in this assessment affected the shaft of the penis.
Factor 9(6): for warts on the hands only, using shared gloves or shared utensils on more days than not for 3 months in the preparation of meat, poultry or fish for consumption, within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts on the hands; the veteran's warts in this assessment affected the shaft of the penis.
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical onset of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation, and nothing in his history suggests substantially lowered immune function when the warts appeared in about January 1984.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Warts, No.
7 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having direct physical contact with another person s cutaneous warts, within the 20 months before the clinical onset of warts — MET - This factor is not confined to cutaneous warts in the person affected.
In the 20 months before about January 1984 the veteran lived and worked in close quarters with other sailors in a patrol boat, at a patrol boat and in a patrol boat, whose sick bay held a wart clinic in October 1983, and it is reasonable to infer direct skin contact with another person's cutaneous warts in that period, although none is recorded.
Such contact is an occasional source of anogenital warts, though a less likely one than sexual contact.
Factor 9(2): for warts affecting the cervix uteri only, having penetrative sexual intercourse with a person with genital warts within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the cervix uteri and cannot apply to the veteran, who is a man.
Factor 9(3): for warts affecting the anogenital region only, having contact with the anogenital warts of another person within the 20 months before the clinical onset of warts — MET - the veteran's genital warts, on the shaft of the penis, affected the anogenital region.
Such warts usually follow intimate skin-to-skin contact with another person's anogenital warts, which may be small or unnoticed, by about three weeks to eight months; with onset in about January 1984 (six months before the referral of 17 June 1984), that contact most probably occurred within the preceding 20 months.
The source is not recorded, but that is not evidence that the contact did not occur.
Factor 9(4): for warts affecting the oral cavity or the larynx only, having oral sex with a person with anogenital warts within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the oral cavity or larynx; the veteran's warts in this assessment affected the shaft of the penis.
Factor 9(5): for plantar warts only, using communal showering or bathing facilities within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to plantar warts; the veteran's warts in this assessment affected the shaft of the penis.
Factor 9(6): for warts on the hands only, using shared gloves or shared utensils on more days than not for 3 months in the preparation of meat, poultry or fish for consumption, within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts on the hands; the veteran's warts in this assessment affected the shaft of the penis.
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical onset of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation, and nothing in his history suggests substantially lowered immune function when the warts appeared in about January 1984.
Other Plausible Links to Service When the genital warts were diagnosed, the veteran also had active warts on his left hand and fingers, recorded by the surgeon on 17 June 1984 and treated at the same operation on 20 June 1984; he is left-hand dominant and had had warts on the hands and wrists since at least August 1981.
Transfer of the wart virus from the hands to the genital skin, including by a person's own hands, is a recognised though less common route by which anogenital warts arise.
To the extent that this occurred, the genital warts are a consequence of his in-service hand warts.
Conclusion the veteran's genital warts are an anogenital human papillomavirus infection that first appeared in about January 1984, while he was serving in a patrol boat.
The usual route, and the most likely one here, is intimate contact with another person's anogenital warts in the preceding months (factor 9(3)); transfer from his extensive in-service warts of the left hand is a recognised alternative that would make them a consequence of that service condition.
The warts enlarged for about six months before he presented (factor 9(9)) and were treated in service by diathermy under general anaesthetic on 20 June 1984; the condition therefore arose during his service.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's genital warts are found not to have arisen out of his service, the following factors address whether service rendered after their clinical onset (about January 1984) aggravated them or contributed to them in a material degree.
The warts enlarged over about six months before they were treated by diathermy under general anaesthetic on 20 June 1984.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Warts, No.
8 of 2023) Factor 9(8): being in an immunocompromised state as specified at the time of the clinical worsening of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation while the warts enlarged in 1984; the antimalarial prophylaxis with chloroquine and Maloprim from 2 February to 23 February 1984 is not immunosuppressive treatment of that kind.
Factor 9(9): inability to obtain appropriate clinical management for warts — MET - the veteran's penile warts had been present for about six months and were enlarging when first recorded on 17 June 1984.
In those months he served in a patrol boat, including the ship's voyage in early 1984, and although he attended the sick bay for other problems, the warts were not presented until July.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), inability is assessed objectively and subjectively and includes psychological or emotional barriers; embarrassment about a genital condition in a small shipboard community is a recognised barrier of that kind.
The delay allowed multiple enlarging warts to develop that required diathermy under general anaesthetic on 20 June 1984, although treatment was prompt once he presented.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Warts, No.
7 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(8): being in an immunocompromised state as specified at the time of the clinical worsening of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation while the warts enlarged in 1984; the antimalarial prophylaxis with chloroquine and Maloprim from 2 February to 23 February 1984 is not immunosuppressive treatment of that kind.
Factor 9(9): inability to obtain appropriate clinical management for warts — MET - The penile warts enlarged for about six months, including a patrol boat's voyage in early 1984, before they were first recorded and referred on 17 June 1984, although he attended the sick bay for other problems in that time; embarrassment about a genital condition in a shipboard community is a psychological barrier of the kind recognised in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J).
By then the warts were multiple and required diathermy under general anaesthetic on 20 June 1984
Sequelae
No specific sequelae documented
Unintended Consequence
Not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
The penile warts had been present for about six months and were enlarging when first recorded on 17 June 1984; in that time he served in a patrol boat, including the ship's voyage in early 1984, and although he attended the sick bay for other problems the warts were not presented until July, embarrassment about a genital condition in a shipboard community being a recognised psychological barrier.
By then the warts were multiple and required diathermy under general anaesthetic on 20 June 1984, although treatment was prompt once he presented.
Assessed objectively and subjectively under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this is an inability to obtain appropriate clinical management — MET
Date of Clinical Onset
Genital warts are an acute condition.
Their date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: approximately January 1984 — appearance of penile warts, recorded as present for six months when he was referred on 17 June 1984 [CHART REVIEW document].
The later records, including the diathermy of 20 June 1984, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: approximately January 1984.
This date falls within the veteran's ADF service (20 March 1980 4 January 1987).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
