Circumcision and STD in the United States: cross sectional and cohort analyses

BACKGROUND: Male circumcision status has been shown to be associated with sexually transmitted disease (STD) acquisition in some, but not all, studies. Most studies have been cross sectional. OBJECTIVES: We examined the association between circumcision status and the prevalence and incidence of gonorrhoea, chlamydia, and syphilis. METHODS: We analysed cross sectional and cohort study data from a multicentre controlled trial in the United States. Between July 1993 and September 1996, 2021 men visiting public inner city STD clinics in the United States were examined by a clinician at enrolment and 1456 were examined at follow up visits 6 and 12 months later. At each visit, men had laboratory tests for gonorrhoea, chlamydia, and syphilis and were examined for circumcision status. We used multiple logistic regression to compare STD risk among circumcised and uncircumcised men adjusted for potentially confounding factors. RESULTS: Uncircumcised men were significantly more likely than circumcised men to have gonorrhoea in the multivariate analyses, adjusted for age, race, and site, in both the cross sectional (odds ratio (OR), 1.3; 95% confidence interval (CI), 0.9 to 1.7) and in the cohort analysis (OR, 1.6; 95% CI, 1.0 to 2.6). There was no association between lack of circumcision and chlamydia in either the cross sectional (OR, 1.0; 95% CI 0.7-1.4) or the cohort analysis (OR, 0.9; 95% CI 0.5-1.5). The magnitude of association between lack of circumcision and syphilis was similar in the cross sectional (OR, 1.4; 95% CI 0.6 to 3.3) and cohort analysis (OR, 1.5; 95% CI 0.4 to 6.1). CONCLUSION: Uncircumcised men in the United States may be at increased risk for gonorrhoea and syphilis, but chlamydia risk appears similar in circumcised and uncircumcised men. Our results suggest that risk estimates from cross sectional studies would be similar to cohort findings.     

Bacterial vaginosis is not associated with circumcision status of the current male partner

OBJECTIVE: Bacterial vaginosis (BV) is common in sexually active women, and in a large proportion the underlying aetiology is unknown. We evaluated partner circumcision status as a potential risk and hypothesised that women with uncircumcised partners were at increased risk for BV. METHODS: Retrospective audit of a partner study (272 heterosexual couples) conducted in Baltimore between 1990 and 1992. BV defined by clinical criteria and circumcision status of males was determined by physical examination. RESULTS: BV was diagnosed in 83 (30%) female partners; 75 (27%) males were uncircumcised. In males and females respectively, gonorrhoea was diagnosed in 20% and 16%, and chlamydia in 7% and 11%. In women with circumcised partners, 58/197 (29%) had BV compared with 25/75 (33%) with uncircumcised partners (p = 0.53). CONCLUSION: Women with uncircumcised current partners are not at increased risk for BV.     

Fleeting foreskins: the misclassification of male circumcision status

BACKGROUND: Errors in the classification of male circumcision status could bias studies linking infection to lack of circumcision. GOAL: To determine the frequency and factors associated with the reproducibility of reporting circumcision status. STUDY DESIGN: Secondary analysis of data using logistic regression modeling from a multicenter randomized controlled trial was performed. RESULTS: At follow-up assessment, 15.6% of clinician reports on circumcision status disagreed with baseline reports. Disagreement was more common if both clinicians were women than if both were men (odds ratio [OR], 2.8; 95% CI, 1.9-4.1). As compared with whites reported as circumcised (4%, 19/532 visits), the highest disagreement involved uncircumcised Hispanic (OR, 3.3; 95% CI, 1.7-6.3), white (OR, 12.2; 95% CI, 5.8-25.6), or black (OR, 17.1; 95% CI, 10.4-27.9) men. CONCLUSIONS: This is one study among a small number of studies examining the reproducibility of clinician-reported circumcision status by comparing multiple clinical examinations of the same patient. The magnitude of the misclassification discovered could bias results and indicates the need for greater accuracy in reporting circumcision status in future studies.     

