Risk factors for genital HPV DNA in men resemble those found in women: a study of male attendees at a Danish STD clinic

Human Papillomaviruses and Genital Disease

Human papillomavirus (HPV) infection is causally related to several benign and malignant diseases of the anogenital tract. In this article the authors detail the epidemiology, methods of transmission and risk factors, pathogenesis, and oncogenesis of HPV, and describe clinical manifestations and current treatments. Special attention is given to condyloma acuminatum and non-cervical anogenital intraepithelial neoplasia. The authors conclude with the latest information on prophylactic vaccine development and prospects for future control of HPV-related disease.

Human papillomavirus in men: comparison of different genital sites

OBJECTIVE

To elucidate which anatomical sites need to be sampled to detect human papillomavirus (HPV) infection in the lower male genital tract.

METHOD

In an HPV survey of Mexican soldiers (median age 24 years; range 16-50 years), a cell sample from 2 cm deep into the distal urethra (group 1; n = 168 men), or 0.5 cm deep into the meatus urethralis (group 2; n = 414 men) was collected, along with a sample from the external genitalia. The different samples were tested for 27 HPV types using a polymerase chain reaction based strip assay.

RESULTS

HPV DNA was detected more frequently in external genitalia samples (46.4%) than in the urethra (20.8%) or meatus samples (12.1%). Lack of samples from the urethra or meatus would have led to 5.1% and 1.5% false HPV negative results, respectively. The most frequently detected high risk HPV types (HPV 59, 52, 51, and 16) were similar in different sites, whereas low risk types were found rarely in urethra samples.

CONCLUSIONS

The addition of cell samples from the meatus to those from external genitalia contributed negligibly to the evaluation of the prevalence of HPV in men. HPV detection was slightly improved by the addition of urethra samples, but the gain may not justify the discomfort of the procedure in large epidemiological studies.

Genital human papillomavirus infection in men

Genital human papillomavirus (HPV) infection, globally one of the most common sexually transmitted infections, is associated with cancers, genital warts, and other epithelial lesions. Although a consistent and coherent picture of the epidemiology and pathogenesis of genital HPV infections in women has developed over the past two decades, less is known about these infections in men. Available data suggest that, as with women, most genital HPV infections in men are symptomless and unapparent, and that HPV16 is probably the most frequently detected type. In populations of similar age, the prevalence of specific HPV types is usually lower in men than in women. Whether this observation relates to lower incidence or shorter duration of infection in men than in women has not yet been determined. Seroprevalence of specific anti-HPV antibodies also seems to be lower in men than in women of similar age, a difference that might be due to lower viral load, lower incidence or duration of infection or lower antibody responses, or both, in men compared with women. Differences in sexual behaviour may also be important predictors of genital HPV infection. With the anticipated availability of prophylactic HPV vaccines in the near future, it becomes increasingly important to understand the incidence and duration of HPV infections in men to develop cost-effective approaches to prevention through a combination of immunisation and promotion of risk-reduction strategies.

Prevalence and determinants of human papillomavirus infection in men attending vasectomy clinics in Mexico

Large studies of genital human papillomavirus (HPV) infection in men are few and mainly include high-risk groups. We interviewed 779 men who requested a vasectomy in 27 public clinics in 14 states of Mexico. Exfoliated cells were obtained from the scrotum, the shaft of the penis, the top of the penis including the coronal sulcus, the glans and the opening of the meatus. HPV testing was performed using biotinylated L1 consensus primers and reverse line blot. Unconditional logistic regression was used to estimate odds ratios (ORs) of being HPV-positive and corresponding 95% confidence intervals (CIs). The prevalence of any type of HPV was 8.7%. HPV positivity was highest among men below age 25 (13.6%), and lowest among men aged 40 years or older (6.0%). The most commonly found HPV types were, in decreasing order, HPV59, 51, 6, 16 and 58. Lifetime number of sexual partners was associated with HPV positivity (OR for > or = 4 vs. 1 partner = 3.7, 95% CI: 2.0-6.8), mainly on account of the strong association with number of occasional and sex-worker partners. Condom use with both regular (OR = 0.4, 95% CI: 0.1-1.0) and sex-worker (OR = 0.1, 95% CI: 0.0-0.3) partners and circumcision (OR = 0.2, 95% CI: 0.1-0.4) were inversely associated with HPV positivity. HPV prevalence in Mexican men was similar to the prevalence found in Mexican women of the same age groups. The association between HPV positivity and lifetime number of sexual partners in the present low-risk male population is one of the strongest ever reported in studies in men. Condom use and circumcision were associated with a strong reduction in HPV prevalence.

Presence of human papillomavirus DNA in testicular biopsies from nonobstructive azoospermic men

CONTEXT

Human papillomavirus (HPV) plays a major role in the etiology of many malignancies of diverse localization, such as uterine cervical carcinoma and its precursors. Human papillomavirus sequences have been detected throughout the male lower genitourinary tract, but the role of men as transmitters remains unclear.

OBJECTIVE

To investigate the relationship between azoospermia and the presence of HPV DNA in testicular cells.

