Urinary Tract Infections

An American invention

The first appearance of the claim that uncircumcised boys were more vulnerable to infections of the urinary tract was made by American doctors in 1982. This was the very time when the American medical profession became alarmed at the sharp decline in the number of parents wanting to get their boys circumcised. For all the fuss subsequently made abut UTIs, however, all the paper did was observe in passing that “95% of the [male] infants [with a UTI] were uncircumcised”. It failed to mention the vital fact that hardly any babies born at that hospital (Parkland in Dallas, Texas) were circumcised. The figure thus had no significance at all. Even if it did, it hardly mattered, for the paper continued: “All infants responded promptly to antimicrobial therapy.” That is to say, the infections cleared up quickly after treatment with antibiotics.

Reference:  Ginsburg G.M. and McCracken G.H. Urinary tract infections in young children. Pediatrics 1982; 69: 409-12

Claims for the greater susceptibility of uncircumcised boys to UTIs, and thus for the desirability (if not the necessity) of circumcision, rely heavily on the research and publications of the American military doctor Thomas Wiswell. His studies have generally been taken as authoritative, even though they were not done on randomly selected “live” subjects, but retrospectively on boys born on army bases. Wiswell merely looked at the information on their charts and never examined the boys themselves or asked about their general management. All these clues are important. Having been born under military rule, it is pretty certain that all boys well enough to stand it would have been circumcised pronto in accordance with U.S. army policy. This suggests that premature or otherwise frail babies, considered too weak to tolerate the surgery, were over-represented among the intact. Many of these might well have been subjected to a catheter, and thus the vastly increased potential for infection that such interventions provide.

Wiswell’s studies, like many of those that have followed, are fatally flawed beause they do no more than compare the incidence of UTIs in a group of circumcised boys with the incidence in a group of uncircumcised boys. They fail to take into account a number of vital factors, including:

All these issues are highly relevant to the risk of UTIs and should have been factored into Wiswell’s conclusions.

The policy in American military hospitals at the time when Wiswell collected his data was to apply the erroneous Edwardian advice that, if a baby was not circumcised, his foreskin should be retracted daily so at to allow the interior to be washed. This is very bad advice, as nothing could be better calculated to spread bacteria from the hands and clothing of medical and nursing staff and into the boy’s urethra, which would otherwise have been shielded by the tight, valve-like foreskin normal in infants. Discredited in Britain in 1949, this harmful routine was still commonly followed in the U.S.A. as late as the 1980s, and some deluded health “experts” still advise it today. This policy alone would probably account for many of the UTIs found in the uncircumcised sample.

It may also be that excessive cleanliness favours the growth of harmful bacteria, since the liberal use of disinfectants common in hospitals kills the benign or neutral bacteria that would otherwise colonise skin surfaces and prevent harmful bacteria from gaining a foothold.

Recent studies disprove foreskin-UTIs link

Since Wiswell’s inadequate and grossly flawed studies, research on far larger and more representative samples of boys and girls have disproved the claim of a causal link between the foreskin and a significantly heightened risk of UTI infection.

Circumcision for the prevention of urinary tract infection in boys

In an analysis of controlled trials and observational studies covering over 400,000 children, the authors concluded that although there was evidence that circumcision could reduce the incidence of urinary tract infections in boys, the protective effect was not sufficient to justify preventive or prophylactic circumcision with this object in mind.

Extract from conclusion

"The benefit of circumcision on UTI only outweighs the risk in boys who have had UTI previously and have a predisposition to repeated UTI. As this analysis has used a conservative circumcision complication rate of 2%, if the complication rate were in reality higher the risk–benefit analysis may not favour circumcision even in the higher risk populations.

"In conclusion, the data we present do not support the routine circumcision of normal boys with standard risk in order to prevent UTI. However, our data suggest that circumcision of boys with higher than normal risk of UTI should be considered. As there is no direct evidence of the effect of circumcision on UTI in this group, confirmation through a randomised trial of circumcision in high risk patients would be beneficial. Using an OR of 0.2 (the upper limit of the 95% CI of the combined OR found in this study) and a power of 80%, the sample size required to study this hypothesis would be 140 (70 in each treatment arm), assuming a recurrence risk of 10%.

"Until this additional information is available, the present data do not support the routine circumcision of boys to prevent UTI. However, circumcision should be considered in those with recurrent UTI or significantly increased risk of UTI."

It should be noted that the equation used by the authors of the article was the very narrow calculus of estimated risk of surgery compared with estimated benefit. If they had factored in the loss of the foreskin and the affront to personal dignity and autonomy inherent in circumcision without consent, the balance would swing far more heavily towards the “don’t cut” end of the scale.

