Changes

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 |first=C.M. |last2=McCracken |first2=G.H. |url=http://www.cirp.org/library/disease/UTI/ginsburg/ |title=Urinary tract infections in young infants |journal=Pediatrics |date=1982 |volume=69 |pages=409-412}}</ref><refname="McCracken 1989">{{REFjournal |last=McCracken GH |first=G. [H. |url=http://www.cirp.org/library/disease/UTI/mccracken/ |title=Options in antimicrobial management of urinary tract infections in infants and children]. '' |journal=Pediatr Infect Dis J'' |volume=8( |issue=8), Aug |date=1989; -08 |pages=552-555.}}</ref>

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.<ref>{{REFjournal |last=Maskell, |first=R. ''et al''. |etal=yes |title=Urinary Pathogens in the Male. '' |journal=British Journal of Urology'', ( |date=1975) vol. |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, 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.<refname="Fleiss 1998">{{REFjournal

UTIs are usually associated with congenital abnormalities of the urinary tract.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/name="ginsburguti"/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref><ref>{{REFjournal |last=Amato |first=D, . |last2=Garduno-Espinosa |first2=J. [ |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]. '' |journal=Bol Med Infant Mex'' Volume |volume=49, Number |issue=10, October |date=1992, -10 |pages=652-658.}}}</ref><ref>{{REFjournal |last=Schlager TA, |first=T.A. |last2=Hendley JO, |first2=J.O. |last3=Dudley SM, |first3=S.M. |last4=Hayden GF, |first4=G.F. |last5=Lohr JA |first5=J.A. |title=Explanation for false-positive urine cultures obtained by bag technique. '' |journal=Arch Pediatr Adolesc Med'' |date=1995; |volume=149: |pages=170-3.173}}</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.

In infant boys, UTIs originate from the external environment, strongly suggesting that these infections are iatrogenically caused.<ref>{{REFjournal |last=Maskell, |first=R. ''et al''. |etal=yes |title=Urinary Pathogens in the Male. '' |journal=British Journal of Urology'', ( |date=1975) vol. |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,<refname="Winberg 1989">{{REFjournal |last=Winberg |first=J ''et al''. [ |etal=yes |url=http://www.cirp.org/library/disease/UTI/winberg-bollgren/ |title=The Prepuce: A Mistake of Nature?] '' |journal=Lancet'' |date=1989, pp. |pages=598-99.599}}</ref> which binds to the glans penis of the infant.<refname="Cunningham 1986">{{REFjournal |last=Cunningham |first=N. [ |url=http://www.cirp.org/library/disease/UTI/cunningham/ |title=Circumcision and urinary tract infections]. (letter) '' |journal=Pediatrics'' |date=1986; |volume=77( |issue=2): |page=267.}}</ref> Urinary tract infections (UTI) are a complication of circumcision.<ref>{{REFjournal |last=Smith RM |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=235-43.243}}</ref><refname="Cohen 1992">{{REFjournal |last=Cohen, |first=H. ''et al.'' [ |etal=yes |url=http://www.cirp.org/library/disease/UTI/cohen/ |title=Postcircumcision Urinary Tract Infection]. '' |journal=Clinical Pediatrics'' ( |date=1992), pp. |pages=322-4.324}}</ref><refname="Goldman 1996">{{REFjournal |last=Goldman |first=M, . |last2=Barr |first2=J, . |last3=Bistritzer |first3=T, . |last4=Aladjem |first4=M. [ |url=http://www.cirp.org/library/disease/UTI/goldman/ |title=Urinary tract infection following ritual jewish circumcision]. '' |journal=Israel Journal of Medical Sciences'' |date=1996; |volume=32( |issue=11), |pages=1098-102.1102}}</ref><ref>{{REFjournal |last=Prais |first=D. |last2=Shoov-Furman |first2=R, . |last3=Amir |first3=J. |title=Is circumcision a risk factor for neonatal urinary tract infections? '' |journal=Arch Dis Child'' Published Online First: 6 October |date=2008. doi:-10-06 |DOI=10.1136/adc.2008.144063 [ |url=http://adc.bmj.com/cgi/content/abstract/adc.2008.144063v1 Abstract]}}</ref>

The most common way of relieving a urinary tract infection is the administration of anti biotics,<ref name="ginsburg uti">Ginsburg CM, McCracken, Jr. GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ Urinary tract infections in young infants]. ''Pediatrics'' 1982;69(4):409-412.</ref> if the infection does not clear up on its own.

