Circumcision

Circumcision is the removal of some or all of the foreskin (prepuce) from the penis.The word "circumcision" comes from Latin circum (meaning "around") and cdere (meaning "to cut"). Early depictions of circumcision are found in cave drawings and ancient Egyptian tombs. Male circumcision is a commandment from God in Judaism. In Islam, though not discussed in the Koran, circumcision is widely practiced and most often considered to be a sunnah. It is also customary in some Christian churches in Africa. According to the World Health Organization (WHO), global estimates suggest that 30% of males are circumcised, of whom two thirds are Muslim. The prevalence of circumcision varies widely between different populations. There is scientific evidence supporting both sides of the circumcision controversy. Routine neonatal circumcision advocates claim circumcision provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a complication rate of less than 0.5% when carried out by an experienced physician, and is best performed during the neonatal period. Opponents of routine neonatal circumcision claim circumcision violates the individual's bodily rights, is medically unnecessary, adversely affects sexual pleasure and performance, and is a practice defended through the use of myths.

The importance of Circumcision 1

Circumcision has been around for religious and cultural reasons for thousands of years. Originally it was most likely done as a hygienic measure in hot, dry and often sandy environments and is still an important ritual in some religious groups. Circumcision has been associated with a number of medical benefits, including lower rates of urinary tract infections, penile cancer, penile inflammation, penile dermatoses and sexually transmitted diseases. Parents of newborn males often face many questions in the decision-making process on circumcision with major factors concerning opinions of family and friends, conformity with their dad and medical issues. It is important that parents are presented with unbiased, accurate information so that they can make an informed decision as well as consider that the magnitude of some benefits depends on the age that circumcision is performed. Talking to people they trust can be another important step for parents in the decision-making process. The benefits of Circumcision Reduction in urinary tract infections: the prevalence is higher in infancy than in older males. The risk of urinary tract infection is higher in males with underlying renal tract abnormalities and it is likely that "a small group of boys" will benefit from circumcision.
2.

1.

Reduction of cancer: compared to uncircumcised men, circumcised men appear to have a lower risk of penile cancer and their female sexual partners may have a lower risk of cervical cancer.

Penile cancer is rare but the risk is increased three - to six fold in uncircumcised men;

Uncircumcised men may be more likely to acquire and transmit the human papillomavirus (HPV) that is responsible for most cervical cancers.

3.

Reduction in penile inflammation and retractile disorders. Penile inflammatory disorders are less common in circumcised men but can develop whether or not circumcision has been performed.

4.

Reduction in sexually transmitted diseases (eg syphilis, gonorrhoea, herpes, HPV, HIV). The uncircumcised penis is protected by the foreskin and does not become keratinised and so is more susceptible to irritation.

The risks of Circumcision The rate of procedure-related complications is about 1 - 5% with most of these problems readily treatable with no long-term effects. Pain and distress: surgical excision of the foreskin is painful. Safe and effective pain control exists and should be offered to all infants undergoing the procedure.
2.

1.

Bleeding and local infection: these are the most common, significant complications. The risk of severe bleeding is higher if there is an underlying problem such as haemophilia. Wound infection occurs infrequently and is usually mild enough to be treated with local treatment.

3. 4.

Cosmetic reasons: too much or too little skin removal may present problems Ulceration: irritation from wet nappies may cause ulceration in the first few weeks after circumcision.

5.

Sexual dissatisfaction: Some literature indicates that the end of the penis becomes less sensitive when the foreskin is removed. However, most circumcised males do not describe psychological trauma or decreased sexual function as a result of being circumcised.

HPV Infection of Glans Penis

HPV (human papilloma virus) is a group of over 100 related viruses. HPVs are called papilloma viruses because some of the HPV types cause warts, or papillomas, which are non-cancerous tumors. The papilloma viruses are attracted to and are able to live only in