Herpes simplex virus type 2 status at age 26 is not related to early circumcision in a birth cohort

OBJECTIVE: The objective of this study was to determine if circumcision in early childhood affects the risk of acquiring herpes simplex virus type 2 (HSV-2) infection. STUDY: Study members were born in 1972-1973 in Dunedin, New Zealand. Circumcision status was sought at age 3, when the cohort was established. Information about sexual behavior was obtained at ages 21 and 26. Serum was tested for HSV-2 antibodies at age 26 for 435 men (82.9% of the surviving cohort). RESULTS: Of eligible men, 40.2% had been circumcised. The prevalence of HSV-2 antibodies was 7.3% in uncircumcised men and 7.4% in circumcised men. Social and sexual factors were very similar between the 2 groups and adjustment had no effect on the association (odds ratio, 1.1; 95% confidence interval, 0.46-2.5). Seroconversion rates according to years since first sexual intercourse were 0.85 and 0.86 per 100 person-years for uncircumcised and circumcised men. CONCLUSION: The results support a lack of association between circumcision status and HSV-2 acquisition, although a small effect cannot be ruled out.     

Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis

OBJECTIVES: Male circumcision is associated with reduced risk of HIV infection. This may be partly because of a protective effect of circumcision on other sexually transmitted infections (STI), especially those causing genital ulcers, but evidence for such protection is unclear. Our objective was to conduct a systematic review and meta-analyses of the associations between male circumcision and infection with herpes simplex virus type 2 (HSV-2), Treponema pallidum, or Haemophilus ducreyi. METHODS: Electronic databases (1950-2004) were searched using keywords and text terms for herpes simplex, syphilis, chancroid, ulcerative sexually transmitted diseases, or their causative agents, in conjunction with terms to identify epidemiological studies. References of key articles were hand searched, and data were extracted using standardised forms. Random effects models were used to summarise relative risk (RR) where appropriate. RESULTS: 26 articles met the inclusion criteria. Most syphilis studies reported a substantially reduced risk among circumcised men (summary RR = 0.67, 95% confidence interval (CI) 0.54 to 0.83), although there was significant between study heterogeneity (p = 0.01). The reduced risk of HSV-2 infection was of borderline statistical significance (summary RR = 0.88, 95% CI 0.77 to 1.01). Circumcised men were at lower risk of chancroid in six of seven studies (individual study RRs: 0.12 to 1.11). CONCLUSIONS: This first systematic review of male circumcision and ulcerative STI strongly indicates that circumcised men are at lower risk of chancroid and syphilis. There is less association with HSV-2. Potential male circumcision interventions to reduce HIV in high risk populations may provide additional benefit by protecting against other STI.     

Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic.

INTRODUCTION--A recent study comparing heterosexual men with and without confirmed sexually transmitted diseases (STDs) in an urban STD clinic showed that uncircumcised men were less likely than circumcised men to have genital warts detectable by clinical examination (adjusted odds ratio 0.7, 95% confidence interval 0.4, 0.9). Based on these initial findings we hypothesised that the appearance and anatomic distribution of genital warts, and possibly treatment response, may be different for circumcised and uncircumcised men. METHODS--The anatomic location, appearance, number of warts, and response to treatment was investigated through review of medical records of 459 heterosexual men with genital warts detected in 1988. RESULTS--Age- and race-adjusted estimates indicated that among men with genital warts, warts were detected much more commonly on the distal penis--that is, the corona, frenulum, glans or urethral meatus-, among uncircumcised men (26%) than among circumcised men (3%) (OR 10.0, 95% CI 3.9, 25.7). Where the appearance was specified, warts were more often described as condylomatous in uncircumcised men and slightly more often as papular in circumcised men. No significant difference between circumcised and uncircumcised men was seen in the number of return visits to the clinic for persistent warts after treatment with liquid nitrogen: 2.2 visits for 19 uncircumcised men and 2.3 visits for 149 circumcised men. CONCLUSION--Circumcised men were more likely than uncircumcised men to have genital warts, but when present, warts were more often located on the distal portion of the penis among uncircumcised men. This paradox is not understood, but could reflect either nonspecific resistance to proximal penile warts conferred by the foreskin, or heightened susceptibility to various HPV types in uncircumcised men, some of which may confer subsequent immunity to genital warts.     