It should also be noted that the author’s estimate of the risks of circumcision was, as they acknowledge, “conservative”: with estimates of the complication rate ranging from 2 to 10 per cent, they chose to base their calculations the lowest estimate (2%). Had they selected a mid-point, their conclusions would have been much stronger. As they write:

“While circumcision is protective for UTI, the overall risk–benefit derived from circumcision in preventing UTI is not easily quantifiable, as the incidence of important sequelae of UTI (sepsis, permanent renal damage, hypertension, and chronic renal failure) are not known. The complication rate of circumcision is documented to be between 2% and 10%, and no data are available on the relative risks and benefits of circumcision. Thus we have used a conservative estimate of circumcision complications of 2% and assumed equal utility for benefits and harms in the following analysis.”

It follows that a more comprehensive assessment of the risks of circumcision surgery would tilt the scales even further towards the position that prophylactic circumcision of normal boys should not be performed.

D. Singh-Grewal, J. Macdessi, J. Craig
Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies
Archives of Diseases in Childhood 2005;90:853-858

(Registration needed for access)

Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children

A study of Australian children found that long-term administration of low doses of antibiotics was effective in controlling UTIs in both male and female infants. The article made no mention of circumcision, except to state that only 4 per cent of the antibiotic (study) group and 5 per cent of the placebo (control) were circumcised. There was no difference in outcome observed between the circumcised and the uncircumcised boys.

Conclusion: "Long-term, low-dose trimethoprim–sulfamethoxazole was associated with a decreased number of urinary tract infections in predisposed children. The treatment effect appeared to be consistent but modest across subgroups."

Jonathan Craig, Gabrielle Williams et al
Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children
New England Journal of Medicine, Vol. 361, October 2009, 1748-59

Risk factors for urinary tract infection in children

The most recent Australian study aiming to identify the risk factors for UTIs in children found that parents grossly over-estimated the incidence of such infections, but that the foreskin was not a significant risk factor. The study suggested that a major contributing factor was leaving babies and toddlers in wet nappies. The simplest preventive strategy, therefore, was to let them run around without nappies or other clothing that allowed urine to accumulate against their body, or otherwise make sure that they were kept dry.

Circumcision as a preventive strategy for UTIs was not considered.

Abstract

AIM: To identify risk factors for urinary tract infection (UTI) in children to inform the development of preventative strategies.

METHOD: A validated questionnaire covering demographic factors, perinatal, developmental, bowel and urinary history was sent to a cross-sectional sample of parents of elementary school children randomly selected from the first 4 years of school. UTI was ascertained by parental report, verified by cross-referencing with microbiological reports for all positive cases and 50 randomly selected negative cases.

RESULTS: Parents of 2856 children (mean age 7.3 years, range 4.8–12.8 years) responded. A total of 3.6% of children had a bacteriologically verified UTI, compared with 12.6% by parental report alone. Multivariate polychotomous logistic regression showed that a history of structural kidney abnormalities (odds ratio (OR) 15.7, 95% confidence interval 8.1–30.4), daytime incontinence (OR 2.6, 1.6–4.5), female gender (OR 2.4, 1.5–3.8), and encopresis (OR 1.9, 1.1–3.4) were independently associated with UTI. Daytime incontinence increased risk more in boys (8.3% vs. 1.2%) than girls (8.1% vs. 4.6%), and kidney problems increased risk in older compared with younger children (29% vs. 2% in _8 year olds, 0% vs. 4% in 4–6 year olds).

CONCLUSIONS: Parents over-report UTI by about threefold. Effective treatment of daytime urinary incontinence and encopresis may prevent UTI in children, especially boys.

Premala Sureshkumar, Mike Jones, Robert G Cumming, and Jonathan C Craig

Risk factors for urinary tract infection in children: A population-based study of 2856 children
Journal of Paediatrics and Child Health 45 (2009) 87–97

Could circumcision increase incidence of UTIs?

Evidence from Israel suggests that circumcision in early infancy could cause UTIs.

Is ritual circumcision a risk factor for neonatal urinary tract infections?

Objective: Although circumcision is commonly believed to protect against urinary tract infection (UTI), it is not unusual in neonates in Israel, where almost all male infants are circumcised. The aim of the study was to evaluate the burden of neonatal UTI in Israel and its relationship to circumcision.

Design: Medical records of neonates (?T2 months old) hospitalized with UTI were reviewed and demographic and clinical data were collected. The second part of the study consisting of a telephone survey to assess timing and details concerning the circumcision, included two groups: the study group consisting of parents of male infants, aged 8-30 days, hospitalized with UTI and a control group consisting of healthy neonates.

