Developmental factors of urethral human papillomavirus lesions: correlation with circumcision

To assess the relationship between circumcision and urethral human papillomavirus (HPV) lesions, and the influence of urethritis on the development of urethral HPV infections on inducing squamous metaplasia of the urethral epithelium.

The study included 210 heterosexual, HIV-negative men (median age 29 years) who all had female partners with genital HPV infection. The patients were divided into three groups according to clinical findings, i.e. 97 patients with no clinical HPV lesions on peniscopy and urethroscopy, 70 patients with balanopreputial lesions but no urethral lesions, and 43 patients with urethral HPV lesions, including 17 who had associated penile lesions. They all underwent meatopeniscopy for HPV screening, urethral biopsy for histological analysis, and bacterial cultures were taken. The results in each subgroup were compared between circumcised and uncircumcised men.

There was no significant difference in the incidence of HPV infection (58% vs 42%, odds ratio, OR, 1.8; 95% confidence interval, CI, 0.98-3.62) between uncircumcised and circumcised men, but this relationship differed with the developmental site of HPV lesions (shaft-foreskin, P<0.02; urethra, not significant). There was also a significant difference in the prevalence of urethritis between uncircumcised and circumcised men (34.5% vs 19%, OR 2.35, 95% CI 1. 08-5.11), and between HPV-infected and uninfected men (41.5% vs 18%, OR 3.17, 95% CI 1.71-5.83). This positive relationship of the prevalence of urethritis for both factors (circumcision and HPV) depended on the type of organism (sexually transmitted disease, not significant; common organism, P<0.02). The frequency of urethritis was related to the site of HPV lesions; urethritis was present in 36% of the patients with preputial HPV lesions, compared with 51% of those with urethral HPV lesions. Chlamydia trachomatis was detected in 1% of the patients without and in 7% of those with HPV lesions. In 68% of the patients, histological analysis of the urethral mucosa showed a squamous metaplasia of the urethral epithelium associated with urethritis.

Being uncircumcised did not seem to increase the risk of HPV urethral infection in young men. Genital bacterial infections and urethral HPV lesions appear to be linked. Urethritis can induce squamous metaplasia of the urethral epithelium, which appears to favour the colonization of the anterior urethra by HPVs.