Increased risk of chlamydial and gonococcal infection in adolescent sex workers in Madagascar

GOAL: To examine and compare young sex workers' risk of acquisition of sexually transmitted infections (STIs) with the risk among their older counterparts. OBJECTIVE: To evaluate the effect of young age--16-19 years vs. 20 years and older--on risk of incident infection with Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT). STUDY DESIGN: A randomized controlled trial of 1,000 sex workers in Madagascar was conducted. STI testing was conducted at baseline, 6, 12, and 18 months. RESULTS: About 13% of the cohort (n = 134) was composed of young women aged 16-19 years. STI incidence rates in this group over the 18-month study period were high: 51.9/100 woman-years (WY) for GC and 47.4/100 WY for CT compared to 27.4/100 WY and 19.1/100 WY for sex workers over age 20, respectively. In multivariable models, young sex workers were at significantly higher STI risk compared with their older peers: The adjusted risk ratio (aRR) for GC comparing younger to older women was 1.50 (95% confidence interval (CI): 1.20, 1.88); for CT, the aRR was 1.72 (95% CI: 1.35, 2.19) and for GC or CT combined, the aRR was 1.42 (95% CI: 1.22, 1.66). CONCLUSIONS: This exploratory analysis suggests that additional research is warranted to identify effective and acceptable prevention strategies that benefit young women, and interventions already proven effective among adolescents should be given high priority for scale-up.     

Male circumcision and common sexually transmissible diseases in a developed nation setting.

OBJECTIVE--To determine whether the circumcision status of men affected their likelihood of acquiring sexually transmissible diseases (STDs). DESIGN--A cross-sectional study employing an anonymous questionnaire, clinical examination and type specific serology for herpes simplex virus type 2 (HSV-2). SETTING--A public STD clinic in Sydney, Australia. SUBJECTS--300 consecutive heterosexual male patients. MAIN OUTCOME MEASURES--Associations between circumcision status and past or present diagnoses of STDs including HSV-2 serology and clinical pattern of genital herpes. RESULTS--185 (62%) of the men were circumcised and they reported similar ages, education levels and lifetime partner numbers as men who were uncircumcised. There were no significant associations between the presence or absence of the male prepuce and the number diagnosed with genital herpes, genital warts and non-gonococcal urethritis. Men who were uncircumcised were no more likely to be seropositive for HSV-2 and reported symptomatic genital herpes outbreaks of the same frequency and severity as men who were circumcised. Gonorrhoea, syphilis and acute hepatitis B were reported too infrequently to reliably exclude any association with circumcision status. Human immunodeficiency virus infection (rare among heterosexual men in the clinic) was an exclusion criterion. CONCLUSIONS--From the findings of this study, circumcision of men has no significant effect on the incidence of common STDs in this developed nation setting. However, these findings may not necessarily extend to other setting where hygiene is poorer and the spectrum of common STDs is different.     

Characteristics of those who repeatedly acquire sexually transmitted infections: a retrospective cohort study of attendees at three urban sexually transmitted disease clinics in England.