Recurrent UTIs are associated with congenital abnormalities of the upper urinary tract.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/name="ginsburguti"/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref><ref>name="McCracken GH. [http://www.cirp.org/library/disease/UTI/mccracken/ Options in antimicrobial management of urinary tract infections in infants and children]. ''Pediatr Infect Dis J'' 8(8), Aug 1989; 552-555.<"/ref><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><refname="Mueller 1997">{{REFjournal |last=Mueller ER, |first=E.R. |last2=Steinhardt |first2=G, . |last3=Naseer |first3=S. [ |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]. '' |journal=Pediatrics'', September |date=1997, Vol. -09 |volume=100, |page =580 (supplement)}}</ref><ref>Saez-Llorens X. ''et al.'' [http://www.cirp.org/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> McCracken recommends investigation with radiographic and/or sonography.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/name="ginsburguti"/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref>

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 |first=A. [ |url=http://www.bmj.com/cgi/content/full/317/7171/1473 |title=Burrowing bacteria may explain recurrent urinary tract infections]. '' |journal=BMJ'' |date=1998; |volume=317: |page=1473 (Link to www.bmj.com)}}</ref> or forming pods,<ref>{{REFjournal |last=Anderson GG, |first=G.G. |last2=Palermo JJ, |first2=J.J. |last3=Schilling JD, ''et al |first3=J.D.'' [ |etal=yes |url=http://www.cirp.org/library/disease/UTI/anderson1/ |title=Intracellular bacterial biofilm-like pods in urinary tract infections]. '' |journal=Science'' |date=2003; |volume=301( |issue=5629): |pages=105-7.107}}</ref> thus hiding from antibiotics.<ref>{{REFjournal |last=Berger |first=A. [ |url=http://www.bmj.com/cgi/content/full/317/7171/1473 |title=Burrowing bacteria may explain recurrent urinary tract infections]. '' |journal=BMJ'' |date=1998; |volume=317: |page=1473 (Link link to www.bmj.com)}}</ref> Recurrent infections may actually be recurrence of the original infection, rather than a new infection ascending from the external genitals.

In the past it was claimed that UTI could lead to renal failure, however, new evidence has disproved this claim.<refname="Sreenarasimhaiah 1998">{{REFjournal |last=Sreenarasimhaiah |first=S, . |last2=Hellerstein |first2=S. [ |url=http://www.cirp.org/library/disease/UTI/sreenarasimhaiah1/ |title=Urinary tract infections per se do not cause end-stage kidney disease]. '' |journal=Pediatr Nephrol'' |date=1998; |volume=12( |issue=3): |pages=210-3.213}}</ref><ref>{{REFjournal |last=Lane |first=W, . |last2=Robson |first2=M, . |last3=Van Howe RS |first3=R. [S. |author3-link=Robert Van Howe |url=http://www.cirp.org/library/disease/UTI/robson1/ |title=Circumcisions: Again]. '' |journal=Pediatrics'' |date=2001; |volume=108( |issue=2): |page=522.}}</ref>

