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→UTIs in boys: Relocate reference.
|date=1975
|volume=47
}}</ref> Two interventions that put the male infant at immediate risk for UTIs are [[circumcision]], <ref>{{REFjournal |last=Smith |init=RM |url=http://www.cirp.org/library/disease/UTI/smith1916/ |title=Recent contributions to the study of pyelitis in infancy |journal=Am J Dis Child |date=1916 |volume=XII |pages=235.243}}</ref> which removes the protection of the [[foreskin]], and [[forced retraction]] of the foreskin. These interventions tear away the synechia which binds the [[foreskin]] to the [[glans]] in male infants, thereby creating entry points for ''E. coli'' bacteria,<ref name="Winberg 1989">{{REFjournal
|last=Winberg
|init=J
|issue=2
|page=267
}}</ref> Urinary tract infections (UTI) are a [[complication]] of [[circumcision]].<ref>{{REFjournal |last=Smith |init=RM |url=http://www.cirp.org/library/disease/UTI/smith1916/ |title=Recent contributions to the study of pyelitis in infancy |journal=Am J Dis Child |date=1916 |volume=XII |pages=235[[Israel]].243}}</ref><ref name="Cohen 1992">{{REFjournal
|last=Cohen
|init=H
}}</ref> Based on their observations of these old charts, they reported that [[intact]] boys had a slightly higher rate of bacteriuria (bacteria in the [[urine]]) than [[circumcised]] boys during their first year of life, leading to the sensational statistic that [[circumcision]] resulted in a "ten to hundred times decrease in urinary tract infections in circumcised boys."
Wiswell's findings generated a great deal of controversy at the time. The prepuce (foreskin) is a protective organ, and one would not normally expect the removal of a healthy organ to reduce the risk of infections.<ref name="Cunningham 1986"/> Nevertheless, the apparent correlation of [[intact ]] [[foreskin ]] to bacteriuria (and hence UTI) prompted the [[American Academy of Pediatrics]] (AAP) to review the evidence available in 1989.
=== Confounding factors to Wiswell's work ===
|issue=1
|pages=123-132
}}</ref> so the majority of its young male client population would have necessarily remained [[intact]]. The observation that 95% of the boys were not [[circumcised]], therefore, indicated nothing more than that the majority of male infant patients at Parkland Hospital were not circumcised.
Wiswell's retrospective reviews of old hospital records failed to take a few factors into account:
}}</ref> There is a significant false-positive rate in diagnosing UTI when [[urine]] cultures alone are used.<ref name="Mueller 1997"/><ref name="Saez-Llorens 1989"/> This criticism was addressed to some extent in Wiswell's second review.<ref name="Wiswell 1986"/>
* The hospital chart data used in the retrospective studies are unreliable. Hospitals frequently omit to record a [[circumcision ]] on a baby's chart. In Atlanta, O'Brien found that circumcision was recorded only 84.3% of the time for circumcised boys.<ref>{{REFjournal
|last=O'Brien
|init=TR
|issue=88
|pages=411-415
}}</ref> If the records used in the retrospective bacteriuria studies are similarly inaccurate, then a statistically significant number of the infants with bacteriuria that were claimed to be [[intact ]] were, in fact, [[circumcised]]. This would naturally overstate the rate of infection in intact boys.<ref>{{REFjournal
|last=Van Howe
|init=RS
* No information on rooming-in or breastfeeding history for the infants before they were hospitalized was recorded. [[Breastfeeding]] and rooming-in are important factors in the prevention of UTI.<ref name="Winberg 1989"/> (See above.)
* Breastfeeding is a major confounding factor in any study of the role of [[circumcision]] in UTI. The Wiswell studies and all other studies in the literature fail to control for the effects of [[breastfeeding]]. The AAP observes that "breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status."<<ref name="Sreenarasimhaiah 1998"/>
=== Even if... ===