squamous epithelial cells in the body, for example thin, flat cells that are found on the surface of the skin, cervix, vagina, anus, vulva, head of the penis, mouth, and throat. HPVs will not grow in other parts of the body. Of the more than 100 strains of HPV, about 60 HPV types cause warts on non-genital skin, such as on the hands and feet. These are the common warts. The other 40 HPV types are mucosal types of HPV. "Mucosal" refers to the bodys mucous membranes, or the moist skin-like layers that line organs and cavities of the body that open to the environment. The genital type HPVs have been linked with genital or anal cancers in both men and women. They also cause low and high-grade cervix cell changes and pre-cancers. These are called "high-risk" HPV types and include HPV-16, HPV-18, HPV-31, HPV -35, HPV-39, HPV45, HPV-51, HPV-52, and HPV-58, as well as some others. Health problems caused by HPV in men? Most men who get HPV (of any type) never develop any symptoms or health problems, but some types of HPV can cause genital warts, while other types can cause penile cancer or anal cancer. The types of HPV that can cause genital warts are not the same as the types that can cause penile or anal cancer. About 1% of sexually active men in the U.S. have genital warts at any one time. Penile cancer is rare, especially in circumcised men. In the U.S., it affects about 1 in every 100,000 men. The American Cancer Society (ACS) estimated that about 1,530 men would be diagnosed with penile cancer in the U.S. in 2006. Anal cancer is also uncommonespecially in men with healthy immune systems. According to the ACS, about 1,900 men will be diagnosed with anal cancer in the U.S. in 2007.

Some men are more likely to develop HPV-related diseases than others. Gay and bisexual men are 17 times more likely to develop anal cancer than heterosexual men. Immunocompromised men, including those who have human immunodeficiency virus (HIV), are more likely than other men to develop anal cancer. Men with HIV are also more likely to get severe cases of genital warts that are hard to treat. Signs of genital warts are : One or more growths on the penis, testicles, groin, thighs, or anus. Warts may be raised, flat, or cauliflower-shaped. They usually do not cause pain. Warts may appear within weeks or months after sexual contact with an infected person. Signs and symptoms of anal cancer are : Sometimes there are no signs or symptoms. Anal bleeding, pain, itching, or discharge. Swollen lymph nodes in the anal or groin area. Changes in bowel habits or the shape of the stool.

1. 2. 3.

1. 2. 3. 4.

Signs of penile cancer are : First signs: changes in color, skin thickening, or a build-up of tissue on the penis. Later signs: a growth or sore on the penis. It is usually painless, but in some cases, the sore may be painful and bleed.
3.

1. 2.

There may be no symptoms until the cancer is quite advanced.

Transmision of HPV HPV is passed on through genital contact most often during vaginal and anal sex. Since HPV usually causes no symptoms, most men and women can get HPV and pass it on without realizing it. People can have HPV even years after they had sexual intercourse. Diagnosis test for HPV Infection Currently, there is no test designed or approved to find HPV in men. The only approved HPV test on the market is for women, for use as part of cervical cancer screening. HPV is very common in men and women. Most men with HPV will never develop health problems. Finding out HPV is not as important as diagnosis HPV infection which shows symptoms. Scientists are still studying how best to screen for penile and anal cancers in men who may be at highest risk for those diseases. Screening test for HPV-related cancer in men Screening tests can find early signs of disease in people without any symptoms. Screening tests for penile or anal cancer are not widely recommended. Some experts recommend yearly anal Pap smear for gay, bisexual, and HIV-positive men, since anal cancer is more common in these groups. This test can find abnormal cells in the anus that could turn into cancer over time. If abnormal cells are found, they can be removed. Treatment for HPV infection

There is no treatment or cure for HPV infection, but there are some effort to treat the health problems caused by HPV in men. Genital warts can be treated with medicine, removal by surgery, or frozen off by professional(doctors). Penile and anal cancers can be treated with new forms of surgery, radiation therapy, and chemotherapy. Often, two or more of these treatments are used together. Prevention of HPV infection HPV is so common and usually invisible, so that the only way to prevent is prevently sexual intercourse. Even people with only one lifetime sex partner can get HPV, if their partner was infected with HPV. Condoms may lower the chances of passing HPV to a partner or developing HPV-related diseases. But HPV can infect areas that are not covered by a condomso condoms may not fully protect against HPV. The new HPV vaccine was developed to protect against most cervical cancers and genital warts. At this point, it is only licensed to be used in girls/women, ages 9-26 years. Studies are now being done to find out if the vaccine is also safe in men, and wheter it can protect them against genital warts and certain penile and anal cancers. The FDA will consider in licensing the vaccine for boys and men if it is proved to be safe and effective for them.

