Difference between revisions of "Urinary tract infection"
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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). | + | 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 |
|last=Ginsburg | |last=Ginsburg | ||
| − | | | + | |init=CM |
|last2=McCracken | |last2=McCracken | ||
| − | | | + | |init2=GH |
|url=http://www.cirp.org/library/disease/UTI/ginsburg/ | |url=http://www.cirp.org/library/disease/UTI/ginsburg/ | ||
|title=Urinary tract infections in young infants | |title=Urinary tract infections in young infants | ||
| Line 10: | Line 10: | ||
|volume=69 | |volume=69 | ||
|pages=409-412 | |pages=409-412 | ||
| − | }}</ref><ref name="McCracken 1989">{{REFjournal | + | }}</ref> <ref name="McCracken 1989">{{REFjournal |
|last=McCracken | |last=McCracken | ||
| − | | | + | |init=GH |
|url=http://www.cirp.org/library/disease/UTI/mccracken/ | |url=http://www.cirp.org/library/disease/UTI/mccracken/ | ||
|title=Options in antimicrobial management of urinary tract infections in infants and children | |title=Options in antimicrobial management of urinary tract infections in infants and children | ||
| Line 24: | Line 24: | ||
== Causes == | == Causes == | ||
| − | 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 | + | 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 [[infection]]s are [[iatrogenic]].<ref>{{REFjournal |
|last=Maskell | |last=Maskell | ||
| − | | | + | |init=R |
|etal=yes | |etal=yes | ||
|title=Urinary Pathogens in the Male | |title=Urinary Pathogens in the Male | ||
| Line 32: | Line 32: | ||
|date=1975 | |date=1975 | ||
|volume=47 | |volume=47 | ||
| − | }}</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 cause UTI | + | }}</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. 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">{{FleissP HodgesF VanHoweRS 1998}}</ref> |
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| − | }}</ref> | ||
UTIs are usually associated with congenital abnormalities of the urinary tract.<ref name="ginsburg uti"/><ref>{{REFjournal | UTIs are usually associated with congenital abnormalities of the urinary tract.<ref name="ginsburg uti"/><ref>{{REFjournal | ||
|last=Amato | |last=Amato | ||
| − | | | + | |init=D |
|last2=Garduno-Espinosa | |last2=Garduno-Espinosa | ||
| − | | | + | |init2=J |
|url=http://www.cirp.org/library/disease/UTI/amato/ | |url=http://www.cirp.org/library/disease/UTI/amato/ | ||
|title=Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis | |title=Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis | ||
| Line 67: | Line 48: | ||
}}}</ref><ref>{{REFjournal | }}}</ref><ref>{{REFjournal | ||
|last=Schlager | |last=Schlager | ||
| − | | | + | |init=TA |
|last2=Hendley | |last2=Hendley | ||
| − | | | + | |init2=JO |
|last3=Dudley | |last3=Dudley | ||
| − | | | + | |init3=SM |
|last4=Hayden | |last4=Hayden | ||
| − | | | + | |init4=GF |
|last5=Lohr | |last5=Lohr | ||
| − | | | + | |init5=JA |
|title=Explanation for false-positive urine cultures obtained by bag technique | |title=Explanation for false-positive urine cultures obtained by bag technique | ||
|journal=Arch Pediatr Adolesc Med | |journal=Arch Pediatr Adolesc Med | ||
| Line 81: | Line 62: | ||
|volume=149 | |volume=149 | ||
|pages=170-173 | |pages=170-173 | ||
| − | }}</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. | + | }}</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. |
=== UTIs in boys === | === UTIs in boys === | ||
| − | In infant boys, UTIs originate from the external environment, strongly suggesting that these infections are iatrogenically caused.<ref>{{REFjournal | + | In infant boys, UTIs originate from the external environment, strongly suggesting that these infections are [[iatrogenic| iatrogenically]] caused.<ref>{{REFjournal |
|last=Maskell | |last=Maskell | ||
| − | | | + | |init=R |
|etal=yes | |etal=yes | ||
|title=Urinary Pathogens in the Male | |title=Urinary Pathogens in the Male | ||
| Line 93: | Line 74: | ||
|date=1975 | |date=1975 | ||
|volume=47 | |volume=47 | ||
| − | }}</ref> Two interventions that put the male infant at immediate risk for UTIs are [[circumcision]], 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 | + | }}</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 | |last=Winberg | ||
| − | | | + | |init=J |
|etal=yes | |etal=yes | ||
|url=http://www.cirp.org/library/disease/UTI/winberg-bollgren/ | |url=http://www.cirp.org/library/disease/UTI/winberg-bollgren/ | ||
| Line 102: | Line 92: | ||
|date=1989 | |date=1989 | ||
|pages=598-599 | |pages=598-599 | ||
| − | }}</ref> which binds to the glans penis of the infant.<ref name="Cunningham 1986">{{REFjournal | + | }}</ref> which binds to the [[glans penis]] of the infant.<ref name="Cunningham 1986">{{REFjournal |
|last=Cunningham | |last=Cunningham | ||
| − | | | + | |init=N |
|url=http://www.cirp.org/library/disease/UTI/cunningham/ | |url=http://www.cirp.org/library/disease/UTI/cunningham/ | ||
|title=Circumcision and urinary tract infections (letter) | |title=Circumcision and urinary tract infections (letter) | ||
| Line 112: | Line 102: | ||
|issue=2 | |issue=2 | ||
|page=267 | |page=267 | ||
| − | }}</ref> Urinary tract infections (UTI) are a complication of circumcision | + | }}</ref> Urinary tract infections (UTI) are a [[complication]] of [[circumcision]] in [[Israel]].<ref name="Cohen 1992">{{REFjournal |
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|last=Cohen | |last=Cohen | ||
| − | | | + | |init=H |
|etal=yes | |etal=yes | ||
|url=http://www.cirp.org/library/disease/UTI/cohen/ | |url=http://www.cirp.org/library/disease/UTI/cohen/ | ||
| Line 132: | Line 113: | ||
}}</ref><ref name="Goldman 1996">{{REFjournal | }}</ref><ref name="Goldman 1996">{{REFjournal | ||
|last=Goldman | |last=Goldman | ||
| − | | | + | |init=M |
|last2=Barr | |last2=Barr | ||
| − | | | + | |init2=J |
|last3=Bistritzer | |last3=Bistritzer | ||
| − | | | + | |init3=T |
|last4=Aladjem | |last4=Aladjem | ||
| − | | | + | |init4=M |