BACKGROUND: Individuals who repeatedly acquire sexually transmitted infections (STIs) may facilitate the persistence of disease at endemic levels. Identifying those most likely to become reinfected with an STI would help in the development of targeted interventions. GOAL: To investigate the demographic and behavior characteristics of sexually transmitted disease (STD) clinic patients most likely to reattend with an STI. STUDY DESIGN: The proportion of patients attending three STD clinics in England between 1994 and 1998 who reattended for treatment of acute STI within 1 year was estimated from Kaplan-Meier failure curves. A Cox proportional hazard model was used to investigate the relation between rate of reattendance with an acute STI and patient characteristics. RESULTS: Of the 17,466 patients presenting at an STD clinic with an acute STI, 14% reattended for treatment of an STI within 1 year. Important determinants of reinfection were age, sexual orientation, and ethnicity: 20% of 12- to 15-year-old females (adjusted hazard ratio [HR], 1.90; CI, 1.13-3.18, compared with 20- to 24-year-old females), 22% of homosexual men (adjusted HR, 1.30; CI, 1.07-1.58, compared with heterosexual men), and 25% of black Caribbean attendees (adjusted HR, 1.87; CI, 1.63-2.13, compared with whites) reattended for treatment of acute STI within 1 year. In addition, 21% of those with a history of STI (adjusted HR, 1.42; CI, 1.28-1.59, compared with those with no history of STI) and 17% of individuals reporting three or more partners in the recent past (adjusted HR, 1.53; CI, 1.34-1.73, compared with those with one partner) reattended for treatment of an acute STI within 1 year. CONCLUSIONS: In this STD clinic population, teenage females, homosexual men, black Caribbean attendees, individuals with a history of STI, and those reporting high rates of sexual partner change repeatedly re-presented with acute STIs. Directing enhanced STD clinic-based interventions at these groups may be an effective strategy for STI control.     

An argument for circumcision. Prevention of balanitis in the adult

A cross-sectional study and a retrospective study were performed to determine the frequency of balanitis in a randomly selected group of dermatology patients. A total of 398 subjects were included in the cross-sectional study, 213 (53.5%) of whom had been circumcised. Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men. In patients with diabetes mellitus, balanitis occurred with a prevalence of 34.8% in the uncircumcised population, compared with 0% in the circumcised population. Balanitis did occur with increased frequency in the diabetic population (16%), regardless of circumcision status, compared with the nondiabetic population (5.8%). Of 63 circumcisions performed at our institution between 1987 and 1989, 28.6% were for the treatment of balanitis; 44.4%, for phimosis (which was probably induced by chronic balanitis); 19% in preparation for placement of penile prostheses; and 8% for miscellaneous reasons. No complications of circumcision were reported. In this group of patients, balanitis was more frequent in diabetic than in nondiabetic uncircumcised men (50% vs 15.4%).     

Identification of novel risks for nonulcerative sexually transmitted infections among young men in Kisumu, Kenya

OBJECTIVES: STI prevention interventions often aim to reduce HIV incidence. Understanding STI risks may lead to more effective HIV prevention. GOAL: To identify STI risks among men aged 18-24 in Kisumu, Kenya. STUDY DESIGN: We analyzed baseline data from a randomized trial of male circumcision. Participants were interviewed for sociodemographic and behavioral risks. Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were diagnosed by polymerase chain reaction assay and Trichomonas vaginalis (TV) by culture. The outcome for logistic regression analysis was infection with NG, CT, or TV. RESULTS: Among 2743 men, 214 (7.8%; 95% CI: 6.8%-8.8%) were infected with any STI. In multivariable analysis, statistically significant risks for infection were: living one's whole life in Kisumu (OR = 1.50; 95% CI: 1.12-2.01), preferring "dry" sex (OR = 1.47; 95% CI: 1.05-2.07), HSV-2 seropositivity (OR = 1.37; 95% CI: 1.01-1.86), and inability to ejaculate during sex (OR = 2.04; 95% CI: 1.15-3.62). Risk decreased with increasing age and education, and cleaning one's penis less than 1 hour after sex (OR = 0.51; 95% CI: 0.33-0.80). CONCLUSION: Understanding how postcoital cleaning, "dry" sex, and sexual dysfunction relate to STI acquisition may improve STI and HIV prevention.     

