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A '''urinary tract infection''', also commonly known as a '''UTI''', is a bacterial [[infection ]] in the urinary tract (kidneys, ureters, bladder and/or [[urethra]]). UTIs can affect both males and females, although, due to the difference in structures of the male and female urinary tract, infections occur most commonly in girls and women, as the urinary tract is shorter in females than it is in males. UTIs can become serious if undetected, and may lead to permanent kidney damage. However, they are easily and effectively treated with antibiotics.<ref name="ginsburg uti">{{REFjournal

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UTIs are often caused by ''Escherichia coli'' (E. coli) bacteria, to which the infant has no passive immunity. In infant girls UTIs generally originate in the colon, whereas in infant boys they originate from the external environment, strongly suggesting that for boys such infections [[infection]]s are [[iatrogenic]].<ref>{{REFjournal

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}}</ref> Although ''E. coli'' is one of the most common bacteria on the surface of human [[skin]], strains found in hospitals tend to be particularly virulent. ''E. coli'' that live in the intestinal tract cause urinary tract infections when allowed to get into the sterile urinary tract. Whether [[intact ]] or [[circumcised]], baby boys sitting in poopy diapers allows ''E. coli'' an opportunity to enter the urinary tract. And, of course, fiddling with the [[foreskin ]] and introducing bacteria foreign to the baby's body or his urinary tract can also cause UTI, too. The tight [[foreskin]] of the infant boy acts as a sphincter to allow [[urine ]] to flow out, but prevents contaminants and pathogens from coming in.<ref name="Fleiss 1998">{{REFjournal |last=Fleiss |first=P.M. |author-link=Paul M. Fleiss |last2=Hodges |first2=F.M. |author2-link=Frederick M. Hodges |last3=Van Howe |first3=RS |author3-link=Robert Van Howe |url=http://www.cirp.org/library/disease/STD/fleiss3/ |title=Immunological functions of the human prepuce |journal=Sex Trans Infect |location=London |volume=74 |issue=5 |pages=364-367 |date=FleissP HodgesF VanHoweRS 1998-10 |accessdate=2019-10-31}}</ref>

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}}</ref> The term ''vesicoureteral [ureterovesical] reflux'' refers to backflow of [[urine ]] from the bladder to the ureters or kidneys. ''Ureteropelvic obstruction'' is a blockage or narrowing of part of the urinary tract. These kinds of congenital abnormalities are known to be the root cause of most UTI, as they may allow pathogens to flow upstream within the urinary tract.

In infant boys, UTIs originate from the external environment, strongly suggesting that these infections are [[iatrogenic| iatrogenically ]] caused.<ref>{{REFjournal

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}}</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

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}}</ref> which binds to the [[glans penis ]] of the infant.<ref name="Cunningham 1986">{{REFjournal

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}}</ref> Urinary tract infections (UTI) are a [[complication ]] of [[circumcision.<ref>{{REFjournal |last=Smith |first=R.M. |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

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The most common way of relieving a urinary tract infection is the administration of anti bioticsprescription antibiotics,<ref name="ginsburg uti"/> <ref name="McCracken 1989"/> if the infection does not clear up on its own. Drinking cranberry juice is a home remedy that may also help.

Recurrent UTIs are associated with congenital abnormalities of the upper urinary tract.<ref name="ginsburg uti"/><ref name="McCracken 1989"/><ref>Craig JC ''et al.'' [http://www.cirp.org/library/disease/UTI/craig/ Effect of circumcision on incidence of urinary tract infection in preschool boys]. From the Department of Nephrology, Royal Alexandra Hospital for Children, Sydney, Australia.</ref><ref name="Mueller 1997">{{REFjournal

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|title=The incidence of genitourinary abnormalities in circumcised and [[uncircumcised ]] boys presenting with an initial urinary tract infection by 6 months of age

}}</ref><refname="Saez-Llorens 1989">{{REFjournal |last=Saez-Llorens |init=X |last2=Umana |first2=Maria A. ''et al |ini2=MA |last3=Odio |first3=Carla M. |init3=CM |last4=Lohr |first4=Jacob A.'' [ |init4=JA |url=http://www.cirp.org/library/disease/UTI/llorens/ |title=Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in uncircumcised boys]. From the |publisher=Department of Pediatrics. Hospital Nacional de Ninos, San Jose, Costa Rica, and the Department of Pediatrics, the Children's Medical Center of the {{UNI|University of Virginia|UVA}}, Charlottesville , {{USSC|VA.}} |journal=J Pediatr |date=1989 |volume=114 |issue=1 |pages=93-5}}</ref> McCracken recommends investigation with radiographic and/or sonography.<ref name="ginsburg uti"/>

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It was determined in the 1990s that [[breastfeeding ]] plays a central role substantially reducing the incidence of UTIs.<ref name="Winberg 1989"/><ref>{{REFjournal

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}}</ref> Outerbridge points (1998) pointed out that [[breastfeeding ]] is very effective in reducing incidence of UTI in both boys and girls.<ref name="Outerbridge 1998">{{REFjournal

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Rooming-in permits colonization of the infant's [[skin ]] and [[mucosa ]] with the mother's own bacteria. The prepuce and other [[skin ]] and [[mucosa ]] of the infant should be specifically brought into contact with the mother's own [[skin ]] to pass along her flora and initiate the child's natural immunity.<ref>{{REFjournal

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Doctors and parents should refrain from touching a child's genitals as much as possible, as this could introduce E. coli into the urinary tract. When changing a child's diaper/nappy, parents should make sure their hands are sanitized, and be careful not to touch the area near the meatus (urinary opening) in either boys or girls. The insertion of parents' fingers into the [[foreskin]], or even the handling of a baby's penis, could introduce bacteria into the [[preputial sac| preputial space ]] of [[intact ]] infants.