|url=http://www.cirp.org/library/disease/UTI/goldman/ | |url=http://www.cirp.org/library/disease/UTI/goldman/ | ||
|title=Urinary tract infection following ritual jewish circumcision | |title=Urinary tract infection following ritual jewish circumcision | ||
| Line 148: | Line 129: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Prais | |last=Prais | ||
| − | | | + | |init=D |
|last2=Shoov-Furman | |last2=Shoov-Furman | ||
| − | | | + | |init2=R |
|last3=Amir | |last3=Amir | ||
| − | | | + | |init3=J |
|title=Is circumcision a risk factor for neonatal urinary tract infections? | |title=Is circumcision a risk factor for neonatal urinary tract infections? | ||
|journal=Arch Dis Child | |journal=Arch Dis Child | ||
| Line 162: | Line 143: | ||
== Treatment == | == Treatment == | ||
| − | The most common way of relieving a urinary tract infection is the administration of | + | The most common way of relieving a urinary tract infection is the administration of prescription 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 UTI == | == Recurrent UTI == | ||
| − | Recurrent UTIs are associated with congenital abnormalities of the upper urinary tract.<ref name="ginsburg uti"/><ref name="McCracken 1989"/><ref>Craig JC | + | 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 |
|last=Mueller | |last=Mueller | ||
| − | | | + | |init=ER |
|last2=Steinhardt | |last2=Steinhardt | ||
| − | | | + | |init2=G |
|last3=Naseer | |last3=Naseer | ||
| − | | | + | |init3=S |
|url=http://www.cirp.org/library/disease/UTI/mueller/ | |url=http://www.cirp.org/library/disease/UTI/mueller/ | ||
| − | |title=The incidence of genitourinary abnormalities in circumcised and uncircumcised boys presenting with an initial urinary tract infection by 6 months of age | + | |title=The incidence of genitourinary abnormalities in circumcised and [[uncircumcised]] boys presenting with an initial urinary tract infection by 6 months of age |
|journal=Pediatrics | |journal=Pediatrics | ||
|date=1997-09 | |date=1997-09 | ||
|volume=100 | |volume=100 | ||
|page=580 (supplement) | |page=580 (supplement) | ||
| − | }}</ref><ref>Saez-Llorens X. | + | }}</ref><ref name="Saez-Llorens 1989">{{REFjournal |
| + | |last=Saez-Llorens | ||
| + | |init=X | ||
| + | |last2=Umana | ||
| + | |first2=Maria A. | ||
| + | |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 | ||
| + | |publisher=Department of Pediatrics. Hospital Nacional de Ninos, San Jose, Costa Rica, and 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"/> | ||
A recent study of mice indicates that p-fimbriated ''Escherichia Col''i, the organism responsible for about 85% of UTI, is capable of burrowing into the deeper tissue of the bladder<ref>{{REFjournal | A recent study of mice indicates that p-fimbriated ''Escherichia Col''i, the organism responsible for about 85% of UTI, is capable of burrowing into the deeper tissue of the bladder<ref>{{REFjournal | ||
|last=Berger | |last=Berger | ||
| − | | | + | |init=A |
|url=http://www.bmj.com/cgi/content/full/317/7171/1473 | |url=http://www.bmj.com/cgi/content/full/317/7171/1473 | ||
|title=Burrowing bacteria may explain recurrent urinary tract infections | |title=Burrowing bacteria may explain recurrent urinary tract infections | ||
| Line 192: | Line 193: | ||
}}</ref> or forming pods,<ref>{{REFjournal | }}</ref> or forming pods,<ref>{{REFjournal | ||
|last=Anderson | |last=Anderson | ||
| − | | | + | |init=GG |
|last2=Palermo | |last2=Palermo | ||
| − | | | + | |init2=JJ |
|last3=Schilling | |last3=Schilling | ||
| − | | | + | |init3=JD |
|etal=yes | |etal=yes | ||
|url=http://www.cirp.org/library/disease/UTI/anderson1/ | |url=http://www.cirp.org/library/disease/UTI/anderson1/ | ||
| Line 207: | Line 208: | ||
}}</ref> thus hiding from antibiotics.<ref>{{REFjournal | }}</ref> thus hiding from antibiotics.<ref>{{REFjournal | ||
|last=Berger | |last=Berger | ||
| − | | | + | |init=A |
|url=http://www.bmj.com/cgi/content/full/317/7171/1473 | |url=http://www.bmj.com/cgi/content/full/317/7171/1473 | ||
|title=Burrowing bacteria may explain recurrent urinary tract infections | |title=Burrowing bacteria may explain recurrent urinary tract infections | ||
| Line 220: | Line 221: | ||
In the past it was claimed that UTI could lead to renal failure, however, new evidence has disproved this claim.<ref name="Sreenarasimhaiah 1998">{{REFjournal | In the past it was claimed that UTI could lead to renal failure, however, new evidence has disproved this claim.<ref name="Sreenarasimhaiah 1998">{{REFjournal | ||
|last=Sreenarasimhaiah | |last=Sreenarasimhaiah | ||
| − | | | + | |init=S |
|last2=Hellerstein | |last2=Hellerstein | ||
| − | | | + | |init2=S |
|url=http://www.cirp.org/library/disease/UTI/sreenarasimhaiah1/ | |url=http://www.cirp.org/library/disease/UTI/sreenarasimhaiah1/ | ||
|title=Urinary tract infections per se do not cause end-stage kidney disease | |title=Urinary tract infections per se do not cause end-stage kidney disease | ||
| Line 232: | Line 233: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Lane | |last=Lane | ||
| − | | | + | |init=W |
|last2=Robson | |last2=Robson | ||
| − | | | + | |init2=M |
|last3=Van Howe | |last3=Van Howe | ||
| − | | | + | |init3=RS |
|author3-link=Robert Van Howe | |author3-link=Robert Van Howe | ||
|url=http://www.cirp.org/library/disease/UTI/robson1/ | |url=http://www.cirp.org/library/disease/UTI/robson1/ | ||
| Line 253: | Line 254: | ||
=== Breastfeeding === | === Breastfeeding === | ||
| − | It was determined in the 1990s that breastfeeding plays a central role substantially reducing the incidence of UTIs.<ref name="Winberg 1989"/><ref>{{REFjournal | + | It was determined in the 1990s that [[breastfeeding]] plays a central role substantially reducing the incidence of UTIs.<ref name="Winberg 1989"/><ref>{{REFjournal |
|last=Pisacane | |last=Pisacane | ||
| − | | | + | |init=A |
|etal=yes | |etal=yes | ||
|url=http://www.cirp.org/library/disease/UTI/pisacane/ | |url=http://www.cirp.org/library/disease/UTI/pisacane/ | ||