Mycoplasma genitalium infection and persistence in a cohort of female sex workers in Nairobi, Kenya

OBJECTIVE: The objective of this study was to assess the risk factors for and persistence of Mycoplasma genitalium (MG) in a highly exposed female population in Kenya. STUDY DESIGN: Two hundred fifty-eight sex workers in Nairobi, Kenya, 18 to 35 years of age, were enrolled. Every 2 months, cervical samples were collected for MG, Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (GC) testing by polymerase chain reaction. RESULTS: At enrollment, 16% were infected with MG. Seventy-seven subjects acquired 107 MG infections, giving an incidence of 22.7 per 100 women-years. Incident CT (adjusted hazard ratio [HR] = 2.4; 95% confidence interval [CI] = 1.5-4.0), GC (HR = 2.0; 95% CI = 1.2-3.5), and HIV infection (adjusted HR = 2.2; 95% CI = 1.3-3.7) were associated with an increased risk of MG. Seventeen percent, 9%, and 21% of MG infections persisted 3, 5, and >or=7 months, respectively. CONCLUSION: The high incidence of MG, greater than that for both CT (14.0%) and GC (8%), association with common sexually transmitted infection risk factors, and persistence in the female genital tract supports its role as a common sexually transmitted infection in Kenyan women.     

Male circumcision: an acceptable strategy for HIV prevention in Botswana

BACKGROUND: Male circumcision is known to reduce the risk of acquiring HIV, but few studies have been performed to assess its acceptability among either children or adults in sub-Saharan Africa. METHODS: We conducted a cross sectional survey in nine geographically representative locations in Botswana to determine the acceptability of male circumcision in the country, as well as the preferred age and setting for male circumcision. Interviews were conducted using standardised questionnaires both before and after an informational session outlining the risks and benefits of male circumcision. RESULTS: Among 605 people surveyed, the median age was 29 years (range 18-74 years), 52% were male, and >15 ethnicities were represented. Before the informational session, 408 (68%) responded that they would definitely or probably circumcise a male child if circumcision was offered free of charge in a hospital setting; this number increased to 542 (89%) after the informational session. Among 238 uncircumcised men, 145 (61%) stated that they would definitely or probably get circumcised themselves if it were offered free of charge in a hospital setting; this increased to 192 (81%) after the informational session. In a multivariate analysis of all participants, people with children were more likely to favour circumcision than people without children (adjusted odds ratio 1.8, 95% CI 1.0 to 3.4). Most participants (55%) felt that the ideal age for circumcision is before 6 years, and 90% of participants felt that circumcision should be performed in the hospital setting. CONCLUSIONS: Male circumcision appears to be highly acceptable in Botswana. The option for safe circumcision should be made available to parents in Botswana for their male children. Circumcision might also be an acceptable option for adults and adolescents, if its efficacy as an HIV prevention strategy among sexually active people is supported by clinical trials.     

Risk factors for incident herpes simplex type 2 virus infection among women attending a sexually transmitted disease clinic

OBJECTIVES: To estimate the incidence of herpes simplex type 2 virus (HSV-2) infection, to identify risk factors for its acquisition, and to assess the protective effect of condoms. STUDY DESIGN: Prospective study of 293 HSV-2 seronegative women, aged 18 to 35 years, attending a sexually transmitted disease clinic in Alabama from 1992 to 1995. RESULTS: Incidence of HSV-2 infection was 20.5 per 100 woman-years [95% confidence interval (CI), 13.1-30.5]. Young women (18-20 years) had a significantly higher risk of incident HSV-2 infection [adjusted hazard ratio (HR), 2.8; 95% CI, 1.3-6.4] than older women. Women diagnosed with prevalent or incident bacterial vaginosis had a higher incidence of HSV-2 infection than those who were not so diagnosed (adjusted HR, 2.4; 95% CI, 1.1-5.6). No significant protective effect was observed for consistent (100%) condom use without breakage and slippage against HSV-2 acquisition (adjusted HR, 0.8; 95% CI, 0.2-2.3). CONCLUSION: Acquisition of HSV-2 infection among study participants was higher than previous estimates for adult female sexually transmitted disease clinic attendees, and no protective effect for condoms was demonstrated. The high incidence of HSV-2 infection with its potential for adverse health consequences emphasizes the need for better prevention strategies.     