It was determined in the 1990s that breastfeeding plays a central role substantially reducing the incidence of UTIs.<ref>name="Winberg J ''et al.'' [http://www.cirp.org/library/disease/UTI/winberg-bollgren/ The Prepuce: A Mistake of Nature?] ''Lancet'' 1989, pp.598-99.<"/ref><ref>{{REFjournal |last=Pisacane |first=A, ''et al.'' [ |etal=yes |url=http://www.cirp.org/library/disease/UTI/pisacane/ |title=Breastfeeding and urinary tract infection]. '' |journal=The Lancet,'' July 7, |date=1990, p50.-07-07 |page=50}}</ref><refname="Marild 1990">{{REFjournal |last=Mårild |first=S. [ |url=http://www.cirp.org/library/disease/UTI/marild/ |title=Breastfeeding and Urinary Tract Infections]. '' |journal=Lancet'' |date=1990; |volume=336: |page=942.}}</ref><ref>{{REFjournal |last=Coppa JV ''et al |first=J.'' [V. |etal=yes |url=http://www.cirp.org/library/disease/UTI/coppa/ |title=Preliminary Study of Breastfeeding and Bacterial Adhesion to Uroepithelial Cells]. '' |journal=The Lancet'' |date=1990; |volume=335: |pages=569-571.}}</ref><ref>{{REFjournal |last=Pisacane |first=A, . |last2=Graziano |first2=L, . |last3=Mazzarella |first3=G, ''et al.'' [ |etal=yes |url=http://www.cirp.org/library/disease/UTI/pisacane1992/ |title=Breast-feeding and urinary tract infection]. |journal=J Pediatr |date=1992; |volume=120: |pages=87-89.}}</ref><ref>{{REFjournal |last=Mårild |first=S, . |last2=Hansson |first2=S, . |last3=Jodal |first3=U, . |last4=Oden |first4=A, . |last5=Svedberg |first5=K. [ |url=http://www.cirp.org/library/disease/UTI/marild4/ |title=Protective effect of breastfeeding against urinary tract infection]. '' |journal=Acta Paediatr'' |date=2004; |volume=93( |issue=2): |pages=164-8.168}}</ref><ref>{{REFjournal |last=Hanson LÅ |first=L. [Å. |url=http://www.cirp.org/library/disease/UTI/marild4/ |title=Protective effects of breastfeeding against urinary tract infection]. '' |journal=Acta Paediatr Scand'' |date=2004; |volume=93( |issue=2); |pages=154-6.156}}</ref> Outerbridge points out that breastfeeding is very effective in reducing incidence of UTI in both boys and girls.<refname="Outerbridge 1998">{{REFjournal |last=Outerbridge EW |first=E. [W. |url=http://www.cirp.org/library/disease/UTI/outerbridge/ |title=Decreasing the risk of urinary tract infections]. (Letter). '' |journal=Paediatr Child Health'' |date=1998; |volume=3( |issue=1): |page=19.}}</ref>

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 |first=L, . |last2=Olling |first2=S, . |last3=Winberg |first3=J. |title=Breast feeding and biological properties of faecal ''E. coli'' strains. '' |journal=Acta Paediatr Scand'' |date=1975; |volume=64( |issue=6): |pages=807-12.812}}</ref><ref>name="Winberg J ''et al.'' [http://www.cirp.org/library/disease/UTI/winberg-bollgren/ The Prepuce: A Mistake of Nature?] ''Lancet'' 1989, pp.598-99.<"/ref>

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 J ''et al''. [http://www.cirp.org/library/disease/UTI/winberg-bollgren/ The Prepuce: A Mistake of Nature?] ''Lancet'' 1989, pp.598-99.<"/ref>

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 EW. [http://www.cirp.org/library/disease/UTI/outerbridge/ Decreasing the risk of urinary tract infections]. (Letter). ''Paediatr Child Health'' 1998; 3(1):19.<"/ref> 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 N. [http://www.cirp.org/library/disease/UTI/cunningham/ Circumcision and urinary tract infections]. (letter) ''Pediatrics'' 1986; 77(2):267.<"/ref> 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 PM, Hodges FM, Van Howe RS. [http://www.cirp.org/library/disease/STD/fleiss3/ Immunological functions of the human prepuce]. ''Sex Trans Inf'' 1998: 364-367<"/ref> Oligosaccharides excreted in the urine of breastfed babies prevent adhesion of pathogens to uroepithelial tissue.<ref>Mårild S. [http://www.cirp.org/library/disease/UTI/marild/ Breastfeeding and Urinary Tract Infections]. ''Lancet'' name="Marild 1990;336:942.<"/ref>

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>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/name="ginsburguti"/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref>, 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 |last=Wiswell TE, |first=T.E. |last2=Smith FR, |first2=F.R. |last3=Bass JW |first3=J. W. |title=Decreased incidence of urinary tract infections in circumcised male infants. '' |journal=Pediatrics'' |date=1985, |volume=75: |pages=901-903.}}</ref><ref>{{REFjournal |last=Wiswell TE |first=T. E. |title=Circumcision and urinary tract infections. '' |journal=Pediatrics'' |date=1986; |volume=77: |pages=267-8.268}}</ref><refname="Wiswell 1986">{{REFjournal |last=Wiswell TE, |first=T.E. |last2=Roscelli JD |first2=J. D. |title=Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants. '' |journal=Pediatrics'' |date=1986; |volume=78: |pages=96-99.}}</ref><ref>{{REFjournal |last=Wiswell TE, |first=T.E. |last2=Enzenauer RW, |first2=R.W. |last3=Holton ME, |first3=M.E. |last4=Cornish JD, |first4=J.D. |last5=Hankins CT |first5=C. T. |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'' |date=1987; |volume=79: |pages=338-42.342}}</ref><ref>{{REFjournal |last=Wiswell TE, |first=T.E. |last2=Geschke DW |first2=D. W. |title=Risks from circumcision during the first month of life compared with those for uncircumcised boys. '' |journal=Pediatrics'' |date=1989; |volume=83: |pages=1011-5.1015}}</ref><ref>{{REFjournal |last=Wiswell TE |first=T.E. |title=Routine neonatal circumcision: a reappraisal. '' |journal=Am Fam Physician'' |date=1990; |volume=41: |pages=859-63.863}}</ref><ref>{{REFjournal |last=Wiswell TE, |first=T.E. |last2=Hachey WE |first2=W.E. |title=Urinary tract infections and the uncircumcised state: an update. '' |journal=Clin Pediatr'' (Phila) |date=1993; |volume=32: |pages=130-4.134}}</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 N. [http://www.cirp.org/library/disease/UTI/cunningham/ Circumcision and urinary tract infections]. (letter) ''Pediatrics'' 1986; 77(2):267.<"/ref> 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.

