When clinical manifestations of vulvar HPV infection do occur, they often present as bumps or growths on the vulvovaginal or perianal mucosa. Although commonly asymptomatic, genital warts can cause itching, burning, pain or bleeding. On examination, warts can range in morphologic appearance from flat-topped papules to flesh-colored, dome-shaped papules, keratotic warts or true condylomata acuminata. External genital warts tend to occur on the moist surfaces of the vulva, introitus and perianal area. Distinguishing warts from vulvar neoplasia based on appearance alone is not always possible. In general, hyperpigmented, indurated, fixed or ulcerative lesions, or lesions that do not respond to treatment or worsen during treatment, should be biopsied, as VIN can present as red, white, dark, raised or eroded lesions. If the diagnosis is uncertain, or the patient is immunocompromised, biopsy should be undertaken (CDC, 2006). Women with genital warts should undergo routine cervical cancer screening. The use of HPV testing, a change in the frequency of cervical cytologic screening or cervical colposcopy are not indicated in the presence of genital warts. If exophytic cervical warts are detected during examination or if vulvar neoplasia is confirmed by biopsy, referral for colposcopic evaluation is indicated (CDC, 2006).