| Line 264: | Line 265: | ||
}}</ref><ref name="Marild 1990">{{REFjournal | }}</ref><ref name="Marild 1990">{{REFjournal | ||
|last=Mårild | |last=Mårild | ||
| − | | | + | |init=S |
|url=http://www.cirp.org/library/disease/UTI/marild/ | |url=http://www.cirp.org/library/disease/UTI/marild/ | ||
|title=Breastfeeding and Urinary Tract Infections | |title=Breastfeeding and Urinary Tract Infections | ||
| Line 273: | Line 274: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Coppa | |last=Coppa | ||
| − | | | + | |init=JV |
|etal=yes | |etal=yes | ||
|url=http://www.cirp.org/library/disease/UTI/coppa/ | |url=http://www.cirp.org/library/disease/UTI/coppa/ | ||
| Line 283: | Line 284: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Pisacane | |last=Pisacane | ||
| − | | | + | |init=A |
|last2=Graziano | |last2=Graziano | ||
| − | | | + | |init2=L |
|last3=Mazzarella | |last3=Mazzarella | ||
| − | | | + | |init3=G |
|etal=yes | |etal=yes | ||
|url=http://www.cirp.org/library/disease/UTI/pisacane1992/ | |url=http://www.cirp.org/library/disease/UTI/pisacane1992/ | ||
| Line 297: | Line 298: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Mårild | |last=Mårild | ||
| − | | | + | |init=S |
|last2=Hansson | |last2=Hansson | ||
| − | | | + | |init2=S |
|last3=Jodal | |last3=Jodal | ||
| − | | | + | |init3=U |
|last4=Oden | |last4=Oden | ||
| − | | | + | |init4=A |
|last5=Svedberg | |last5=Svedberg | ||
| − | | | + | |init5=K |
|url=http://www.cirp.org/library/disease/UTI/marild4/ | |url=http://www.cirp.org/library/disease/UTI/marild4/ | ||
|title=Protective effect of breastfeeding against urinary tract infection | |title=Protective effect of breastfeeding against urinary tract infection | ||
| Line 315: | Line 316: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Hanson | |last=Hanson | ||
| − | | | + | |init=LÅ |
|url=http://www.cirp.org/library/disease/UTI/marild4/ | |url=http://www.cirp.org/library/disease/UTI/marild4/ | ||
|title=Protective effects of breastfeeding against urinary tract infection | |title=Protective effects of breastfeeding against urinary tract infection | ||
| Line 323: | Line 324: | ||
|issue=2 | |issue=2 | ||
|pages=154-156 | |pages=154-156 | ||
| − | }}</ref> Outerbridge | + | }}</ref> Outerbridge (1998) pointed out that [[breastfeeding]] is very effective in reducing incidence of UTI in both boys and girls.<ref name="Outerbridge 1998">{{REFjournal |
|last=Outerbridge | |last=Outerbridge | ||
| − | | | + | |init=EW |
|url=http://www.cirp.org/library/disease/UTI/outerbridge/ | |url=http://www.cirp.org/library/disease/UTI/outerbridge/ | ||
|title=Decreasing the risk of urinary tract infections (Letter) | |title=Decreasing the risk of urinary tract infections (Letter) | ||
| Line 337: | Line 338: | ||
=== Rooming in === | === Rooming in === | ||
| − | 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 | + | 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 |
|last=Gothefors | |last=Gothefors | ||
| − | | | + | |init=L |
|last2=Olling | |last2=Olling | ||
| − | | | + | |init2=S |
|last3=Winberg | |last3=Winberg | ||
| − | | | + | |init3=J |
|title=Breast feeding and biological properties of faecal ''E. coli'' strains | |title=Breast feeding and biological properties of faecal ''E. coli'' strains | ||
|journal=Acta Paediatr Scand | |journal=Acta Paediatr Scand | ||
| Line 354: | Line 355: | ||
=== Non-intervention === | === Non-intervention === | ||
| − | 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 space of intact infants. | + | 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"/> | + | 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 | + | 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"/> |
== The UTI scare == | == The UTI scare == | ||
| − | 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"/> | + | 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 retrospectively examined charts of a number of boys born at U.S. military hospitals.<ref>{{REFjournal | + | 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 |
|last=Wiswell | |last=Wiswell | ||
| − | | | + | |init=TE |
| + | |author-link=Thomas E. Wiswell | ||
|last2=Smith | |last2=Smith | ||
| − | | | + | |init2=FR |
|last3=Bass | |last3=Bass | ||
| − | | | + | |init3=JW |
|title=Decreased incidence of urinary tract infections in circumcised male infants | |title=Decreased incidence of urinary tract infections in circumcised male infants | ||
|journal=Pediatrics | |journal=Pediatrics | ||
| Line 378: | Line 380: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Wiswell | |last=Wiswell | ||
| − | | | + | |init=TE |
| + | |author-link=Thomas E. Wiswell | ||
|title=Circumcision and urinary tract infections | |title=Circumcision and urinary tract infections | ||
|journal=Pediatrics | |journal=Pediatrics | ||
| Line 386: | Line 389: | ||
}}</ref><ref name="Wiswell 1986">{{REFjournal | }}</ref><ref name="Wiswell 1986">{{REFjournal | ||
|last=Wiswell | |last=Wiswell | ||
| − | | | + | |init=TE |
| + | |author-link=Thomas E. Wiswell | ||
|last2=Roscelli | |last2=Roscelli | ||
| − | | | + | |init2=JD |
|title=Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants | |title=Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants | ||
|journal=Pediatrics | |journal=Pediatrics | ||
| Line 396: | Line 400: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Wiswell | |last=Wiswell | ||
| − | | | + | |init=TE |
| + | |author-link=Thomas E. Wiswell | ||
|last2=Enzenauer | |last2=Enzenauer | ||
| − | | | + | |init2=RW |
|last3=Holton | |last3=Holton | ||
| − | | | + | |init3=ME |
|last4=Cornish | |last4=Cornish | ||
| − | | | + | |init4=JD |
|last5=Hankins | |last5=Hankins | ||
| − | | | + | |init5=CT |
|title=Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy | |title=Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy | ||
|journal=Pediatrics | |journal=Pediatrics | ||
| Line 412: | Line 417: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Wiswell | |last=Wiswell | ||
| − | | | + | |init=TE |
