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EDITORIAL  
Year : 2012  |  Volume : 4  |  Issue : 1  |  Page : 1-3
State of the Globe: The relationship between male circumcision and genitourinary infections


Departments of Obstetrics and Gynecology, Women's Health Center, Assiut University, Egypt

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Date of Web Publication13-Mar-2012
 

How to cite this article:
Nasr A. State of the Globe: The relationship between male circumcision and genitourinary infections. J Global Infect Dis 2012;4:1-3

How to cite this URL:
Nasr A. State of the Globe: The relationship between male circumcision and genitourinary infections. J Global Infect Dis [serial online] 2012 [cited 2019 Oct 19];4:1-3. Available from: http://www.jgid.org/text.asp?2012/4/1/1/93747


Male circumcision, i.e., partial or complete surgical removal of the foreskin (prepuce) of the penis, is a practice known since antiquity. Ancient Egyptian paintings testify to its long existence. The word 'circumcision' comes from the Latin circumcidere (meaning 'to cut around'). [1] Driven by religious, cultural, social, secular, or health-related motives, male circumcision is commonly performed during adolescence or even during infancy. According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom almost two-thirds are Muslims. [1,2] It is possibly the most common surgical procedure performed in the world. It is a religious commandment in Islam, where male circumcision is widely practiced [3] Moreover, it is customary in some Oriental, Orthodox, and other Christian churches of Africa and a routine procedure among the Jews. [1],[3]

Male circumcision is believed by many to be a defense against a wide range of bacterial and non-bacterial pathogens; however, the precise mechanism of this effect is still to be defined. Circumcision has been suggested as an effective method of maintaining penile hygiene from the time of the Egyptian Pharaohs. [1] What remains unclear is the particular association of the penile microbiological environment on the one hand and reproductive tract infection (RTI) and urinary tract infection (UTI) on the other. This is in clear distinction to the situation in females, where there have been extensive investigations into vaginal microflora and their potential to cause RTI and UTI. The relative paucity of information in males calls for a focused exploration of this important issue. A multitude of epidemiological studies have illustrated that circumcised men have lower risk of several RTIs than uncircumcised men. A potential biological explanation for this is the fact that the area under the foreskin is a warm, moist environment that may allow some pathogens to persist and replicate, especially when penile hygiene is poor. [2] A number of recent randomized clinical trials (RCTs) have shown that circumcision decreases human immunodeficiency virus (HIV) infection in men by 50%-60%. [4],[5] Following the publication of many clinical trials the WHO/UNAIDS has advised that promotion of male circumcision should be included as an additional strategy for the prevention of heterosexually acquired HIV infection in men in areas of high HIV prevalence. [2],[6] Although the foreskin has been seen as the primary target of HIV infection, HIV target cells have also been reported to be present in the in the epithelia of the penile shaft, glans/corona, meatus, and urethral introitus. Sexually transmitted infections (STIs) can affect any of these sites and increase susceptibility to HIV acquisition by eroding the protective epithelial layer and by attracting and activating HIV target cells in the epithelium. [4] In most uncircumcised men the moist subpreputial cavity that encompasses the entire penile tip, including the glans, meatus, and urethral introitus, plays an important role in STI acquisition. Circumcised men have a lower rate of STIs that infect not only the foreskin but also other distal penile sites, especially the urethra. Also, the foreskin may trap HIV and HIV-infected cells after intercourse, thereby increasing the risk of HIV acquisition not only through the inner foreskin but also through other sites covered by the foreskin. The subpreputial cavity also hosts a unique microbiome that may play a role in HIV infection. The penile urethra may be the primary HIV acquisition site in circumcised men and possibly also in non-circumcised men because of the presence of superficial HIV target cells and a high incidence of STIs at this site. [4] Both innate and adaptive immune defense mechanisms are operative in the lower male genital region. The penile urethral mucosa contains accumulations of IgA(+) plasma cells and T-lymphocytes and may provide a responsive target for future mucosal vaccines to prevent HIV sexual transmission. [4]

Educational materials about the benefits of male circumcision as an HIV prevention intervention should be made available to healthcare providers and specific target groups. [7] Although many observational studies and a few RCTs have reported an association between male circumcision and reduced risk of HIV infection in female partners, circumcision of HIV-infected men was not shown to reduce HIV transmission to female partners. [8] Cumulative data from one RCT and six longitudinal analyses have shown little evidence that male circumcision directly reduces risk of HIV in women. Definitive data would ideally come from RCTs of circumcision among men infected with HIV and in serodiscordant heterosexual relationships; however, this would involve enrolling about 10000 couples and is unlikely to be logistically feasible.