Results: 162 neonates (108 males, 54 females) were hospitalized with UTI. Mean age at admission was significantly lower in males (27.5 vs 37.7 days, p=0.0002). The incidence of UTI in males peaked at 2-4 weeks of age i.e. the period immediately following circumcision. In females, the incidence tended to rise with age. Accordingly, male predominance disappeared at 7 weeks and the male-to-female ratio reversed. In the second part of the study, 111 males (?T1 month old) were included: 48 post-UTI and 63 as a control group. While evaluating the impact of circumcision technique, we found that UTI occurred in 6 of the 24 infants circumcised by a physician (25%), and in 42 of the 87 infants (48%) circumcised by a religious authority; the calculated odds ratio for contracting UTI was 2.8 (95% CI: 1-9.4).

Conclusions: There was a higher preponderance of UTI among male neonates. Its incidence peaked during the early post-circumcision period, as opposed to the age-related rise in females. UTI seems to occur more frequently after traditional circumcision than after physician performed circumcision. We speculate that changes in the hemostasis technique or shortening the duration of the shaft wrapping might decrease the rate of infection after Jewish ritual circumcision.

[Or in other words: Not circumcising would decrease the occurrence of Urinary Tract Infections.]


Dario Prais, Rachel Shoov-Furman and Jacob Amir, Is ritual circumcision a risk factor for neonatal urinary tract infections?

Archives of Disease in Childhood, September, 2008

Breast feeding: Best defence against UTIs

Another vital question is how soon the baby started breast-feeding, since mother’s milk is a valuable source of the antibodies that fight harmful bacteria. There are some interesting remarks about the value of breast milk as an anti-bacterial and anti-fungal agent in Sarah Hrdy‘s study, Mother Nature. Hrdy suggests that lactation evolved in mammals mainly because milk was not merely highly nutritious, but also a disinfectant:

"A particular component of bodily secretions called lysozymes – enzymes present in human tears and blood that digest bacteria – was present in secretions accidentally applied to eggs. If this serendipitous secretion happened to protect eggs from fungi and bacteria during incubation, then leaking mothers would have higher hatching success than mothers that ran tighter ships. ... A protein specific to mother’s milk (alphalactalbumin) evolved from lysozymes. Newly hatched babies who lapped up this protein-rich antibiotic would have gotten a nutritional boost along with their immunological dose. If the anti-bacterial hypothesis is correct, colostrum, the thick, yellowish fluid present in the breasts before and for several days after birth, maybe the closest analogue to ancient mother's milk. Colostrum is packed with antibodies.”

Lysozymes have also been found in the secretions of the foreskin: see articles by Parkash et al and Fleiss & Hodges.

Hrdy reports that some cultures (both ancient and modern) have enjoined mothers not to feed their babies colostrum, including British doctors from the 17th century, but that when they changed their minds (she does not say when) and advised mothers to breastfeed immediately, there was a rapid fall in the infant death rate in the first month of life.

“Although parents in some cultures dispose of colostrum, in many others they incorporate it ... into customary childcare. An American nurse collecting a milk sample in a Swedish clinic was surprised when a new father requested a dab of the fluid. He immediately smeared it on the baby’s rump. “Why?” she asked. “Oh, to prevent diaper rash. A drop of milk can also be applied to a baby’s eyes to prevent infections.” [Trust the Swedes to know.]

“Laboratory experiments corroborate such folk wisdom. Fresh mother’s milk in a test tube kills one of the main dysentery-causing amoebas, Entamoeba histolytica, along with another common diarrhoea-causing parasite, Giardia lamblia. A particular glycoprotein in mother’s milk (lactadherin) has been shown to protect against rotavirus, one of the major causes of infantile diarrhoea.”

Sarah Blaffer Hrdy Mother Nature (Vintage pbk, 2000), pp. 135-7

More information on the importance of breast-feeding

Confirmed by other research

These observations are confirmed by an article published in a leading Swedish medical journal in 2004.

Marild S, Hanson S, Jodal U, Oden A, Svedberg K. Protective effect of breastfeeding against urinary tract infection. Acta  Paediatr. 2004 Feb;93(2):154-6.

AIM: To assess the possible protective effect of exclusive breastfeeding against first-time febrile urinary tract infection (UTI) in children.

METHODS: Two children’s hospitals and local child health centres in the Goteborg area, Sweden, participated in a prospective case-control study. In total, 200 consecutive cases (89M, 111F), aged 0-6y, presenting with first-time febrile UTI were enrolled. The mean +/- SD age was 0.98 +/- 1.15 y. As control subjects, 336 children (147M, 189F) were recruited from the child health centre of the case, matched for age and gender and included consecutively for each case during the first days after diagnosis. The duration of exclusive breastfeeding was obtained from the case and controls by a standardized procedure.

RESULTS: Ongoing exclusive breastfeeding gave a significantly lower risk of infection. A longer duration of breastfeeding gave a lower risk of infection after weaning, indicating a long-term mechanism. The protective role of breastfeeding was strongest directly after birth, then decreased until 7 months of age, after which age no effect was demonstrated.

CONCLUSION: A protective role of breastfeeding against UTI was demonstrated. The study provides statistical support to the view that breast milk is a part of the natural defence against UTI.

