Int J STD AIDS 2008;19:821-823
doi:10.1258/ijsa.2008.008106
© 2008 Royal Society of Medicine Press
Original research articles |
Foreskin length in uncircumcised men is associated with subpreputial wetness
N O'Farrell MD FRCP * 
,
C-K Chung RCN * and
H A Weiss PhD
* Pasteur Suite, Ealing Hospital;
Infectious Diseases Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, UK
Correspondence to: Dr Nigel O'Farrell, Pasteur Suite, Ealing Hospital, Uxbridge Road, London UB1 3HW, UK Email: nigel.o'farrell{at}eht.nhs.uk/nigel.ofarrell{at}lshtm.ac.uk
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Summary
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This study was performed to identify possible factors associated
with penile wetness, defined as the observation of a diffuse
homogenous film of moisture on the surface of the glans and
coronal sulcus, in men attending a sexually transmitted infection
clinic. Genital examination was undertaken in 422 uncircumcised
men and any degree of subpreputial wetness observed was recorded.
The degree of visibility of the urinary meatus on direct inspection
was also assessed. Subjects were asked whether they retracted
the foreskin while urinating and how long since they had last
passed urine. Penile wetness was observed in 13.0% of the men
and was more common in those whose foreskin covered the urinary
meatus on direct inspection (17.4% vs. 4.9%) and those with
balanitis (33.3%). On multivariate analysis, penile wetness
was independently associated with balanitis, non-specific urethritis/chlamydia,
reporting sex with another man and having a visible urinary
meatus on direct inspection. Penile wetness was not associated
with retracting the foreskin while passing urine or duration
since last passed urine. Men with a foreskin covering the urinary
meatus on direct observation should be advised about the benefits
of good genital hygiene if penile wetness was observed.
Key Words: genital hygiene • male circumcision • penile wetness • STDs
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INTRODUCTION
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In a study of uncircumcised male sexually transmitted infection
(STI) clinic attenders in Durban, South Africa, subpreputial
penile wetness, defined as the observation of a diffuse homogenous
film of moisture on the surface of the glans and coronal sulcus,
was identified in 49% and was significantly associated with
HIV.
1 The nature of penile wetness was poorly understood although
it is thought to be related to poor genital hygiene, a clinical
observation reported previously in India.
2 However, questions
about genital hygiene are particularly susceptible to social
desirability bias and few studies have been done in this area.
A previous suggestion that prostatic, vesicular and urethral secretions might play a role in penile wetness is unlikely given the marked differences in penile wetness observed in different populations: a much lower prevalence of penile wetness was identified in a London STI clinic compared with that in South Africa.1,3
A significant proportion of uncircumcised men do not retract the foreskin while passing urine and it could be that that some residual urine is retained in the subpreputial space accounting for the wetness. We therefore sought to identify possible factors associated with penile wetness in men attending a STI clinic.
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METHODS
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Consecutive uncircumcised men attending the Ealing Hospital
STI clinic with a new problem were enrolled between April 2005
and December 2006. Those with urethral discharge on clinical
examination were excluded. Sociodemographic information was
collected and standard STI tests were performed. A urethral
specimen was examined by Gram stain for pus cells and the Strand
Displacement Amplification Probe Tec ET assay (Becton Dickinson
Sparks, MD, USA) was used to identify chlamydia. Balanitis,
genital herpes and warts were diagnosed clinically. Serological
tests for syphilis were done on new patients. Patients were
tested for HIV if they requested for the test after informed
consent. Genital examination was undertaken by either a senior
doctor or nurse and any degree of subpreputial wetness observed
was classified as dry or wet. Penile wetness was defined as
the observation of a diffuse homogeneous film of moisture on
the surface of the glans and coronal sulcus. The degree of visibility
of the urinary meatus on direct inspection was assessed while
patients were standing. Subjects were asked whether they retracted
the foreskin while urinating and since how long they had last
passed urine. Ethical approval for the study was granted by
the local Ealing Hospital ethics Committee.
Data analysis
Penile wetness was classified as a binary variable with either dry or with any degree of penile wetness. The sample size was calculated to detect a difference in penile wetness of 6% in those who retracted the foreskin when passing urine and 15% in those who did not as significant at the 5% level with a power of 80%. Data were entered into Excel and analysed using Stata, Version 9.2 (Stata Corporation, TX, USA).
Univariate analysis was performed to compare proportions in the tables using the chi-squared test. Logistic regression was performed to estimate crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Statistical significance was assessed with the likelihood ratio test. Factors significant at P < 0.05 in the univariate analysis were included in a multivariate logistic regression model and retained in the model if they remained statistically significant.
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RESULTS
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Sixty-three men who sometimes retracted their foreskin while
urinating and five with non-retractile foreskins were excluded
leaving 422 subjects for the final analysis. The sociodemographic
details of these men are shown in Table
1. Of these, 255
(60.4%) retracted their foreskin while passing urine and 167
(39.6%) did not.
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Table 1 Prevalence of penile wetness among uncircumcised men attending a sexually transmitted infection (STI) clinic
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Overall, 13.0% of men had penile wetness and this was more common
among men whose foreskin covered the urinary meatus on direct
inspection (17.4% vs. 4.9%) and those with balanitis (33.3%)
or non-specific urethritis (NSU)/chlamydia (20.6%). Penile wetness
was also more common among men who have sex with men (MSM, 28.0%)
than heterosexual men (12.1%).