| + | |author-link=Thomas E. Wiswell | ||
|last2=Geschke | |last2=Geschke | ||
| − | | | + | |init2=DW |
| − | |title=Risks from circumcision during the first month of life compared with those for uncircumcised boys | + | |title=Risks from circumcision during the first month of life compared with those for [[uncircumcised]] boys |
|journal=Pediatrics | |journal=Pediatrics | ||
|date=1989 | |date=1989 | ||
| Line 422: | Line 428: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Wiswell | |last=Wiswell | ||
| − | | | + | |init=TE |
| + | |author-link=Thomas E. Wiswell | ||
|title=Routine neonatal circumcision: a reappraisal | |title=Routine neonatal circumcision: a reappraisal | ||
|journal=Am Fam Physician | |journal=Am Fam Physician | ||
| Line 430: | Line 437: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Wiswell | |last=Wiswell | ||
| − | | | + | |init=TE |
| + | |author-link=Thomas E. Wiswell | ||
|last2=Hachey | |last2=Hachey | ||
| − | | | + | |init2=WE |
| − | |title=Urinary tract infections and the uncircumcised state: an update | + | |title=Urinary tract infections and the [[uncircumcised]] state: an update |
|journal=Clin Pediatr (Phila) | |journal=Clin Pediatr (Phila) | ||
|date=1993 | |date=1993 | ||
|volume=32 | |volume=32 | ||
|pages=130-134 | |pages=130-134 | ||
| − | }}</ref> Based on their observations of these old charts, they reported that | + | }}</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. | + | 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 === | === Confounding factors to Wiswell's work === | ||
| Line 446: | Line 454: | ||
The problem began with Ginsburg and McCracken's study, which failed to notice that Parkland Hospital had made it hospital policy not to perform non-therapeutic circumcisions in neonates,<ref>{{REFjournal | The problem began with Ginsburg and McCracken's study, which failed to notice that Parkland Hospital had made it hospital policy not to perform non-therapeutic circumcisions in neonates,<ref>{{REFjournal | ||
|last=Wallerstein | |last=Wallerstein | ||
| − | | | + | |init=E |
|url=http://www.cirp.org/library/general/wallerstein/ | |url=http://www.cirp.org/library/general/wallerstein/ | ||
|title=Circumcision: the uniquely American medical enigma | |title=Circumcision: the uniquely American medical enigma | ||
| Line 454: | Line 462: | ||
|issue=1 | |issue=1 | ||
|pages=123-132 | |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. | + | }}</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: | Wiswell's retrospective reviews of old hospital records failed to take a few factors into account: | ||
| − | *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. | + | * 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 | + | * Littlewood (1972) found an association of UTI with maternal infection, perinatal anoxia, and high or low birthweight.<ref>{{REFjournal |
|last=Littlewood | |last=Littlewood | ||
| − | | | + | |init=JM |
|url=http://www.cirp.org/library/disease/UTI/littlewood1/ | |url=http://www.cirp.org/library/disease/UTI/littlewood1/ | ||
|title=Infants with urinary tract infection in first month of life | |title=Infants with urinary tract infection in first month of life | ||
| Line 472: | Line 480: | ||
}}</ref> Wiswell failed to account for these confounding factors, although they should have been known to him. | }}</ref> Wiswell failed to account for these confounding factors, although they should have been known to him. | ||
| − | *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 | + | * 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 |
|last=Schlager | |last=Schlager | ||
| − | | | + | |init=TA |
|last2=Hendley | |last2=Hendley | ||
| − | | | + | |init2=JO |
|last3=Dudley | |last3=Dudley | ||
| − | | | + | |init3=SM |
|last4=Hayden | |last4=Hayden | ||
| − | | | + | |init4=GF |
|last5=Lohr | |last5=Lohr | ||
| − | | | + | |init5=JA |
|title=Explanation for false-positive urine cultures obtained by bag technique | |title=Explanation for false-positive urine cultures obtained by bag technique | ||
|journal=Arch Pediatr Adolesc Med | |journal=Arch Pediatr Adolesc Med | ||
| Line 488: | Line 496: | ||
|volume=149 | |volume=149 | ||
|pages=170-173 | |pages=170-173 | ||
| − | }}</ref> There is a significant false-positive rate in diagnosing UTI when urine cultures alone are used.<ref name="Mueller 1997"/><ref | + | }}</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 | + | * 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 | |last=O'Brien | ||
| − | | | + | |init=TR |
|last2=Calle | |last2=Calle | ||
| − | | | + | |init2=EE |
|last3=Poole | |last3=Poole | ||
| − | | | + | |init3=WK |
|title=Incidence of neonatal circumcision in Atlanta, 1985-1986 | |title=Incidence of neonatal circumcision in Atlanta, 1985-1986 | ||
|journal=Southern Medical Journal | |journal=Southern Medical Journal | ||
| Line 502: | Line 510: | ||
|issue=88 | |issue=88 | ||
|pages=411-415 | |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 | + | }}</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 | |last=Van Howe | ||
| − | | | + | |init=RS |
|author-link=Robert Van Howe | |author-link=Robert Van Howe | ||
|url=http://www.cirp.org/library/disease/UTI/vanhowe/ | |url=http://www.cirp.org/library/disease/UTI/vanhowe/ | ||
| Line 513: | Line 521: | ||
* It is very possible that the use of surgical antiseptic (to kill pathogenic organisms during the circumcision procedure itself) was in part responsible for the slight reduction in bacteriuria observed in these studies. This possibility was not accounted for in the studies. | * It is very possible that the use of surgical antiseptic (to kill pathogenic organisms during the circumcision procedure itself) was in part responsible for the slight reduction in bacteriuria observed in these studies. This possibility was not accounted for in the studies. | ||
| − | * 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.) | + | * 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"/> | + | * 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... === | === Even if... === | ||