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 |first=E. [ |url=http://www.cirp.org/library/general/wallerstein/ |title=Circumcision: the uniquely American medical enigma]. '' |journal=Urol Clin North Am'' |date=1985; |volume=12( |issue=1): |pages=123-132.}}</ref> so the majority of its young male client population would have necessarily remained intact. The observation that 95% of the boys were not circumcised, therefore, indicated nothing more than that the majority of male infant patients at Parkland Hospital were not circumcised.

*Littlewood (1972) found an association of UTI with maternal infection, perinatal anoxia, and high or low birthweight.<ref>{{REFjournal |last=Littlewood JM |first=J. [M. |url=http://www.cirp.org/library/disease/UTI/littlewood1/ |title=Infants with urinary tract infection in first month of life]. '' |journal=Arch Dis Child'' |date=1972; |volume=47( |issue=252): |pages=218-26.226}}</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 |last=Schlager TA, |first=T.A. |last2=Hendley JO, |first2=J.O. |last3=Dudley SM, |first3=S.M. |last4=Hayden GF, |first4=G.F. |last5=Lohr JA |first5=J. A. |title=Explanation for false-positive urine cultures obtained by bag technique. '' |journal=Arch Pediatr Adolesc Med'' |date=1995; |volume=149: |pages=170-3.173}}</ref> There is a significant false-positive rate in diagnosing UTI when urine cultures alone are used.<ref>name="Mueller ER, Steinhardt G, Naseer S. [http://www.cirp.org/library/disease/UTI/mueller/ 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, Vol. 100, page 580 (supplement)<"/ref><ref>Saez-Llorens X. ''et al.'' [http://www.cirp.org/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 TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants. ''Pediatrics'' 1986;78:96-99.<"/ref>

*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 TR, |first=T.R. |last2=Calle EE, |first2=E.E. |last3=Poole WK |first3=W.K. |title=Incidence of neonatal circumcision in Atlanta, 1985-1986. '' |journal=Southern Medical Journal'' |date=1995; |issue=88: |pages=411-5.415}}</ref> If the records used in the retrospective bacteriuria studies are similarly inaccurate, then a statistically significant number of the infants with bacteriuria that were claimed to be intact were, in fact, circumcised. This would naturally overstate the rate of infection in intact boys.<ref>{{REFjournal |last=Van Howe RS |first=R.S. [ |author-link=Robert Van Howe |url=http://www.cirp.org/library/disease/UTI/vanhowe/ |title=To the Editor], '' |journal=Southern Medical Journal'' (unpublished).}}</ref>

*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 J ''et al.'' [http://www.cirp.org/library/disease/UTI/winberg-bollgren/ The Prepuce: A Mistake of Nature?] ''Lancet'' 1989, pp.598-99.<"/ref> (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 S, Hellerstein S. [http://www.cirp.org/library/disease/UTI/sreenarasimhaiah1/ Urinary tract infections per se do not cause end-stage kidney disease]. ''Pediatr Nephrol'' 1998;12(3):210-3.<"/ref>

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 |first=T, . |last2=Agha |first2=M, . |last3=Dick PT, ''et al |first3=P.T.'' [ |etal=yes |url=http://www.cirp.org/library/disease/UTI/to2/ |title=Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection]. '' |journal=Lancet'' |date=1998; |volume=352: |pages=1813-16.181699</ref>