Cervical Cancer

Cervical cancer Cervical cancer is a malignant tumor of the cervix uteri or cervical area. The cervix is part of a woman's reproductive system. It is the lower, narrow part of the uterus (womb). The uterus is a hollow, pear-shaped organ in the lower abdomen. The cervix connects the uterus to the vagina. Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor. Risk factors and causes of cervical cancer Doctors cannot always explain why one woman develops cervical cancer while the others do not. However, we do know that a woman with certain risk factors may be more likely than others. These factors may act together to increase the risk even more: Human papillomaviruses (HPVs) infction : It is the main risk factor for cervical cancer. HPV is a group of viruses that can infect the cervix. HPV infections are very common. These viruses can be passed from person to person through sexual contact.
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1.

Lack of regular Pap tests: Cervical cancer is more common among women who do not have regular Pap tests. The Pap test helps doctors find precancerous cells. Treating precancerous cervical changes often prevents cancer.

3.

Weakened immune system (the body's defense system): Women with HIV infection or who take drugs that suppress the immune system like a stereoid have a higher-than-average risk of developing cervical cancer.

4. 5.

Age: Cancer of the cervix occurs most often in women over the age of 40. Sexual history: Women who have had many sexual partners have a higher-thanaverage risk of developing cervical cancer. Also, a woman who has had sexual intercourse with a man who has had many sexual partners may be at higher risk of developing cervical cancer.

6.

Smoking cigarettes: Women with an HPV infection who smoke cigarettes have a higher risk of cervical cancer than women with HPV infection who do not smoke.

7.

Using birth control pills for a long time: Using birth control pills for a long time (5 or more years) may increase the risk of cervical cancer among women with HPV infection.

8.

Having many children: Studies suggest that giving birth to many children may increase the risk of cervical cancer among women with HPV infection.

Diethylstilbestrol (DES) may increase the risk of a rare form of cervical cancer and certain other cancers of the reproductive system in daughters exposed to this drug before birth.

Screening for cervical cancer Screening to check for cervical changes before there are symptoms is very important. Screening can help the doctor find abnormal cells before cancer develops. Finding and

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treating abnormal cells can prevent most cervical cancer. Screening can also help find cancer early, when treatment is more likely to be effective. Pap smear or cervical smear is a simple test used to look at cervical cells. The doctor or nurse scraps a sample of cells from the cervix, and then smears the cells on a glass slide. In a new type of Pap smear (liquid-based Pap smear), the cells are rinsed into a small container of liquid. Pap smear can find cervical cancer or abnormal cells that can lead to cervical cancer. Doctors generally recommend that: Women should begin having Pap smear 3 years after they begin having sexual intercourse, or when they reach age 21 (whichever comes first).
2. 3. 4.

1.

Most women should have a Pap smear at least once every 3 years. Women aged 65 to 70. Women who have had a total hysterectomy.

Some activities can hide abnormal cells and affect Pap test results. Doctors suggest the following tips: Do not douche for 48 hours before the test. Do not have sexual intercourse for 48 hours before the test. Do not use vaginal medicines (except as directed by a doctor) or birth control foams, creams, or jellies for 48 hours before the test. Doctors also suggest that a woman schedule her Pap smear for a time that is 10 to 20 days after the first day of her menstrual period.

1. 2. 3.

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Most often, abnormal cells found by a Pap smear are not cancerous. However, some abnormal conditions may become cancer over time: LSIL (low-grade squamous intraepithelial lesion): LSILs are mild cell changes on the surface of the cervix. LSILs are common, especially in young women. LSILs are not cancer. However, some turn into high-grade lesions, which may lead to cancer.
2.

1.

HSIL (high-grade squamous intraepithelial lesion): HSILs are not cancer, but without treatment they may lead to cancer. The precancerous cells are only on the surface of the cervix.

Symptoms of cervical cancer Precancerous changes and early cancers of the cervix generally do not cause pain or other symptoms. It is important not to wait to feel pain before seeing a doctor. When the disease gets worse, women may notice one or more of these symptoms: Abnormal vaginal bleeding
1.1. 1.2. 1.3. 1.4. 2. 3. 4.