Parents should be careful not to [[Forced retraction|forcibly retract]] the [[foreskin ]] of a baby's [[penis]], and to instruct the child's doctor and/or caretaker likewise. The act of forced retraction involves forcible separation that destroys a structural defense mechanism; the [[synechia]] which binds the foreskin to the glans is torn away, which allows E. coli to invade where it could not before.<ref name="Winberg 1989"/>

As [[circumcision ]] necessitates [[forced retraction]] of the [[foreskin]], additionally creating an open wound that is vulnerable to additional infection, parents are advised against circumcision.<ref name="Outerbridge 1998"/> These functions suggest that the [[intact ]] prepuce may offer protection against UTI if undisturbed. The [[foreskin]] provides two physical lines of defense in the [[intact ]] male child, which are removed in [[circumcision]]: the preputial sphincter, which closes when a boy is not urinating, and a protected meatus (urinary opening), which is often inflamed and open in [[circumcised ]] boys.<ref name="Cunningham 1986"/> Recently, Fleiss ''et al''. (1998) reviewed the immunological functions of the prepuce. In addition, the sub-preputial moisture contains lysosyme, which has an anti-bacterial action.<ref name="Fleiss 1998"/> Oligosaccharides excreted in the [[urine ]] of breastfed babies prevent adhesion of pathogens to uroepithelial tissue.<ref name="Marild 1990"/>

Drs. Charles Ginsburg & George McCracken (1982) carried out a study of UTI in boys at [https://www.parklandhospital.com/ Parkland Hospital], a public hospital for indigent patients in Dallas, Texas. They reported that 95% of the boys in their study were not [[circumcised]],<ref name="ginsburg uti"/>, and this piqued the interest of US Army pediatrician [[Thomas E. Wiswell]].

In a determined search for an association between the presence of the [[foreskin ]] and UTI, Wiswell et al . (1985) retrospectively examined charts of a number of boys born at U.S. military hospitals.<ref>{{REFjournal

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}}</ref> Based on their observations of these old charts, they reported that Intact [[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.

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}}</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.

*The parents of some of the intact infants may have been instructed to [[Forced retraction|forcibly retract]] the foreskin and scrub beneath, which would have put the children at a higher risk of infection. The same criticism applies to the later Wiswell studies and other American studies of infant UTI [Herzog, Roscelli] to date: None have taken care to ensure that there was a control group of infants whose foreskins were simply left alone.

*Littlewood (1972) found an association of UTI with maternal infection, perinatal anoxia, and high or low birthweight.<ref>{{REFjournal

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*The Wiswell studies considered bacteriuria as diagnostic of UTI. However, a positive [[urine ]] culture alone is not necessarily indicative of symptomatic UTI requiring treatment.<ref>{{REFjournal

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}}</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 X. ''et al.'' [http://www.cirp.org1989"/library/disease/UTI/llorens/ Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in uncircumcised boys]. From the Department of Pediatrics. Hospital Nacional de Ninos, San Jose, Costa Rica, and the Department of Pediatrics, the Children's Medical Center of the University of Virginia, Charlottesville VA.</ref> 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

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}}</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

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* 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"/>

Wiswell's sensational statistic, that [[circumcision ]] resulted in a "ten to hundred times decrease in urinary tract infections in circumcised boys," has often been quoted; however, it is misleading. In fact, UTIs are so rare in either case that,even giving Wiswell's data the benefit of the doubt, 50 to 100 healthy boys would have to be [[circumcised ]] in order to prevent a UTI from developing in only one patient. Using more recent data from a better-controlled study, the number of unnecessary operations needed to prevent one hospital admission for UTI would jump to 195.<ref>{{REFjournal

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}}</ref> In a prospective study, Kayaba et al. found a zero incidence of UTI in 603 [[intact ]] boys, over a range of ages.<ref>{{REFjournal

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The American Academy of Pediatrics (AAP) formed a 1989 task force under the chairmanship of the late [[Edgar J. Schoen]] to reconsider its 1975 policy statement. This task force issued a statement in 1989 which cited the UTI papers of circumcision promoter [[Thomas E. Wiswell]] as a reason that one might circumcise a child., but it included a disclaimer. The report stated:

The [[American Academy of Pediatrics ]] (AAP) has issued two statements which, when read together, constitute a substantial change in AAP policy toward the prevention of UTI in infants. First, in 1997, the AAP Workgroup on Breastfeeding recommended [[breastfeeding ]] as highly beneficial in preventing a wide range of infections including UTI.<ref name="AAP 1997">{{REFjournal

The 1999 AAP Task Force on Circumcision did, however, declare that breastfeeding produces a three fold reduction in UTI in infants. Two separate panels of the AAP, the Work Group on Breastfeeding and the 1999 Task Force on Circumcision, now recommend [[breastfeeding ]] to reduce incidence of UTI.<<ref name="AAP 1997"/><ref name="AAP 1999"/>

The notion that [[circumcision ]] is a useful prophylactic against UTI has been laid to rest by the 1999 AAP Task Force on Circumcision.<ref name="AAP 1999"/> Instead, healthy, natural alternatives such as [[breastfeeding ]] and rooming-in must be given favor. Breastfeeding offers a wide range of benefits for both mother and baby. Circumcision is surgery, and as such it has attendant risks, which include includes UTI itself.The proper treatment of UTI, if it occurs, is antimicrobial.<ref name="McCracken 1989" />

* [[Care of intact, foreskinned boys]]* [[The Immunological and protective and hygienic function of the foreskin]]

|publisher=Genital Autonomy AmericaPresented at The First International Symposium on Circumcision, Anaheim, California, March 1-2, 1989.

|publisher=[[Doctors Opposing Circumcision(D.O.C.)]]