In high-HIV-prevalence settings, rapid integration with existing prevention strategies would maximize benefits for both men and women. [9] Consequently, condom use even after male circumcision is essential for HIV prevention. [8],[9] The nonkeratinized epithelium of the inner foreskin in humans is also thought to be more susceptible to human papilloma virus (HPV) entry than the rest of the penis. However, studies exploring the potential association between male circumcision and HPV infection have produced conflicting results. A number of recent studies have also shown a lower prevalence and incidence of high-risk HPV infection among circumcised men. This protective effect could be explained by the role of the foreskin on HPV transmission. Moreover, the prevalence of low-risk HPV genotypes 6 and 11 that cause genital warts was also significantly lower among circumcised men compared to the uncircumcised. [10] Male circumcision has been shown to reduce the risk of HPV infection in a stage- and type-specific manner. There is no consistent association of HPV acquisition with circumcision status; however, circumcision has been associated with a reduced prevalence and persistence of oncogenic HPV infections. Circumcised men were also found to be less susceptible to multiple infections. These findings indicate that circumcision modulates HPV persistence rather than acquisition. Through promoting HPV infection clearance, male circumcision could be an important adjunct to education, condom use, and vaccination in reducing the global burden of HPV morbidity and mortality. [11]

Uncircumcised infants are more likely to harbor a reservoir of uropathogenic organisms (e.g.,  Escherichia More Details coli) in the urethral meatus and periurethral area; these organisms may adhere especially well to the inner mucosal surface of the foreskin as opposed to the keratinized external surface. [2] Such adherent organisms may then ascend to the bladder and kidneys, causing UTIs and pyelonephritis. Moreover, in contrast to the penile shaft and the outer surface of the foreskin, the inner mucosal surface of the foreskin is only thinly keratinized and thereby more susceptible to abrasions and minor trauma that could facilitate access of pathogens. In the uncircumcised, the cells of the inner foreskin and frenulum are directly exposed to vaginal secretions during intercourse, whereas in the circumcised male the penile shaft is covered with a thickly keratinized epithelium, offering a considerable safeguard against infection.

One of the major arguments in favor of circumcision is that it improves penile hygiene. In the non-circumcised, regular cleansing is necessary to prevent the accumulation of secretions in the space in between the inner foreskin and glans, which can lead to the proliferation of pathogens. Smegma is a mixture of transudated skin oils, exfoliated epithelial cells, moisture, and bacteria. [2]

Although the beneficial impact of male circumcision on HIV and HPV infections has been clearly demonstrated in a number of recent studies, its influence on the incidence of other RTIs has been controversial. [2],[4],[5],[6],[7],[8],[9],[10],[11],[12] A recent meta-analysis of observational data extracted from 26 studies came to the conclusion that male circumcision was associated with lower rates of syphilis, chancroid, and gonorrhea, as well as a significantly reduced risk of Chlamydia trachomatis infection in female partners of circumcised men. [13] However, in contrast, other studies have failed to elicit such a prophylactic benefit. A recent prospective trial concluded that male circumcision does not provide a substantial protective benefit against syphilis or gonorrhea. [4] Balanitis, balanoposthitis, meatitis, phimosis, and paraphimosis were reportedly higher among uncircumcised children. [14] A meta-analysis of 12 studies (one RCT, four cohort studies, and seven case-control studies) representing 402908 children determined that circumcision is associated with a significantly reduced risk of UTI. [15] Intriguingly, those who benefited the most were those at high risk of UTI, such as those with high-grade vesicoureteral reflux or a history of recurrent UTIs, where the number needed to treat (NNT) was 11 and 4, respectively. [15] These findings support the hypothesis that circumcision protects boys from UTI, but the magnitude of this effect may be less than previously estimated. [16]

In conclusion, male circumcision is a minor surgical procedure that is commonly performed around the globe. Promotion of male circumcision on medical grounds has always been a contentious issue, largely due to lack of sufficient evidence. However, there is now conclusive evidence that male circumcision significantly reduces the risk of HIV and HPV infection in men. What still remains enigmatic is its relation to other RTIs. The study published in this issue may help unravel part of this enigma.