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 MS |first=M. [S. |url=http://www.cirp.org/library/disease/UTI/altschul1990/ |title=The circumcision controversy] (editorial). '' |journal=Am Fam Physician'' |date=1990; |volume=41: |pages=817-820.}}</ref><ref>{{REFjournal |last=Thompson RS: [ |first=R.S. |url=http://www.cirp.org/library/disease/UTI/thompson/ |title=Does circumcision prevent urinary tract infection? An opposing view]. '' |journal=J Fam Pract' |date=1990; |volume=31: |pages=189-96.196}}</ref><ref>{{REFjournal |last=Bollgren |first=I, . |last2=Winberg |first2=J. Letter. ([ |url=http://www.cirp.org/library/disease/UTI/winberg-bollgren2/ |title=Rebuttal of Edgar J. Schoen]) '' |journal=Acta Paediatrica Scandinavia'' |date=1991; |volume=80: |pages=575-7.577}}</ref><ref>{{REFjournal |last=Chessare JB |first=J. [B. |url=http://www.cirp.org/library/disease/UTI/chessare/ |title=Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue?] '' |journal=Clinical Pediatrics'' |volume=31( |issue=2): |pages=100-4, Feb. 104 |date=1992. -02 |publisher=Department of Pediatrics, Medical College of Ohio, Toledo 43699.}}</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 |first=J. ''et al.'' [ |etal=yes |url=https://jamanetwork.com/journals/jamapediatrics/article-abstract/513140 |title=Circumcision and Urinary Tract Infections in Infants]. '' |journal=Am J Dis Child'' ( |date=1986), vol. |volume=140, p. |page=1092.}}</ref><ref>name="Cohen, H. ''et al.'' [http://www.cirp.org/library/disease/UTI/cohen/ Postcircumcision Urinary Tract Infection]. ''Clinical Pediatrics'' (1992), pp. 322-4.<"/ref><ref>name="Goldman M, Barr J, Bistritzer T, Aladjem M. [http://www.cirp.org/library/disease/UTI/goldman/ Urinary tract infection following ritual jewish circumcision]. ''Israel Journal of Medical Sciences'' 1996;32(11),1098-102.<"/ref><ref>{{REFjournal |last=Van Howe RS |first=R.S. [ |author-link=Robert Van Howe |url=http://www.cirp.org/library/disease/UTI/vanhowe_uti2005/ |title=Effect of confounding in the association between circumcision status and urinary tract infection]. '' |journal=J Infect'' |date=2005; |volume=51( |issue=1): |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 |last=Kayaba |first=H ''et al.'' [ |etal=yes |url=http://www.cirp.org/library/normal/kayaba/ |title=Analysis of shape and retractability of the prepuce in 603 Japanese boys]. '' |journal=J Urol'', |date=1996 Nov, V156 N5:-11 |volume=156 |issue=5 |pages=1813-5.1815}}</ref> Although this study did not focus on UTI, the Japanese researchers concluded: "Awareness of these findings will eliminate unnecessary circumcision in boys."

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 |last=Task Force on Circumcision. |title=Report of the Task Force of Circumcision '' |journal=Pediatrics'' |date=1989; |volume=84( |issue=4): |pages=388-91.391}}</ref>

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.<refname="AAP 1997">{{REFjournal |last=AAP Workgroup on Breastfeeding. [ |url=http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b100/6/1035 |title=Breastfeeding and the use of human milk]. '' |journal=Pediatrics'' |date=1997; |volume=100( |issue=6) |pages=1035-1039.}}</ref> 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.<refname="AAP 1999">{{REFjournal |last=AAP Task Force on Circumcision. [ |url=http://www.cirp.org/library/statements/aap1999/ |title=Circumcision Policy Statement]. '' |journal=Pediatrics'' |date=1999; |volume=103( |issue=3): |pages=686-693.}}</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 Task Force on Circumcision. [http://www.cirp.org/library/statements/aap1999/ Circumcision Policy Statement]. ''Pediatrics'' 1999;103(3):686-693.<"/ref>

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 Workgroup on Breastfeeding. [http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b100/6/1035 Breastfeeding and the use of human milk]. ''Pediatrics'' 1997;100(6)1035-1039.<"/ref><ref>name="AAP Task Force on Circumcision. [http://www.cirp.org/library/statements/aap1999/ Circumcision Policy Statement]. ''Pediatrics'' 1999;103(3):686-693.<"/ref>

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 Task Force on Circumcision. [http://www.cirp.org/library/statements/aap1999/ Circumcision Policy Statement]. ''Pediatrics'' 1999;103(3):686-693.<"/ref> 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 UTI itself.