Human papillomavirus and circumcision: A meta-analysis

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Summary

Background

Determine the relationship of circumcision status to the risk for genital infection with human papillomavirus (HPV).

Methods

A MEDLINE search and a review of references in published articles were used to identify publications from peer-reviewed journals in Index Medicus with data on circumcision status in patients with and without HPV infections. Inclusion criteria included diagnosis by culture, biopsy, or PCR, determination of circumcision status by physical examination, and multiple site sampling including the shaft of the penis. A meta-analysis was performed with sensitivity analyses.

Results

Sixteen articles contained data on circumcision status in patients with and without HPV infections. Eight studies used accurate diagnostic methods. Only three articles satisfied the strict inclusion criteria. There was no significant association between circumcision status and HPV infection (random-effects model summary effect OR = 1.20, 95%CI = 0.80–1.79) in these three studies. If the eight studies using accurate diagnostic methods are adjusted for the method of determining circumcision status and failure to sample the penile shaft using meta-regression the summary effects odds ratio is 1.25 (95%CI = 0.95–1.67).

Conclusions

The medical literature does not support the claim that circumcision reduces the risk for genital HPV infection. To correctly assess the risk of HPV infection in circumcised males, the penile shaft needs to be sampled for HPV infection.

Introduction

A decreased risk for sexually transmitted infections in circumcised adult males has long been used as a justification for neonatal circumcision.1, 2, 3 Other than general review articles and opinion pieces, the association between circumcision status and sexually transmitted infections has not been subjected to systematic review or analysis until recently.4, 5 In 1999, the American Academy of Pediatrics Task Force on Circumcision concluded, “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” In addressing sexually transmitted infections other than HIV, they merely stated, “Evidence regarding the relationship of circumcision to STD in general is complex and conflicting.”6

Human papillomavirus (HPV) is believed to be responsible for cervical cancer in women and penile cancer in men. In an effort to clarify the impact of circumcision status on sexually transmitted HPV infections and indirectly on the female partner's risk of cervical cancer, the medical literature addressing the impact of circumcision status on sexually transmitted HPV infections was reviewed and analyzed.

Section snippets

Methods

The recommendations of Stroup et al. for the meta-analysis of observational studies were followed.7 Inclusion criteria included publication of a cohort, cross-sectional, and case-control study in a peer-reviewed journal, the presence of data on the circumcision status of males both with and without genital HPV infections, diagnosis by culture, biopsy, or HPV DNA detection using PCR or Hybrid capture 2, determination of circumcision status by physical examination, and multiple site sampling

Results

Characteristics of the studies with data on the circumcision status of males both with and without genital HPV infections are shown in Table 1. Table 2 shows the raw data from the sixteen studies comparing HPV infections by circumcision status. Table 3 shows the results of the meta-analyses. The random-effects summary effect odds ratio of the three studies meeting the inclusion criteria was 1.20 (95%CI = 0.80–1.79). There was no evidence of significant between-study heterogeneity.

In our attempt

Discussion

This is the first systematic review of the medical literature looking at the risk of genital HPV infections based on circumcision status. Using strict criteria to include multiple genital sites for sampling, including detection of HPV on the penile shaft the analysis failed to show a significant association between genital HPV infection and circumcision status.

The limitations of the meta-analysis when applied to observational studies, the role of between-study heterogeneity, the role of

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