1.

Bleeding that occurs between regular menstrual periods Bleeding after sexual intercourse, douching, or a pelvic exam Menstrual periods that last longer and are heavier than before Bleeding after menopause

Increased vaginal discharge Pelvic pain Pain during sexual intercourse

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Diagnosis of cervical cancer If a woman has a symptom or Pap smear results that suggest precancerous cells or cancer of the cervix, the doctor will suggest other procedures to make a diagnosis, including : 1. Colposcopy: The doctor uses a colposcope to look at the cervix. 2. Biopsy: The doctor removes tissue to look for precancerous cells or cancer cells. 2.1. Punch biopsy: The doctor uses a sharp, hollow device to pinch of small samples of cervical tissue. 2.2. LEEP: The doctor uses an electric wire loop to slice off a thin, round piece of tissue. 2.3. Endocervical curettage: The doctor uses a curette (a small, spoon-shaped instrument) to scrape a small sample of tissue from the cervical canal. 2.4. Conization: The doctor removes a cone-shaped sample of tissue Removing tissue from the cervix may cause some bleeding or other discharge. The area usually heals quickly. Women may also feel some pain similar to menstrual cramps. Medicine can relieve this discomfort.

Staging If the biopsy shows that the patient have cancer, the doctor will do a thorough pelvic exam and may remove additional tissue to learn the stage of the disease. The stage tells whether

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the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body. These are the stages of cervical cancer: 1. Stage 0: The cancer is found only in the top layer of cells in the tissue that lines the cervix. Stage 0 is also called carcinoma in situ. 2. Stage I: The cancer has invaded the cervix beneath the top layer of cells. It is found only in the cervix. 3. Stage II: The cancer extends beyond the cervix into nearby tissues. It extends to the upper part of the vagina. The cancer does not invade the lower third of the vagina or the pelvic wall (the lining of the part of the body between the hips). 4. Stage III: The cancer extends to the lower part of the vagina. It also may have spread to the pelvic wall and nearby lymph nodes. 5. Stage IV: The cancer has spread to the bladder, rectum, or other parts of the body. 6. Recurrent cancer: The cancer was treated, but has returned after a period of time during which it could not be detected. The cancer may show up again in the cervix or in other parts of the body.

To learn the extent of disease and suggest a course of treatment, the doctor may order some of the following tests: 1. Chest x-rays: X-rays often can show whether cancer has spread to the lungs.

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2. CT scan: A tumor in the liver, lungs, or elsewhere in the body can show up on the CT scan. 3. MRI: A powerful magnet linked to a computer is used to make detailed pictures of the patients pelvis and abdomen. MRI can show whether cancer has spread.. 4. Ultrasound: Tumors may produce echoes that are different from the echoes made by healthy tissues. The picture can show whether cancer has spread. Treatment Many women with cervical cancer want to take an active part in making decisions about their medical care. It is natural for eagerness of the patient to learn all about the disease and the treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything the patient want to ask the doctor. It often helps to make a list of questions before an appointment. Gynecologists, gynecologic oncologists, medical oncologists, and radiation oncologists are specialists who treat cervical cancer. Preparing for treatment The choice of treatment depends mainly on the size of the tumor and whether the cancer has spread. If a woman is of childbearing age, the treatment choice may also depend on whether she wants to become pregnant someday. Methods of treatment Women with cervical cancer may be treated with surgery, radiation therapy, chemotherapy, radiation therapy and chemotherapy, or a combination of all three methods.

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1. Surgery Surgery treats the cancer in the cervix and the area close to the tumor. Most women with early cervical cancer have surgery to remove the cervix and uterus (total hysterectomy). However, for very early (Stage 0) cervical cancer, a hysterectomy may not be needed. Other ways to remove the cancerous tissue include conization, cryosurgery, laser surgery, or LEEP. Some women need a radical hysterectomy. A radical hysterectomy is surgery to remove the uterus, cervix, and part of the vagina. With either total or radical hysterectomy, the surgeon may remove both fallopian tubes and ovaries. This procedure is called a salpingooophorectomy. The surgeon may also remove the lymph nodes near by the tumor to see whwter they are involved. If cancer cells have reached the lymph nodes, it means the disease may have spread to other parts of the body. 2. Radiation therapy Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area. Doctors use two types of radiation therapy to treat cervical cancer. Some women receive both types: 2.1 External radiation: The radiation comes from a large machine outside the body. The woman usually has treatment as an outpatient in a hospital or clinic.