Factors associated with heterosexual transmission of HIV to individuals without a major risk within England, Wales, and Northern Ireland: a comparison with national probability surveys

OBJECTIVE: To compare the prevalence of HIV risk behaviours reported by heterosexuals without major risks for HIV acquisition diagnosed with HIV in England, Wales, and Northern Ireland, with those of the heterosexual general population. METHODS: Demographic and sexual behaviour data for heterosexuals (without major risks for HIV) aged 16-44 from the British National Surveys of Sexual Attitudes and Lifestyles in 1990 and 2000 were compared to 139 HIV infected individuals without major risks for HIV aged 16+ at diagnosis, interviewed between December 1987 and March 2003. Comparisons were made overall and separately for the early and late 1990s. RESULTS: HIV infected heterosexual men without major risks were significantly more likely to report first heterosexual intercourse before age 16 (adjusted odds ratio (AOR): 2.75; 95% confidence interval (CI),1.65 to 4.57), while both HIV infected heterosexual men and women reported greater partner numbers (AOR: men 2.44; CI, 1.4 to 4.05; AOR women 2.17; CI, 1.28 to 3.66) and never using condoms (AOR: men 7.97; CI,4.78 to 13.3; AOR women 3.95; CI, 2.30 to 6.80) than the heterosexual general population. There is evidence to suggest that the two groups were more similar in their reporting of partner numbers in the late 1990s relative to the early 1990s. CONCLUSION: Heterosexual HIV infected individuals without major risks for HIV acquisition in England, Wales, and Northern Ireland are significantly more likely to report high risk sexual behaviours relative to the British heterosexual general population. However, these differences may have decreased over time, at least for the number of partners. Effective sexual health promotion, including the continued promotion of condom use, would impact on the rising rates of STI diagnoses and also prevent HIV transmission among the heterosexual general population.     

HIV testing and high risk sexual behaviour among London's migrant African communities: a participatory research study

OBJECTIVES: To describe the demographic and behavioural factors associated with HIV testing among migrant Africans in London. METHODS: A cross sectional survey of migrants from five sub-Saharan African communities (Congo, Kenya, Uganda, Zambia, Zimbabwe) resident in London was carried out. The study formed part of a larger community based participatory research initiative with migrant African communities in London-the MAYISHA project. Trained, ethnically matched interviewers recruited study participants in a variety of community venues. A brief self completion questionnaire collected data on demographic characteristics, utilisation of sexual health services, HIV testing history, sexual behaviour, and attitudes. RESULTS: Valid questionnaires were obtained from 748 participants (396 men and 352 women), median ages 31 and 27 years, respectively. Median length of UK residence was 6 years. 34% of men and 30% of women reported ever having had an HIV test. HIV testing was significantly associated with age and previous STI diagnosis among women; and additionally, nationality, education, employment, and self perceived risk of acquiring HIV among men. After controlling for significant demographic variables, previous diagnosis of an STI (adjusted odds ratio and 95% confidence interval for men: 2.96, 1.63 to 5.38, and women 2.03, 1.06 to 3.88) and perceived risk of acquiring HIV for men (adjusted OR 2.28, 95%CI 1.34 to 3.90) remained independently associated. CONCLUSION: Among these high HIV prevalence migrant communities, these data suggest that HIV testing remains largely associated with an individual's STI history or self perceived risk. This strategy may be inappropriate given the potential for onward and vertical transmission. Antenatal HIV testing combined with proactive targeted HIV testing promotion should be prioritised.     

What is the potential impact of adult circumcision on the HIV epidemic among men who have sex with men in San Francisco?

With the help of a community-based survey, we assess the potential effect of circumcision on the HIV epidemic among men who have sex with men (MSM) in San Francisco. Only a small minority of MSM would both derive benefit from circumcision (i.e., were uncircumcised, HIV-negative, predominantly insertive, and reported unprotected insertive anal sex) and be willing to participate in circumcision trials (0.7%) or be circumcised if proven effective as a prevention strategy (0.9%). Circumcision would have limited public health significance for MSM in San Francisco.     