Read full text.

This article confirms earlier work by Pisacane et al.

Conclusion: Circumcision not warranted as UTI preventive

The BOTTOM LINE, according to the British Journal of Urology:
Routine circumcision is not warranted for UTI prevention

Clinical question: How effective is circumcision in the reduction of risk of urinary tract infections?

Routine circumcision does not provide enough reduction in risk of urinary tract infection (UTI) to justify the surgical complication risk. For boys at high risk of UTI, however, the reduction in risk may justify the procedure. (LOE = 2a–)

REFERENCE: Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review or randomised trials and observational studies. Arch Dis Child 2005;90:853–8.

SYNOPSIS : Reduction in risk of UTI is usually claimed as the major medical justification for routine circumcision. The meta-analysis was performed to quantify that risk reduction. They included twelve studies including more than 400,000 boys, including mostly cohort and case–control studies and one randomized controlled trial. Circumcision was associated with a significant reduction in episodes of UTI (odds ratio = 0.13; 95% CI, 0.08–0.20; P < .001). The randomized trial was consistent with the overall results, though it was too small to detect a statistically significance difference. An estimated 111 circumcisions must be performed to prevent one UTI in the general population. Since the expected surgical complication rate is at least 1%, the risk is unlikely to justify the benefit. In boys at higher risk (those with at least a 10% risk of UTI, for example), the surgery is medically justified.

Delivered as Daily POEM: 18/10/2005
(Registration needed for access)

The bottom line

Combining the rarity of UTIs with the small risk reduction attributable to circumcision, British doctors have calculated that it would take 195 circumcisions to prevent one UTI.

REFERENCE: To T, Agha M, Dick PT, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet 1998;352(9143):1813-16

An earlier study found that "six hundred and twenty-five infant boys would need to be circumcised to prevent one UTI hospitalization in the first 5 years of life".

REFERENCE:  To T, Agha M, Dick PT. et al. A cohort study on male neonatal circumcision and the subsequent risk of urinary tract infection. Paediatr Child Health 1997;2 (supple A): 55A.

The lessons of the information above can be summarized in these slogans

The foreskin: As wonderful as mother’s milk.

The foreskin and mother’s milk: Nature’s disinfectants

or from the other angle:

Circumcision: Another cruel blow for those who missed out on mother’s milk.

Circumcision: The penalty if you don’t drink your milk.

Circumcision not recommended for urinary tract infection

A study in the latest (April 2012) issue of the Australian Journal of Paediatrics and Child Health reviews the treatment and prevention options for urinary tract infections (UTI) in children. It finds that a UTI occurs in approximately 8% of girls and 2% of boys by 7 years of age, and outlines the best treatment options, depending on the nature of the infection and whether it recurs. The study does not recommend circumcision except in the few cases where recurrent episodes have failed to respond to medical (mainly antibiotic) treatment. The study notes that “approximately 20% of children who have had one UTI experience a symptomatic recurrence. Preventing UTI recurrence would avoid further episodes of illness, discomfort and family stress. The likelihood that preventing UTI would prevent clinically important kidney damage is unknown but likely to be very low, given the very low risk of clinically important kidney damage following UTI, and the modest benefit of prophylactic interventions.

“The Royal Australasian College of Physicians’ policy position is that circumcision is not indicated as primary prevention. It could be estimated that between 110 and 140 circumcisions are required to prevent one UTI, while major complications occur in around 2%.** However, circumcision should be considered in boys with a high risk of recurrent febrile infection, that is boys with previous UTIs and/or high-grade VUR,*** where the number needed to treat is between 4 and 11, so that the benefits outweigh the risk of adverse effects.”

Summary

Source:   Gabrielle J Williams, Elisabeth H Hodson, David Isaacs and Jonathan C Craig, Diagnosis and management of urinary tract infection in children. Journal of Paediatrics and Child Health 48, April 2012, 296-301

** An improbably low figure. In the absence of a systematic and comprehensive study and agreed benchmarks, nobody knows the true incidence of complications. Quite apart from this issue, complications is only a small part of the story: what about the value of the foreskin, the harm of loosing it, the wishes of the individual and the moral harm of violating a person’s bodily integrity without his consent?

*** VUR stands for vesicoureteric reflux, a rare condition in which urine flows backward into the kidney, sometimes causing damage. Further information from PubMed Health. Note that their illustration shows penis with foreskin - i.e. not circumcised!

Prevention of UTIs

United States National Library of Health makes the following recommendations for preventing UITs in children. Circumcision does not rate a mention.

Further information

Studies collected at CIRP

Analysis at Circumstitions



[ Back to Top ]
  1. Studies disprove foreskin-UTI link
  2. Circumcision may increase UTI risk
  3. Breast feeding defence against UTIs
  4. Conclusion: Circumcision not recommended