| − | 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 | + | 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 |
|last=To | |last=To | ||
| − | | | + | |init=T |
|last2=Agha | |last2=Agha | ||
| − | | | + | |init2=M |
|last3=Dick | |last3=Dick | ||
| − | | | + | |init3=PT |
|etal=yes | |etal=yes | ||
|url=http://www.cirp.org/library/disease/UTI/to2/ | |url=http://www.cirp.org/library/disease/UTI/to2/ | ||
| Line 539: | Line 547: | ||
A number of studies in post-circumcision UTIs, and the role of the surgery in possibly facilitating UTIs, were not able to recommend neonatal circumcision.<ref>{{REFjournal | A number of studies in post-circumcision UTIs, and the role of the surgery in possibly facilitating UTIs, were not able to recommend neonatal circumcision.<ref>{{REFjournal | ||
|last=Altschul | |last=Altschul | ||
| − | | | + | |init=MS |
|url=http://www.cirp.org/library/disease/UTI/altschul1990/ | |url=http://www.cirp.org/library/disease/UTI/altschul1990/ | ||
|title=The circumcision controversy (editorial) | |title=The circumcision controversy (editorial) | ||
| Line 548: | Line 556: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Thompson | |last=Thompson | ||
| − | | | + | |init=RS |
|url=http://www.cirp.org/library/disease/UTI/thompson/ | |url=http://www.cirp.org/library/disease/UTI/thompson/ | ||
|title=Does circumcision prevent urinary tract infection? An opposing view | |title=Does circumcision prevent urinary tract infection? An opposing view | ||
| Line 557: | Line 565: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Bollgren | |last=Bollgren | ||
| − | | | + | |init=I |
|last2=Winberg | |last2=Winberg | ||
| − | | | + | |init2=J |
|url=http://www.cirp.org/library/disease/UTI/winberg-bollgren2/ | |url=http://www.cirp.org/library/disease/UTI/winberg-bollgren2/ | ||
|title=Rebuttal of Edgar J. Schoen | |title=Rebuttal of Edgar J. Schoen | ||
| Line 568: | Line 576: | ||
}}</ref><ref>{{REFjournal | }}</ref><ref>{{REFjournal | ||
|last=Chessare | |last=Chessare | ||
| − | | | + | |init=JB |
|url=http://www.cirp.org/library/disease/UTI/chessare/ | |url=http://www.cirp.org/library/disease/UTI/chessare/ | ||
|title=Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue? | |title=Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue? | ||
| Line 579: | Line 587: | ||
}}</ref> Significantly, a number of recent Israeli studies have reported an increase in urinary tract infection rates in the period following ritual circumcision.<ref>{{REFjournal | }}</ref> Significantly, a number of recent Israeli studies have reported an increase in urinary tract infection rates in the period following ritual circumcision.<ref>{{REFjournal | ||
|last=Amir | |last=Amir | ||
| − | | | + | |init=J |
|etal=yes | |etal=yes | ||
|url=https://jamanetwork.com/journals/jamapediatrics/article-abstract/513140 | |url=https://jamanetwork.com/journals/jamapediatrics/article-abstract/513140 | ||
| Line 589: | Line 597: | ||
}}</ref><ref name="Cohen 1992"/><ref name="Goldman 1996"/><ref>{{REFjournal | }}</ref><ref name="Cohen 1992"/><ref name="Goldman 1996"/><ref>{{REFjournal | ||
|last=Van Howe | |last=Van Howe | ||
| − | | | + | |init=RS |
|author-link=Robert Van Howe | |author-link=Robert Van Howe | ||
|url=http://www.cirp.org/library/disease/UTI/vanhowe_uti2005/ | |url=http://www.cirp.org/library/disease/UTI/vanhowe_uti2005/ | ||
| Line 598: | Line 606: | ||
|issue=1 | |issue=1 | ||
|pages=59-68 | |pages=59-68 | ||
| − | }}</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 | + | }}</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 |
|last=Kayaba | |last=Kayaba | ||
| − | | | + | |init=H |
|etal=yes | |etal=yes | ||
|url=http://www.cirp.org/library/normal/kayaba/ | |url=http://www.cirp.org/library/normal/kayaba/ | ||
| Line 615: | Line 623: | ||
== American Academy of Pediatrics policy changes == | == American Academy of Pediatrics policy changes == | ||
| − | The American Academy of Pediatrics (AAP) formed a 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 [[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) 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: |
<blockquote> | <blockquote> | ||
It should be noted that these studies in army hospitals are retrospective in design and may have methodologic flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias.<ref>{{REFjournal | It should be noted that these studies in army hospitals are retrospective in design and may have methodologic flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias.<ref>{{REFjournal | ||
| Line 627: | Line 635: | ||
}}</ref> | }}</ref> | ||
</blockquote> | </blockquote> | ||
| − | 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 [[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 |
|last=AAP Workgroup on Breastfeeding | |last=AAP Workgroup on Breastfeeding | ||
|url=http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b100/6/1035 | |url=http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b100/6/1035 | ||
| Line 647: | Line 655: | ||
}}</ref> The 1999 Task Force found that the bulk of the UTI studies were so methodologically flawed—by failing to control for confounding factors-such as breastfeeding—that no meaningful conclusions could be drawn from them. The 1999 AAP Task Force on Circumcision could not, therefore, recommend circumcision to reduce incidence of UTI (or any other disease).<ref name="AAP 1999"/> | }}</ref> The 1999 Task Force found that the bulk of the UTI studies were so methodologically flawed—by failing to control for confounding factors-such as breastfeeding—that no meaningful conclusions could be drawn from them. The 1999 AAP Task Force on Circumcision could not, therefore, recommend circumcision to reduce incidence of UTI (or any other disease).<ref name="AAP 1999"/> | ||
| − | 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 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"/> |