DESIGN

One hundred eighty-five patients with azoospermia undergoing testicular biopsy were studied. Histologic study was done on formalin-fixed, paraffin-embedded samples from testicular biopsies, stained with hematoxylin-eosin. Molecular study to detect HPV sequences was performed on genomic DNA isolated from paraffin sections by standard protocols. Seven cases containing HPV sequences were studied after microdissection with PALM microlaser technology in order to determine the presence of HPV DNA sequences in different cells, as well as from seminal tubules or stromal (Leydig) cells.

RESULTS

Human papillomavirus DNA sequences were detected in testicular biopsies of 12 patients (6.48%). Human papillomavirus type 16 was the most common genotype encountered. Among the 92 patients who underwent bilateral testicular biopsy, HPV sequences were detected in 9 patients (9.78%), all of whom showed only unilateral testicular affection, more often in the left testicle (ratio, 2: 1). After microdissection, HPV DNA sequences were seen in Leydig and Sertoli cells; the presence of HPV in germinal cells could not be ruled out.

CONCLUSIONS

Leydig cells, Sertoli cells, and probably germinal cells (cases 2, 3, and 4) harbored HPV DNA sequences. Such findings have not been previously described in testicular tissue.

Diagnosis and management of oncogenic cervical human papillomavirus infection

Cervical HPV infection should be managed less as a typical STI and more as a strong risk factor predisposing to cervical cancer development. HPV infection is undeniably transmitted predominately through sexual contact.However, the fact that more than 80% of women followed over time will acquire at least one HR-HPV infection reflects the ubiquitous nature of the infection and the ease of transmission. Although the behavioral profiles typically associated with an increased risk for STI (including lifetime partner number, age at first intercourse, and so forth) will certainly lead to an increased risk for HPV detection, there is a high absolute prevalence of HPV even among women who have few lifetime sex partners. It could be argued that to counsel patients for an HPV infection as an STI would be counterproductive, as short of absolute abstinence, the prevention of infection is difficult and treatment options, short of excisional procedures for neoplasia, are limited. The real promise held in this area is the availability of an apparently highly effective prophylactic HPV vaccine, targeting at least HPV 16, 18, 6, and 11[33,34]. This vaccine cocktail, if it achieved 100% coverage, could theoretically prevent 50% to 70% of invasive cervical cancers and most genital warts. Vaccination will be required among women before initiation of sexual contact, presumably among girls 10 to 13 years of age. Many programmatic issues remain regarding the implementation of HPV vaccine programs, including the marketing of the vaccine as STI or cancer prevention,as reviewed in detail by Gravitt and Shah [72]. Even in the era of potentially effective vaccines, screening for cervical cancer is likely to remain a priority in cervical cancer prevention programs for at least several decades. Vaccine trials have proven high short-term efficacy; however, these effects were clearly type-specific and antibody titers gradually decrease postvaccination. It is unclear whether the protection will remain over an individual's lifetime without vaccine booster, and oncogenic HPV infections not targeted by vaccination will continue to contribute to risk for development of cervical intraepithelial neoplasia and cancer. Therefore, although the public health success of HPV vaccination is undoubtedly promising, the role of cervical cancer screening as a secondary prevention effort should not be trivialized. In fact, the nature of screening programs should continue to be reevaluated in the context of effective but limited spectrum vaccines.

Determinants of Prevalence, Acquisition, and Persistence of Human Papillomavirus in Healthy Mexican Military Men

BACKGROUND

Human papillomavirus (HPV) infection is sexually transmitted, but the nature of the infection in males is poorly understood. We sought to identify determinants of HPV infection, acquisition, and persistence in 1,030 healthy military men in Mexico.

METHODS

From July 2000 to July 2003, trained interviewers administered a questionnaire, conducted a genital examination, and collected samples. The presence of multiple HPV types in genital cells from the urethra, urethral meatus, scrotum, penile shaft, and coronal sulcus was evaluated. At baseline 1,030 participants and after 1-year follow-up 336 individuals were sampled using a highly sensitive DNA reverse blot strip assay.

RESULTS

HPV prevalence was 44.6%; infection with high-risk types was observed in 34.8% participants and 51.1% were multiply infected. After 1-year follow-up, 165 men remained free of HPV, 68 cleared their infection, 45 acquired one, and 37 remained infected with the same HPV type. The period prevalence was 50.9%, the incidence rate was 17.9/1,000 men-months [95% confidence interval (95% CI), 13.0-23.9], clearance was 54%, and persistence was 29.4%. At baseline, the number of partners before age 20 years, a history of a sexually transmitted disease, and the presence of condilomas significantly increased the association with HPV infection. Having anal intercourse with males was associated with the risk of acquiring a HPV infection (odds ratio, 5.2; 95% CI, 1.2-23). The odds ratio for persistent infection was 0.10 (95% CI, 0-0.87) in men who reported being circumcised compared with those who did not.

CONCLUSIONS

High-risk sexual behavior increases the risk of HPV infection in males, whereas circumcision may lower the risk of persistence.