On multivariate analysis, penile wetness was independently associated with balanitis (OR = 4.14, 95% CI 1.5–11.5), NSU/chlamydia (OR = 2.08, 95% CI 1.0–4.3), MSM (OR = 3.29, 95% CI 1.2–8.8) and not having a visible urinary meatus on direct inspection (OR = 4.28, 95% CI 1.9–9.9).
Penile wetness was not associated with retracting the foreskin while passing urine (OR 1.31, 95% CI 0.7–2.3) or duration since last passing urine (P-trend = 0.97).
We also looked for any associations between our selected characteristics and having a visible meatus but none were statistically significant.
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DISCUSSION
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We found that the urinary meatus was not visible during routine
clinical examination in about two-thirds of our patients indicating
considerable variation in the length of the foreskin in this
population of uncircumcised men. Variation in the length of
the foreskin was also observed in circumcised men in Kenya.
4 We also found that having a visible meatus was protective of
penile wetness. This may reflect comparatively poor standards
of hygiene in those with longer foreskins than others. We found
no significant difference between the main racial groups in
our study population in either penile wetness or having a visible
urinary meatus.
We found an association between penile wetness and balanitis diagnosed clinically as before.3 Although we found an association between penile wetness and MSM, the numbers in the latter group were very small. A previous study showed no such association3 and two other recent studies in MSM have shown no association between circumcision status and HIV.5,6
We found no significant difference between penile wetness and retracting the foreskin while passing urine or duration since last passing urine making urine a very unlikely cause of penile wetness. In Durban, penile wetness was associated with younger age, low level of education, low income, higher lifetime numbers of sexual partners and not washing after sex.1
The nature of penile wetness is still unclear. There is a degree of subjectivity to its presence although the previous study in South Africa found a high degree of concordance between doctors in determining its diagnosis. Further studies should look at its chemical composition and measure pH.
We did not ask about the frequency of genital washing because of difficulties in establishing the validity of reported male genital hygiene behaviour. However, we have reported previously that not always washing the whole penis, including retracting the foreskin in non-circumcised men every time they washed, is more common in non-circumcised than circumcised men.7
Three intervention studies implementing male circumcision have identified a significantly reduced risk of HIV among heterosexual men in Africa.8–10 However, mass circumcision of populations at risk will take some time to roll out. While it is likely that some uncircumcised men are at higher risk than others because of differences in the length of their foreskin, it would be difficult to prioritize men for circumcision based on such an assessment. If poor hygiene is a risk factor for HIV,1 men with a foreskin covering the urinary meatus on direct observation should be advised about the potential benefits of good genital hygiene if penile wetness is observed.
In the USA, a panel of experts has not recommended circumcision in heterosexuals as a HIV prevention measure other than in very high-risk groups.11 In the UK, Africans having connections with countries of high HIV prevalence are the heterosexual group with utmost risk of HIV. The results here suggest that penile wetness in Africans in the UK is not significantly different from others. However, those from countries with a high prevalence of HIV having evidence of penile wetness should be considered to be at high risk of HIV and counselled accordingly.
(Accepted May 22, 2008)
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REFERENCES
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- O'Farrell N, Morison L, Moodley P, et al. Association between HIV and subpreputial penile wetness in uncircumcised men in South Africa. J Acquir Immune Defic Syndr 2006;43:69–77[Medline]
- Prakash S, Rao R, Venkatesan K, Ramakrishnan S. Subpreputial wetness-its nature. Ann Nat Med Sci 1982;18:109–12
- O'Farrell N, Chung C-K, Morison L. Low prevalence of penile wetness in STI clinic attenders in London. Sex Transm Dis 2007;24:408–9
- Brown JE, Micheni KD, Grant EM, Mwenda JM, Muthiri FM, Grant AR. Varieties of male circumcision. A study from Kenya. Sex Transm Dis 2001;28:608–12[Medline]
- Millett G, Ding H, Lauby J, et al. Circumcision status and HIV infection among black and Latino men who have sex with men in 3 US cities. J Acquir Immune Defic Syndr 2007;46:643–50[Medline]
- Templeton DJ, Jin F, Prestage GF, Circumcision status and risk of HIV seroconversion in the HIM cohort of homosexually active men in Sydney. Fourth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (abstract WEAC103), Sydney, 2007. See www.ias2007.org/pag/Abstracts.aspx?SID=55&AID=2465 (last accessed 10 September 2008)
- O'Farrell N, Quigley M, Fox P. Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross sectional study. Int J STD AIDS 2005;16:556–9[Abstract/Free Full Text]
- Auvert BA, Puren A, Taljaard D, et al. Randomised controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLOS Med 2005;2:1112–22
- Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised trial. Lancet 2007;369:643–56[Medline]
- Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657–66[Medline]
- Sullivan PS, Climax PH, Peterman TA, et al. Male circumcision for prevention of HIV transmission: what the new data mean for HIV prevention in the United States. PLOS Med 2007;4:1162–6
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Summary
INTRODUCTION