In their 1989 report, the AAP acknowledeged that ''"these studies in army hospitals are retrospective in design and may have methodologic flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias."'' Furthermore, the babies in the studies were all hospitalized due to sickness, and so do not represent infants in the general population. | In their 1989 report, the AAP acknowledeged that ''"these studies in army hospitals are retrospective in design and may have methodologic flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias."'' Furthermore, the babies in the studies were all hospitalized due to sickness, and so do not represent infants in the general population. | ||
== Conclusion == | == Conclusion == | ||
| − | 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 | + | 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 includes UTI itself. The proper treatment of UTI, if it occurs, is antimicrobial.<ref name="McCracken 1989" /> |
Prevention of UTI is not regarded as a reason to circumcise a boy. | Prevention of UTI is not regarded as a reason to circumcise a boy. | ||
{{SEEALSO}} | {{SEEALSO}} | ||
| − | + | * [[Care of intact, foreskinned boys]] | |
| − | * [[ | + | * [[Immunological and protective function of the foreskin]] |
{{LINKS}} | {{LINKS}} | ||
| + | * {{REFweb | ||
| + | |url=https://www.cirp.org/library/disease/UTI/ | ||
| + | |title=Circumcision and urinary tract infection | ||
| + | |last=Anonymous | ||
| + | |first= | ||
| + | |init= | ||
| + | |publisher=Circumcision Reference Library | ||
| + | |date=2009-02-02 | ||
| + | |accessdate=2023-04-20 | ||
| + | }} | ||
* {{REFweb | * {{REFweb | ||
|url=http://www.gaamerica.org/symposia/first/altschul.html | |url=http://www.gaamerica.org/symposia/first/altschul.html | ||
| Line 667: | Line 685: | ||
|first=Martin S. | |first=Martin S. | ||
|author-link= | |author-link= | ||
| − | |publisher= | + | |publisher=Presented at The First International Symposium on Circumcision, Anaheim, California, March 1-2, 1989. |
|website= | |website= | ||
|date=1989-03 | |date=1989-03 | ||
|accessdate=2019-12-20 | |accessdate=2019-12-20 | ||
|quote=It also takes awhile to digest the fact that circumcision was introduced into this country not as physical hygiene measure but as a mental hygiene measure to prevent masturbation. | |quote=It also takes awhile to digest the fact that circumcision was introduced into this country not as physical hygiene measure but as a mental hygiene measure to prevent masturbation. | ||
| + | }} | ||
| + | * {{REFjournal | ||
| + | |last=Fleiss | ||
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| + | |init=PM | ||
| + | |author-link=Paul M. Fleiss | ||
| + | |etal=no | ||
| + | |title=Effect of circumcision on incidence of urinary tract infection | ||
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| + | |journal=J Pediar | ||
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| + | |date=1996-09 | ||
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| + | |volume=129 | ||
| + | |issue=3 | ||
| + | |article= | ||
| + | |page=478 | ||
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| + | |url=https://www.jpeds.com/article/S0022-3476(96)70098-7/fulltext | ||
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| + | |quote= | ||
| + | |pubmedID=8804346 | ||
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| + | |DOI=10.1016/s0022-3476(96)70098-7 | ||
| + | |accessdate=2022-05-23 | ||
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Latest revision as of 21:39, 18 May 2024
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.[1] [2]
Contents
Causes
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 are iatrogenic.[3] 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. 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.[4]
UTIs are usually associated with congenital abnormalities of the urinary tract.[1][5][6] 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.
UTIs in boys
In infant boys, UTIs originate from the external environment, strongly suggesting that these infections are iatrogenically caused.[7] Two interventions that put the male infant at immediate risk for UTIs are circumcision,[8] 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,[9] which binds to the glans penis of the infant.[10] Urinary tract infections (UTI) are a complication of circumcision in Israel.[11][12][13]
Treatment
The most common way of relieving a urinary tract infection is the administration of prescription antibiotics,[1] [2] if the infection does not clear up on its own. Drinking cranberry juice is a home remedy that may also help.
Recurrent UTI
Recurrent UTIs are associated with congenital abnormalities of the upper urinary tract.[1][2][14][15][16] McCracken recommends investigation with radiographic and/or sonography.[1]
A recent study of mice indicates that p-fimbriated Escherichia Coli, the organism responsible for about 85% of UTI, is capable of burrowing into the deeper tissue of the bladder[17] or forming pods,[18] thus hiding from antibiotics.[19] Recurrent infections may actually be recurrence of the original infection, rather than a new infection ascending from the external genitals.
UTI and renal failure
In the past it was claimed that UTI could lead to renal failure, however, new evidence has disproved this claim.[20][21]
Prevention
Studies show fairly conclusively that UTIs can be easily prevented. Hospital-borne strains of E. coli remain the cause of the majority of UTIs, and infection can be resisted by taking certain measures to enhance the immunity of the infant to such pathogens.
Breastfeeding
It was determined in the 1990s that breastfeeding plays a central role substantially reducing the incidence of UTIs.[9][22][23][24][25][26][27] Outerbridge (1998) pointed out that breastfeeding is very effective in reducing incidence of UTI in both boys and girls.[28]
Rooming in
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.[29][9]
Non-intervention
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 space of intact infants.
