CLINICAL PRESENTATION OF GENITAL WARTS AMONG CIRCUMCISED AND UNCIRCUMCISED HETEROSEXUAL MEN ATTENDING AN URBAN STD CLINIC

Introduction-A recent study comparing heterosexual men with and withou t confirmed sexually transmitted diseases (STDs) in an urban STD clini c showed that uncircumcised men were less likely than circumcised men to have genital warts detectable by clinical examination (adjusted odd s ratio 0.7, 95% confidence interval 0-4, 0-9). Based on these initial findings we hypothesised that the appearance and anatomic distributio n of genital warts, and possibly treatment response, may be different for circumcised and uncircumcised men. Methods-The anatomic location, appearance, number of warts, and response to treatment was investigate d through review of medical records of 459 heterosexual men with genit al warts detected in 1988. Results-Age- and race-adjusted estimates in dicated that among men with genital warts, warts were detected much mo re commonly on the distal penis-that is, the corona, frenulum, glans o r urethral meatus-, among uncircumcised men (26%) than among circumcis ed men (3%) (OR 10-0, 95% CI 3-9, 25.7). Where the appearance was spec ified, warts were more often described as condylomatous in uncircumcis ed men and slightly more often as papular in circumcised men. No signi ficant difference between circumcised and uncircumcised men was seen i n the number of return visits to the clinic for persistent warts after treatment with liquid nitrogen: 2-2 visits for 19 uncircumcised men a nd 2-3 visits for 149 circumcised men. Conclusion-Circumcised men were more likely than uncircumcised men to have genital warts, but when pr esent, warts were more often located on the distal portion of the peni s among uncircumcised men. This paradox is not understood, but could r eflect either non-specific resistance to proximal penile warts conferr ed by the foreskin, or heightened susceptibility to various HPV types in uncircumcised men, some of which may confer subsequent immunity to genital warts.