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2.2 Internal radiation (intracavitary radiation): Thin tubes (also called implants) containing a radioactive substance are left in the vagina for a few hours or up to 3 days. The woman may stay in the hospital during that time. To protect others from the radiation, the woman may not be able to have visitors or may have visitors for only a short period of time while the tubes are in place. Once the tubes are removed, no radioactivity is left in her body. Internal radiation may be repeated two or more times over several weeks. Chemotherapy Chemotherapy uses anticancer drugs to kill cancer cells. It is called systemic therapy because the drugs enter the bloodstream and can affect cells all over the body. For treatment of cervical cancer, chemotherapy is generally combined with radiation therapy. For cancer that has spread to distant organs, chemotherapy alone may be used. Anticancer drugs for cervical cancer are usually given through a vein. Women usually receive treatment in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, a woman needs to stay in the hospital during treatment.

Side effects of treatment for cervical cancer Because cancer treatment often damages healthy cells and tissues, unwanted side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, and they may change from one treatment session to the next.

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Surgery It takes time to heal after surgery, and the recovery time is different for each woman. However, medicine can usually control the pain. If women have surgery to remove a small tumor on the surface of the cervix, women may have cramping or other pain, bleeding, or a watery discharge. Hysterectomy, the patient may have problems with nausea and vomiting, bladder and bowel. The doctor may restrict the patient diet to liquids at first, with a gradual return to solid food. Most women return to their normal activities within 4 to 8 weeks after surgery.After a hysterectomy, women no longer have menstrual periods. They cannot become pregnant. When the ovaries are removed, menopause occurs at once. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. After surgery, some women may be concerned about sexual intimacy. Many women find that it helps to share these concerns with their partner. A couple may want to ask a counselor to help them express their concerns. Radiation therapy Side effects depend mainly on the dose of radiation and the part of patient body that is treated. Radiation to the abdomen and pelvis may cause nausea, vomiting, diarrhea, or urinary problems. Patient may lose hair in genital area. Also, patient skin in the treated area may become red, dry, and tender.

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Patient may have dryness, itching, or burning in her vagina. The radiation may also make patient vagina narrower. The doctor may advise patient not to have intercourse during treatment, but most women can resume sexual activity within a few weeks after treatment ends. Chemotherapy The side effects of chemotherapy depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly: 1. Blood cells: These cells fight infection, help patient blood to clot, and carry oxygen to all parts of the body. 2. Cells in hair roots: Chemotherapy can cause patient to lose her hair. The hair will grow back, but it may be somewhat different in color and texture. 3. Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. The drugs used for cervical cancer also may cause skin rash, hearing problems, loss of balance, joint pain, or swollen legs and feet. Complementary and alternative medicine Some people with cancer use complementary and alternative medicine (CAM) to erase stress or to reduce side effects and symptoms. Acupuncture, massage therapy, herbal products, vitamins or special diets, visualization, meditation, and spiritual healing are types of CAM. Many people say that such approaches help them feel better.

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Nutrition It is important to eat well during cancer treatment. Eating well means getting enough calories to maintain a good weight and enough protein to keep up patient strength. Good nutrition often helps people with cancer feel better and have more energy. The doctor, a diet specialist, or another health care provider can suggest ways to maintain a healthy diet. Follow-up care for cervical cancer Follow-up care after treatment for cervical cancer is important. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes will recure because undetected cancer cells remained somewhere in the body after treatment. The doctor will monitor patient recovery and check for recurrence of the cancer. Checkups help ensure that any changes in patient health are noted and treated as needed. Checkups may include a physical exam as well as Pap smeat and chest x-rays.