Acquisition and Persistence of Human Papillomavirus Infection in Younger Men: A Prospective Follow-up Study among Danish Soldiers

No data is yet available on incidence or persistence of human papillomavirus (HPV) infection in men. We enrolled 374 younger male conscripts (18-29 years) in a prospective study, and they were examined twice with an interval of 6 to 8 months. Data collection included a questionnaire and a sample of cells from the penis for HPV detection using PCR. In addition, the presence of Chlamydia trachomatis DNA was assessed in urine samples by means of PCR. The HPV prevalence at the first and second examinations was 33.8% and 31.9%, respectively. The acquisition rate of HPV (overall) during follow-up was 13.8%, and nearly one fourth of the participants were HPV positive at both examinations. Number of sex partners during follow-up was the most important risk factor for acquiring HPV (odds ratio, 17.2; 95% confidence interval, 4.6-64.7, for > or = 3 partners versus < or = 1 partner). In contrast, acquisition of a new HPV type in initially HPV-positive men was strongly related to having multiple HPV types at enrollment (OR, 4.1; 95% confidence interval, 1.4-12.3). This was also the most important risk factor for HPV persistence together with current smoking and having a high-risk HPV type at enrollment. This is the first study to assess risk factors for acquisition and persistence of HPV. The sexually transmitted nature of the infection is confirmed, and the data point to an important role of having multiple HPV types for persistence.

The epidemiology of human papillomavirus infections

Infection with oncogenic human papillomavirus (HPV) types is a necessary cause of cervical cancer, the second most frequently occurring cancer in women worldwide. Rates of acquisition of HPV are high, particularly among sexually active young adults. Reported estimates of incident HPV infection among initially negative women have reached as high as 60% over a 5-year follow-up period. In this article, we review the epidemiology of HPV infection. In addition to estimates of disease frequency, we highlight risk factors for HPV infection, including the number of lifetime sex partners, which is the most salient risk factor. We discuss significant issues surrounding the natural history of HPV infection, including viral persistence versus clearance, immune response, development of lesions and development of cancer. Finally, we discuss strategies for preventing HPV infection.

Genitourinary issues in the male college student: a case-based approach

Five percent of all ambulatory visits by men 18 years of age or older include genitourinary symptoms as a reason for the visit. In this article, using typical, unusual, or otherwise instructive cases, the authors review a select group of genitourinary issues in the college-age male. Warts (human papilloma virus), is the most common sexually transmitted infection, and it may mimic other disease. Testicular cancer is one of the most serious diseases to confront health care providers. Varicoceles are the most common scrotal mass. Urethritis is a common presentation of sexually transmitted infection in the young adult male. Acute prostatitis is an unusual condition in the young adult, but it is easily treatable. Sexual dysfunction causes great distress in the young adult, but a systematic approach usually leads to a treatable psychological or environmental cause. With understanding of these medical conditions, the practitioner should feel comfortable addressing the most challenging genitourinary health needs of this population.

Condom use and other factors affecting penile human papillomavirus detection in men attending a sexually transmitted disease clinic

BACKGROUND AND OBJECTIVES

Human papillomavirus (HPV) is the primary cause of cervical, anal, and other anogenital cancers, but risk factors for penile HPV detection in men have not been well-characterized.

GOAL

The goal of this study was to identify correlates of penile HPV detection in ethnically diverse men attending a sexually transmitted disease clinic.

STUDY

A cross-sectional investigation was conducted among 393 men. Participants completed a risk-factor questionnaire and underwent testing for penile HPV DNA. Presence of HPV DNA was assessed using polymerase chain reaction with PGMY primers and reverse line blot genotyping. Logistic regression analyses were conducted to identify variables associated with any-type, oncogenic, and nononcogenic HPV.

RESULTS

Circumcision was associated with reduced risk for oncogenic, nononcogenic, and overall HPV. Regular condom use was associated with reduced risk for oncogenic and overall HPV.

CONCLUSION

These findings, if confirmed by other studies, could impact public health practices and messages regarding HPV.

Neonatal Circumcision: A Review of the World’s Oldest and Most Controversial Operation

Untimely old, circumcision has elicited more controversy and war of words than any surgical procedure in history. Although previous claims of benefits like curing masturbation, gout, epilepsy, and even insanity were no doubt absurd, important research has shed light on real medical benefits of circumcision. In particular, the procedure has consistently shown to result in the decreased risk of debilitating and costly diseases such as HIV, cervical cancer, and infantile urinary tract infection. Because of advances in the understanding of the anatomy of the foreskin and pain conditioning in infants, prevailing attitudes have changed about anesthesia and analgesia during the procedure. This article objectively summarizes the bulk of significant medical literature over the last century to provide an accurate statement about what we know and what we do not know about neonatal circumcision, including its history, epidemiology, medical benefits, complications, contraindications, techniques, management for pain, and current controversies.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the evolution of circumcision, to list the potential benefits of circumcision, to outline the various neonatal circumcision techniques, and to summarize the data on the use of analgesia for circumcision.