Parents should be careful not to 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.[9]
As circumcision necessitates forced retraction of the foreskin, additionally creating an open wound that is vulnerable to additional infection, parents are advised against circumcision.[28] 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.[10] 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.[4] Oligosaccharides excreted in the urine of breastfed babies prevent adhesion of pathogens to uroepithelial tissue.[23]
The UTI scare
Drs. Charles Ginsburg & George McCracken (1982) carried out a study of UTI in boys at Parkland Hospital, a public hospital for indigent patients in Dallas, Texas. They reported that 95% of the boys in their study were not circumcised,[1] 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.[30][31][32][33][34][35][36] 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.[10] 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
The problem began with Ginsburg and McCracken's study, which failed to notice that Parkland Hospital had made it hospital policy not to perform non-therapeutic circumcisions in neonates,[37] 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:
- The parents of some of the intact infants may have been instructed to 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.[38] Wiswell failed to account for these confounding factors, although they should have been known to him.
- The Wiswell studies considered bacteriuria as diagnostic of UTI. However, a positive urine culture alone is not necessarily indicative of symptomatic UTI requiring treatment.[39] There is a significant false-positive rate in diagnosing UTI when urine cultures alone are used.[15][16] This criticism was addressed to some extent in Wiswell's second review.[32]
- 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.[40] 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.[41]
- It is very possible that the use of surgical antiseptic (to kill pathogenic organisms during the circumcision procedure itself) was in part responsible for the slight reduction in bacteriuria observed in these studies. This possibility was not accounted for in the studies.
- 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.[9] (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."<[20]
Even if...
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.[42]
Later studies
A number of studies in post-circumcision UTIs, and the role of the surgery in possibly facilitating UTIs, were not able to recommend neonatal circumcision.[43][44][45][46] Significantly, a number of recent Israeli studies have reported an increase in urinary tract infection rates in the period following ritual circumcision.[47][11][12][48] In a prospective study, Kayaba et al. found a zero incidence of UTI in 603 intact boys, over a range of ages.[49] Although this study did not focus on UTI, the Japanese researchers concluded: "Awareness of these findings will eliminate unnecessary circumcision in boys."
The AAP lays the UTI/circumcision myth to rest
American Academy of Pediatrics policy changes
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:
It should be noted that these studies in army hospitals are retrospective in design and may have methodologic flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias.[50]
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.[51] Second, in 1999, The 1999 AAP Task Force on Circumcision abandoned the previous stance of the 1989 Task Force on Circumcision that circumcision may provide protection against UTI.[52] The 1999 Task Force found that the bulk of the UTI studies were so methodologically flawed—by failing to control for confounding factors-such as breastfeeding—that no meaningful conclusions could be drawn from them. The 1999 AAP Task Force on Circumcision could not, therefore, recommend circumcision to reduce incidence of UTI (or any other disease).[52]
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.<[51][52]
In their 1989 report, the AAP acknowledeged that "these studies in army hospitals are retrospective in design and may have methodologic flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias." Furthermore, the babies in the studies were all hospitalized due to sickness, and so do not represent infants in the general population.
Conclusion
The notion that circumcision is a useful prophylactic against UTI has been laid to rest by the 1999 AAP Task Force on Circumcision.[52] 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 includes UTI itself. The proper treatment of UTI, if it occurs, is antimicrobial.[2]
Prevention of UTI is not regarded as a reason to circumcise a boy.
See also
External links
Anonymous (2 February 2009). Circumcision and urinary tract infection
, Circumcision Reference Library. Retrieved 20 April 2023.- Altshul, Martin S. (March 1989).
Cultural Bias and the Urinary Tract Infection (UTI) Circumcision Controversy
, Presented at The First International Symposium on Circumcision, Anaheim, California, March 1-2, 1989.. Retrieved 20 December 2019.
Quote:It also takes awhile to digest the fact that circumcision was introduced into this country not as physical hygiene measure but as a mental hygiene measure to prevent masturbation.
Fleiss PM. Effect of circumcision on incidence of urinary tract infection. J Pediar. September 1996; 129(3): 478. PMID. DOI. Retrieved 23 May 2022.- (2019).
Urinary Tract Infections
, Doctors Opposing Circumcision (D.O.C.). Retrieved 20 October 2019.
References
- ↑ a b c d e f Ginsburg CM, McCracken GH. Urinary tract infections in young infants. Pediatrics. 1982; 69: 409-412.
- ↑ a b c d McCracken GH. Options in antimicrobial management of urinary tract infections in infants and children. Pediatr Infect Dis J. August 1989; 8(8): 552-555.
- ↑ Maskell R, et al. Urinary Pathogens in the Male. British Journal of Urology. 1975; 47
- ↑ a b Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Infect. October 1998; 74(5): 364-67. PMID. PMC. DOI. Retrieved 14 January 2022.
- ↑ Amato D, Garduno-Espinosa J. Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis. Bol Med Infant Mex. October 1992; 49(10): 652-658.}
- ↑ Schlager TA, Hendley JO, Dudley SM, Hayden GF, Lohr JA. Explanation for false-positive urine cultures obtained by bag technique. Arch Pediatr Adolesc Med. 1995; 149: 170-173.
- ↑ Maskell R, et al. Urinary Pathogens in the Male. British Journal of Urology. 1975; 47
- ↑ Smith RM. Recent contributions to the study of pyelitis in infancy. Am J Dis Child. 1916; XII: 235.243.
- ↑ a b c d e Winberg J, et al. The Prepuce: A Mistake of Nature?. Lancet. 1989; : 598-599.
- ↑ a b c Cunningham N. Circumcision and urinary tract infections (letter). Pediatrics. 1986; 77(2): 267.
- ↑ a b Cohen H, et al. Postcircumcision Urinary Tract Infection. Clinical Pediatrics. 1992; : 322-324.
