ALTHOUGH POOR GENITAL HYGIENE IN men has been implicated in the spread of chancroid in the past,1 surprisingly little is known about penile hygiene and any association it might have with sexually transmitted infections (STIs) and HIV. Possible reasons for this include difficulties in defining what constitutes both good or bad genital hygiene and the social desirability bias associated with good hygiene when subjects are asked about genital hygiene behavior. Recently, a study in Durban, South Africa, among uncircumcised male STI clinic attendees that used a clinical indicator of penile wetness as a proxy measure for poor genital hygiene showed a significant association between penile wetness and HIV after controlling for STIs, sexual behavior, and socioeconomic status.2 Few studies have examined or assessed penile wetness and no studies have been done in the United Kingdom. We therefore sought to determine the prevalence of penile wetness among STI clinic attendees in London where circumcision rates are around 4%.3
Four hundred ninety consecutive men attending the Ealing Hospital STI clinic in West London with a new complaint were enrolled in a cross-sectional study. This sample size was calculated to detect a difference in the proportion of penile wetness of 10% in those uncircumcised and 2% in circumcised men as significant at the 5% level with a power of 80%. Informed consent was obtained from all subjects. Sociodemographic details were collected routinely and a genital examination performed by either a senior doctor or nurse to assess circumcision status and degree of penile wetness. Penile wetness was defined as the clinical observation of a uniform diffuse layer of moisture on the surface of the glans and coronal sulcus. An initial pilot study was undertaken by both observers jointly to confirm the clinical definition of penile wetness in 10 cases. All patients were investigated, managed, and diagnosed according to the standard clinic protocol. Balanitis was diagnosed clinically. The study received approval from the Ealing Hospital ethics committee.
Six men with nonretractile foreskins and 4 with profuse urethral discharge were excluded leaving 480 for analysis. The proportion of those with penile wetness and the various selected sociodemographic details, STIs, and circumcision status are shown in Table 1. The ethnic origins of the men were 244 white, 109 Asian, 102 black, and 25 other. Overall, 352 (73.3%) were uncircumcised and 48 were homosexual. Penile wetness was observed in 30 (6.3%), including 29 (8.3%) of uncircumcised and one (0.8%) of circumcised men (relative risk = 10.54; 95% confidence interval = 1.45–76.6; P < 0.001) (Fisher exact test) and in 14 of 34 (41.2%) of men with balanitis. Penile wetness was observed in 9.2% Asian, 7% white, 3% of black men, and 6.3% of homosexuals and in 14 of 34 (8.2%) of men with clinical balanitis compared with 8 of 244 (3.3%) with no STI diagnosis (P < 0.001).
In conclusion, we found a prevalence of penile wetness of 6.3% in this population of routine STI clinic attendees. This would have been slightly higher if those with profuse urethral discharge and marked phimosis were included. This prevalence is much lower than that reported from a population of pretreated black STI clinic attendees in Durban, South Africa, where 49% had penile wetness when assessed 14 days after being treated for their initial STI-related complaint.2
We believe that penile wetness is a marker of poor genital hygiene, a clinical observation reported previously in India among men attending as outpatients.4 In this group, urine spreading out in the subpreputial space was not thought to be related to the wetness, although prostatic, vesicular, and urethral secretions were thought to play a role. If these secretions were to be implicated, it is difficult to explain the variation in penile wetness observed in the African and London populations. Furthermore, it is interesting to note that 10 of 30 (33%) of our subjects classified with penile wetness were in uncircumcised Asian men.
The evidence for the protective effect of male circumcision in protecting against HIV in heterosexuals is now compelling. Male circumcision has recently been found to reduce the risk of HIV in an intervention study in South Africa.5 One of the mechanisms by which circumcision might reduce HIV transmission is thought to be through improved hygiene either directly or indirectly through an increased risk of genital ulcers.6 Undertaking circumcision on a large scale, however, will be difficult for both ethical and logistic reasons. Improving male genital hygiene could provide some HIV risk reduction benefit in the same way that circumcision might. However, although circumcision is a one-off surgical intervention, long-term efforts would probably be required to bring about and sustain genital hygiene behavior change. Further studies of male genital hygiene are warranted in other populations with both high and low prevalences of HIV.
1. Moore JE. The diagnosis of chancroid and the effect of prophylaxis upon its incidence in the American Expeditionary Forces. J Urol 1920; 4:169–176.
2. O'Farrell, Morison L, Moodley P, et al. Association between HIV and subpreputial penile wetness in uncircumcised men in Durban, South Africa. J Acquir Immun Defic Syndr. 2006; 43:69–77.
3. Rickwood AM, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: Survey of trends in practice. BMJ 2000; 321:792–793.
4. Prakash S, Jeyakumar S, Subramanyam K, et al. Human subpreputial collection: Its nature and formation. J Urol 1973; 110:211–212.
5. Auvert BA, Puren A, Taljaard D, et al. Randomised controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS trial. PLOS Medicine 2005; 2:1112–1122.
6. O'Farrell N. The need for targeted interventions against genital ulcers in countries worst affected by the HIV epidemic in Africa. Bull World Health Organ 2001; 79:569–577.