DISCUSSION
Circumcision and Penile HPV Infection HPV DNA was detected in 182 of the 1139 penile specimens (16.0 percent). The most common HPV genotypes were 16 (24.7 percent of all positive samples), 18 (4.9 percent), 6 or 11 (3.3 percent), 53 (3.3 percent), 31 (2.7 percent), and 33 (2.2 percent). The type could

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not be identified in the case of 51.1 percent of the positive samples. HPV types 35, 39, 45, 51, 52, 54, and 59 each accounted for less than 1.5 percent of the positive samples. HPV was detected in 19.6 percent of uncircumcised men (166 of 847) and 5.5 percent of circumcised men (16 of 292). As compared with uncircumcised men, circumcised men had a lower prevalence of HPV infection in all subgroups defined according to base-line characteristics. The overall odds ratio for penile HPV infection associated with self-reported circumcision was 0.37 (95 percent confidence interval, 0.16 to 0.85), after adjustment for age, study location, level of education, age at first sexual intercourse, lifetime number of sexual partners, and frequency of genital washing after sex. The adjusted odds ratio associated with clinician-assessed circumcision was 0.44 (95 percent confidence interval, 0.17 to 1.13). There was an inverse association between circumcision and the risk of HPV infection in all studies (P for heterogeneity=0.87), and this finding persisted whether or not the female partner had cervical HPV infection or had been given a diagnosis of cervical cancer. The only other risk factor that was significantly associated with the risk of penile HPV infection was the number of sexual partners the men had had; as compared with men who had five or fewer partners, those who had had six or more partners had an odds ratio of 2.0 (95 percent confidence interval, 1.3 to 3.2). The odds ratio for HPV infection among circumcised men, as compared with uncircumcised men, was similar after the exclusion of men from Spain and Colombia; these men did not undergo a medical examination of the penis (odds ratio, 0.56; 95 percent confidence interval, 0.20 to 1.56). The odds ratio was also not changed significantly by the

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exclusion of men from the Philippines, who represented 65.4 percent of all circumcised men in the study (odds ratio, 0.32; 95 percent confidence interval, 0.11 to 0.93). Circumcision and Cervical Cancer Male circumcision was associated with a moderate, but nonsignificant, decrease in the risk of cervical cancer in the men's female partners (odds ratio for self-reported circumcision, 0.72; 95 percent confidence interval, 0.49 to 1.04; odds ratio for clinician-confirmed circumcision, 0.69; 95 percent confidence interval, 0.43 to 1.11). There was no evidence of heterogeneity with respect to the location of the study (P=0.41), and the inverse association was not substantially altered by any of the characteristics of the women that we assessed. Results were similar after the exclusion of men from Spain and Colombia (odds ratio, 0.79; 95 percent confidence interval, 0.47 to 1.33) and after the exclusion of men from the Philippines (odds ratio, 0.76; 95 percent confidence interval, 0.51 to 1.15).

To minimize confounding as a result of the women's having had male partners other than the current partner, we restricted the analysis to the 1420 men whose female partner reported having had only one sexual partner. We also stratified this analysis according to several variables related to the male partner's sexual behavior in order to test the hypothesis that the reduction in the risk of cervical cancer would be greater among women whose male partners were at higher risk for HPV infection. As one measure of risk, an index based on a man's age when he first had sexual intercourse and his total number of sexual partners was

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computed. Men who had had six or more sexual partners and who had first had intercourse before the age of 17 years were considered to be at high risk; men who had had five or fewer sexual partners and who were at least 17 years of age when they first had intercourse were considered to be at low risk; and the remaining men were classified as being at intermediate risk. The inverse relation between circumcision and the risk of cervical cancer was stronger and was significant in the case of women whose partners had a high risk index and who engaged in sexual practices known to increase the risk of exposure to HPV, such as having had intercourse before the age of 17 years, having had six or more sexual partners, and having a history of contact with prostitutes. Tests for an interaction between circumcision status and the male partner's number of sexual partners and between circumcision status and the risk index were significant (P=0.03 and P=0.02, respectively).

Male circumcision, HPV Infection of Glans Penis and Cervical Cancer in Female Partners In a study, male circumcision was associated with a reduced risk of penile HPV infection in men. The data found an inverse association between circumcision and the risk of cervical cancer was significant among women whose male partners engaged in sexual practices known to increase the risk of infection with HPV, such as having had multiple sexual partners.