 
   References Top

1.Totaro A, Volpe A, Racioppi M, Pinto F, Sacco E, Bassi PF. Circumcision: History, religion and law. Urologia 2011;78:1-9.  Back to cited text no. 1
    
2.Male circumcision: Global trends and determinants of prevalence, safety and acceptability. Geneva: World Health Organization; 2007.  Back to cited text no. 2
    
3.Rizvi SA, Naqvi SA, Hussain M, Hasan AS. Religious circumcision: A Muslim view. BJU Int 1999;83 (Suppl) 1:13-6.  Back to cited text no. 3
    
4.Anderson D, Politch JA, Pudney J. HIV infection and immune defense of the penis. Am J Reprod Immunol 2011;65:220-9.  Back to cited text no. 4
    
5.Albert LM, Akol A, L'engle K, Tolley EE, Ramirez CB, Opio A, et al. Acceptability of male circumcision for prevention of HIV infection among men and women in Uganda. AIDS Care 2011.  Back to cited text no. 5
    
6.Larke N. Male circumcision, HIV and sexually transmitted infections: A review. Br J Nurs 2010;19:629-34.  Back to cited text no. 6
    
7.Gust DA, Kretsinger K, Pals SL, Gaul ZJ, Hefflefinger JD, Begley EB, et al. Male circumcision as an HIV prevention intervention in the U.S.: Influence of health care providers and potential for risk compensation. Prev Med 2011;52:270-3.  Back to cited text no. 7
    
8.Wawer MJ, Makumbi F, Kigozi G, Serwadda D, Watya S, Nalugoda F, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: A randomised controlled trial. Lancet 2009;374:229-37.  Back to cited text no. 8
    
9.Weiss HA, Hankins CA, Dickson K. Male circumcision and risk of HIV infection in women: A systematic review and meta-analysis. Lancet Infect Dis 2009;9:669-77.   Back to cited text no. 9
    
10.Tarnaud C, Lissouba P, Cutler E, Puren A, Taljaard D, Auvert B. Association of low-risk human papillomavirus infection with male circumcision in young men: Results from a longitudinal study conducted in Orange Farm (South Africa). Infect Dis Obstet Gynecol 2011;2011:567408.  Back to cited text no. 10
    
11.Rehmeyer CJ. Male circumcision and human papillomavirus studies reviewed by infection stage and virus type. J Am Osteopath Assoc 2011;111(3 Suppl 2):S11-8.  Back to cited text no. 11
    
12.Reynolds SJ, Shepherd ME, Risbud AR, Gangakhedkar RR, Brookmeyer RS, Divekar AD, et al. Male circumcision and risk of HIV-1 and other sexually transmitted infections in India. Lancet 2004;363:1039-40.  Back to cited text no. 12
    
13.Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: A systematic review and meta-analysis. Sex Transm Infect 2006;82:101-10.  Back to cited text no. 13
    
14.Günþar C, Kurutepe S, Alparslan O, Yilmaz O, Daðlar Z, Sencan A, et al . The effect of circumcision status on periurethral and glanular bacterial flora. Urol Int 2004;72:212-5.  Back to cited text no. 14
    
15.Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomised trials and observational studies. Arch Dis Child 2005;90:853-8.   Back to cited text no. 15
    
16.To T, Agha M, Dick PT, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet 1998;352:1813-6.  Back to cited text no. 16
    

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Correspondence Address:
Ahmed Nasr
Departments of Obstetrics and Gynecology, Women's Health Center, Assiut University
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.93747

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