- ↑ a b Goldman M, Barr J, Bistritzer T, Aladjem M. Urinary tract infection following ritual jewish circumcision. Israel Journal of Medical Sciences. 1996; 32(11): 1098-1102.
- ↑ Prais D, Shoov-Furman R, Amir J. Is circumcision a risk factor for neonatal urinary tract infections?. Arch Dis Child. 6 October 2008; DOI.
- ↑ Craig JC et al. Effect of circumcision on incidence of urinary tract infection in preschool boys. From the Department of Nephrology, Royal Alexandra Hospital for Children, Sydney, Australia.
- ↑ a b Mueller ER, Steinhardt G, Naseer S. The incidence of genitourinary abnormalities in circumcised and uncircumcised boys presenting with an initial urinary tract infection by 6 months of age. Pediatrics. September 1997; 100: 580 (supplement).
- ↑ a b Saez-Llorens X, Umana, Maria A., Odio CM, Lohr JA. (Department of Pediatrics. Hospital Nacional de Ninos, San Jose, Costa Rica, and Department of Pediatrics, the Children's Medical Center of the University of Virginia, Charlottesville, VA) Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in uncircumcised boys. J Pediatr. 1989; 114(1): 93-5.
- ↑ Berger A. Burrowing bacteria may explain recurrent urinary tract infections. BMJ. 1998; 317: 1473 (Link to www.bmj.com).
- ↑ Anderson GG, Palermo JJ, Schilling JD, et al. Intracellular bacterial biofilm-like pods in urinary tract infections. Science. 2003; 301(5629): 105-107.
- ↑ Berger A. Burrowing bacteria may explain recurrent urinary tract infections. BMJ. 1998; 317: 1473 (link to www.bmj.com).
- ↑ a b Sreenarasimhaiah S, Hellerstein S. Urinary tract infections per se do not cause end-stage kidney disease. Pediatr Nephrol. 1998; 12(3): 210-213.
- ↑ Lane W, Robson M, Van Howe RS. Circumcisions: Again. Pediatrics. 2001; 108(2): 522.
- ↑ Pisacane A, et al. Breastfeeding and urinary tract infection. The Lancet. 7 July 1990; : 50.
- ↑ a b Mårild S. Breastfeeding and Urinary Tract Infections. Lancet. 1990; 336: 942.
- ↑ Coppa JV, et al. Preliminary Study of Breastfeeding and Bacterial Adhesion to Uroepithelial Cells. The Lancet. 1990; 335: 569-571.
- ↑ Pisacane A, Graziano L, Mazzarella G, et al. Breast-feeding and urinary tract infection. J Pediatr. 1992; 120: 87-89.
- ↑ Mårild S, Hansson S, Jodal U, Oden A, Svedberg K. Protective effect of breastfeeding against urinary tract infection. Acta Paediatr. 2004; 93(2): 164-168.
- ↑ Hanson LÅ. Protective effects of breastfeeding against urinary tract infection. Acta Paediatr Scand. 2004; 93(2): 154-156.
- ↑ a b Outerbridge EW. Decreasing the risk of urinary tract infections (Letter). Paediatr Child Health. 1998; 3(1): 19.
- ↑ Gothefors L, Olling S, Winberg J. Breast feeding and biological properties of faecal E. coli strains. Acta Paediatr Scand. 1975; 64(6): 807-812.
- ↑ Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics. 1985; 75: 901-903.
- ↑ Wiswell TE. Circumcision and urinary tract infections. Pediatrics. 1986; 77: 267-268.
- ↑ a b Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants. Pediatrics. 1986; 78: 96-99.
- ↑ Wiswell TE, Enzenauer RW, Holton ME, Cornish JD, Hankins CT. Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy. Pediatrics. 1987; 79: 338-342.
- ↑ Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics. 1989; 83: 1011-1015.
- ↑ Wiswell TE. Routine neonatal circumcision: a reappraisal. Am Fam Physician. 1990; 41: 859-863.
- ↑ Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. Clin Pediatr (Phila). 1993; 32: 130-134.
- ↑ Wallerstein E. Circumcision: the uniquely American medical enigma. Urol Clin North Am. 1985; 12(1): 123-132.
- ↑ Littlewood JM. Infants with urinary tract infection in first month of life. Arch Dis Child. 1972; 47(252): 218-226.
- ↑ Schlager TA, Hendley JO, Dudley SM, Hayden GF, Lohr JA. Explanation for false-positive urine cultures obtained by bag technique. Arch Pediatr Adolesc Med. 1995; 149: 170-173.
- ↑ O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. Southern Medical Journal. 1995; (88): 411-415.
- ↑ Van Howe RS. To the Editor. Southern Medical Journal (unpublished).
- ↑ To T, Agha M, Dick PT, et al. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet. 1998; 352: 1813-1816.
- ↑ Altschul MS. The circumcision controversy (editorial). Am Fam Physician. 1990; 41: 817-820.
- ↑ Thompson RS. Does circumcision prevent urinary tract infection? An opposing view. J Fam Pract. 1990; 31: 189-196.
- ↑ Bollgren I, Winberg J. Rebuttal of Edgar J. Schoen. Acta Paediatrica Scandinavia. 1991; 80: 575-577.
- ↑ Chessare JB. (Department of Pediatrics, Medical College of Ohio, Toledo 43699) Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue?. Clinical Pediatrics. February 1992; 31(2): 100-104.
- ↑ Amir J, et al. Circumcision and Urinary Tract Infections in Infants. Am J Dis Child. 1986; 140: 1092.
- ↑ Van Howe RS. Effect of confounding in the association between circumcision status and urinary tract infection. J Infect. 2005; 51(1): 59-68.
- ↑ Kayaba H, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. November 1996; 156(5): 1813-1815.
- ↑ Task Force on Circumcision. Report of the Task Force of Circumcision. Pediatrics. 1989; 84(4): 388-391.
- ↑ a b AAP Workgroup on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 1997; 100(6): 1035-1039.
- ↑ a b c d AAP Task Force on Circumcision. Circumcision Policy Statement. Pediatrics. 1999; 103(3): 686-693.