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The assessment of the reliability and validity of self-reported circumcision status has yielded inconsistent results, and potential misclassification of circumcision status with the use of this method has been a major concern in previous studies. One strength of the study is the high rate of accuracy of self-reported circumcision status. Medical examination of the penis, performed in 43 percent of the men, confirmed the self-reported circumcision status in 95 percent of those examined. Inverse associations with the risks of penile HPV infection and cervical cancer were similar when circumcision status was classified according to selfreport or medical examination. Likewise, the exclusion of subjects who had not undergone a penile examination (men from Spain and Colombia) did not materially affect the findings. A potential concern with respect to the study was the fact that 65 percent of the circumcised men were from the Philippines. This result was not unexpected, since mass circumcision sessions are regularly conducted by many organizations in that country and most boys are circumcised before puberty. A secondary analysis excluding men from this study site was performed and found that results were virtually unchanged. Some studies have reported that genital warts are more common among uncircumcised men than among circumcised men, but other studies have not confirmed these associations. Epidemiologic evidence suggests that the absence of circumcision at birth and the presence of phimosis, poor genital hygiene, genital warts, and HPV infection are risk factors for penile cancer. Other data have suggested that the risk of cervical cancer is reduced among the female partners of circumcised men, but these studies were limited by the small number of circumcised men or the low sensitivity of the methods used to detect HPV DNA.

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Little is known about the mechanisms by which removal of the foreskin may protect against HPV infection. The data suggest that, even though circumcision increases the probability of maintaining good penile hygiene, there are other ways in which circumcision reduces the risk of penile HPV infection. The penile shaft and the outer surface of the foreskin are covered by a keratinized stratified squamous epithelium that provides a protective barrier against HPV infection. In contrast, the mucosal lining of the prepuce is not keratinized and may be more vulnerable to the virus. Since during intercourse the foreskin is pulled back, the inner mucosal surface of the prepuce is wholly exposed to vaginal secretions. HPV might be afforded access to the basal cells through minute ulcers or small epithelial abrasions. Removal of the foreskin could minimize the probability of viral entry by markedly decreasing both the size of the surface area vulnerable to HPV and the likelihood of mucosal trauma during intercourse. The glans of a circumcised penis has a thicker, cornified epithelium, making it more resistant to abrasions and less susceptible to the entry of HPV. The only mucosal epithelium in a circumcised penis is in the distal urethra, a site known to contain comparatively few HPV-related lesions. The finding that male circumcision may reduce the risk of cervical cancer in female sex partners is highly plausible for several reasons. First, circumcision is associated with a significant decrease in the risk of penile HPV infection. Second, and as indicated in further analyses of the same data, penile HPV infection is associated with a fourfold increase in the risk of cervical HPV infection in the female partner (data not shown). Third, cervical HPV infection is associated with a 77-fold increase in the risk of cervical cancer.

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CONCLUSION
The study has provided epidemiologic evidence that male circumcision is associated with a reduced risk of genital HPV infection in men and with a reduced risk of cervical cancer in women with high-risk sexual partners. Thus, circumcision can be considered as important cofactor in the natural history of HPV infection, since it may influence the risks of the acquisition and transmission of HPV as well as of cervical cancer. These findings are consistent with those of other studies that male circumcision is associated with a reduced risk of HIV infection, penile cancer, and a number of other common sexually transmitted diseases. Given the worldwide effect of these diseases on public health, further study is needed to determine whether routine circumcision can reduce the risks of HIV and HPV infections and other sexually transmitted diseases.

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REFERENCE
1. Brown Antony, Vega Charles. Uncircumcised Men at Risk for HPV Infection of Glans Penis. MedScape 2008. Available at www.medscape.com accessed April 12, 2008 2. Castellsague Xavier, Bosch Xavier, Munoz Nubia, et al. Male Circumcision, and Cervical Cancer in Female Partners. NEJM 2002. Available at www.nejm.com accessed April 15, 2008 3. Jewetz, Melnick, Adelbergs. Medical Microbiology. McGraw-Hill Companies Inc 2001;43:284-288. date July 23, 2008 4. Stoppler MC. Cervical Cancer. MedicineNet.com 2008 Available at www.medialnet.com accessed July 23, 2008

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5. Van de Velde CJH, Bosman FT, Houten, et al. Onkologie. Van Zonneveld Leiden 1996;19:493-532.

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