A nested case-control study of sexual practices and risk factors for prevalent HIV-1 infection among young men in Kisumu, Kenya

OBJECTIVES: To investigate sexual practices and risk factors for prevalent HIV infection among young men in Kisumu, Kenya. GOAL: The goal of this study was to identify behaviors associated with HIV in Kisumu to maximize the effectiveness of future prevention programs. STUDY DESIGN: Lifetime sexual histories were collected from a nested sample of 1337 uncircumcised participants within the context of a randomized controlled trial of male circumcision to reduce HIV incidence. RESULTS: Sixty-five men (5%) tested positive for HIV. Multiple logistic regression revealed the following independent predictors of HIV: older age, less education, being married, being Catholic, >4 lifetime sex partners, prior treatment for an STI, sex during partner's menstruation, ever practicing bloodletting, and receipt of a medical injection in the last 6 months. Prior HIV testing and postcoital cleansing were protective. CONCLUSIONS: This analysis confirms the importance of established risk factors for HIV and identifies practices that warrant further investigation.     

Circumcision and genital dermatoses

CONTEXT: It is well recognized that the presence of a foreskin predisposes to penile carcinoma and sexually transmitted infections. We have investigated the relationship between the presence or absence of the foreskin and penile dermatoses. OBJECTIVE: To determine whether there is an association between circumcision and penile dermatoses. DESIGN: A retrospective case control study of patients attending the department of dermatology with genital skin conditions. SUBJECTS: The study population consisted of 357 male patients referred for diagnosis and management of genital skin disease. The control population consisted of 305 male patients without genital skin disease attending the general dermatology clinics over a 4-month period. MAIN OUTCOME MEASURES: The relationship between circumcision and the presence or absence of skin disease involving the penis was investigated. The rate of circumcision in the general male dermatology population was determined. RESULTS: The most common diagnoses were psoriasis (n = 94), penile infections (n = 58), lichen sclerosus (n = 52), lichen planus (n = 39), seborrheic dermatitis (n = 29), and Zoon balanitis (n = 27). Less common diagnoses included squamous cell carcinoma (n = 4), bowenoid papulosis (n = 3), and Bowen disease (n = 3). The age-adjusted odds ratio for all penile skin diseases associated with presence of the foreskin was 3.24 (95% confidence interval, 2.26-4.64). All patients with Zoon balanitis, bowenoid papulosis, and nonspecific balanoposthitis were uncircumcised. Lichen sclerosus was diagnosed in only 1 circumcised patient. Most patients with psoriasis, lichen planus, and seborrheic eczema (72%, 69%, and 72%, respectively) were uncircumcised at presentation. The majority of men with penile infections (84%) were uncircumcised. CONCLUSIONS: Most cases of inflammatory dermatoses were diagnosed in uncircumcised men, suggesting that circumcision protects against inflammatory dermatoses. The presence of the foreskin may promote inflammation by a k?ebnerization phenomenon, or the presence of infectious agents, as yet unidentified, may induce inflammation. The data suggest that circumcision prevents or protects against common infective penile dermatoses.     

Low prevalence of penile wetness among male sexually transmitted infection clinic attendees in London

OBJECTIVE: To determine the prevalence of penile wetness among STI clinic attenders in London. STUDY DESIGN: A total of 480 consecutive men were examined clinically to detect whether penile wetness, defined as the clinical observation of a uniform diffuse layer of moisture on the surface of the glans and coronal sulcus, was present. RESULTS: Penile wetness was observed in 30 (6.3%), including 29 (8.3%) of uncircumcised and 1 (0.8%) of circumcised men (Relative risk 10.54 (95% CI 1.45-76.6, P = <0.001) (Fisher's Exact test) and in 14/34 (41.2%) of men with balanitis. Penile wetness was observed in 9.2% Asian, 7% Caucasian, 3% of black men, and 6.3% of homosexuals, and in 14/34 (8.2%) of men with clinical balanitis compared with 8/244 (3.3%) with no STI diagnosis (P = <0.001). CONCLUSIONS: The prevalence of penile wetness was low in this population of STI clinic attenders in London, much lower than in Durban, South Africa. Further studies of male genital hygiene are warranted.