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A '''urinary tract infection''', also commonly known as a '''UTI''', is a bacterial infection in the urinary tract (kidneys, ureters, bladder and/or urethra). UTIs can affect both males and females, although, due to the difference in structures of the male and female urinary tract, infections occur most commonly in girls and women, as the urinary tract is shorter in females than it is in males. UTIs can become serious if undetected, and may lead to permanent kidney damage. However, they are easily and effectively treated with antibiotics.<ref name="ginsburg uti">{{REFjournal
|last=Ginsburg
|firstinit=C.M.CM
|last2=McCracken
|first2init2=G.H.GH
|url=http://www.cirp.org/library/disease/UTI/ginsburg/
|title=Urinary tract infections in young infants
}}</ref><ref name="McCracken 1989">{{REFjournal
|last=McCracken
|firstinit=G.H.GH
|url=http://www.cirp.org/library/disease/UTI/mccracken/
|title=Options in antimicrobial management of urinary tract infections in infants and children
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
|firstinit=R.
|etal=yes
|title=Urinary Pathogens in the Male
}}</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.<ref name="Fleiss 1998">{{REFjournal
|last=Fleiss
|firstinit=P.M.PM
|author-link=Paul M. Fleiss
|last2=Hodges
|first2init2=F.M.FM
|author2-link=Frederick M. Hodges
|last3=Van Howe
|first3init3=RS
|author3-link=Robert Van Howe
|url=http://www.cirp.org/library/disease/STD/fleiss3/
UTIs are usually associated with congenital abnormalities of the urinary tract.<ref name="ginsburg uti"/><ref>{{REFjournal
|last=Amato
|firstinit=D.
|last2=Garduno-Espinosa
|first2init2=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
}}}</ref><ref>{{REFjournal
|last=Schlager
|firstinit=T.A.TA
|last2=Hendley
|first2init2=J.O.JO
|last3=Dudley
|first3init3=S.M.SM
|last4=Hayden
|first4init4=G.F.GF
|last5=Lohr
|first5init5=J.A.JA
|title=Explanation for false-positive urine cultures obtained by bag technique
|journal=Arch Pediatr Adolesc Med
In infant boys, UTIs originate from the external environment, strongly suggesting that these infections are iatrogenically caused.<ref>{{REFjournal
|last=Maskell
|firstinit=R.
|etal=yes
|title=Urinary Pathogens in the Male
}}</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
|last=Winberg
|firstinit=J.
|etal=yes
|url=http://www.cirp.org/library/disease/UTI/winberg-bollgren/
}}</ref> which binds to the glans penis of the infant.<ref name="Cunningham 1986">{{REFjournal
|last=Cunningham
|firstinit=N.
|url=http://www.cirp.org/library/disease/UTI/cunningham/
|title=Circumcision and urinary tract infections (letter)
}}</ref> Urinary tract infections (UTI) are a complication of circumcision.<ref>{{REFjournal
|last=Smith
|firstinit=R.M.RM
|url=http://www.cirp.org/library/disease/UTI/smith1916/
|title=Recent contributions to the study of pyelitis in infancy
}}</ref><ref name="Cohen 1992">{{REFjournal
|last=Cohen
|firstinit=H.
|etal=yes
|url=http://www.cirp.org/library/disease/UTI/cohen/
}}</ref><ref name="Goldman 1996">{{REFjournal
|last=Goldman
|firstinit=M.
|last2=Barr
|first2init2=J.
|last3=Bistritzer
|first3init3=T.
|last4=Aladjem
|first4init4=M.
|url=http://www.cirp.org/library/disease/UTI/goldman/
|title=Urinary tract infection following ritual jewish circumcision
}}</ref><ref>{{REFjournal
|last=Prais
|firstinit=D.
|last2=Shoov-Furman
|first2init2=R.
|last3=Amir
|first3init3=J.
|title=Is circumcision a risk factor for neonatal urinary tract infections?
|journal=Arch Dis Child
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
|firstinit=E.R.ER
|last2=Steinhardt
|first2init2=G.
|last3=Naseer
|first3init3=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
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
|firstinit=A.
|url=http://www.bmj.com/cgi/content/full/317/7171/1473
|title=Burrowing bacteria may explain recurrent urinary tract infections
}}</ref> or forming pods,<ref>{{REFjournal
|last=Anderson
|firstinit=G.G.GG
|last2=Palermo
|first2init2=J.J.JJ
|last3=Schilling
|first3init3=J.D.JD
|etal=yes
|url=http://www.cirp.org/library/disease/UTI/anderson1/
}}</ref> thus hiding from antibiotics.<ref>{{REFjournal
|last=Berger
|firstinit=A.
|url=http://www.bmj.com/cgi/content/full/317/7171/1473
|title=Burrowing bacteria may explain recurrent urinary tract infections
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
|firstinit=S.
|last2=Hellerstein
|first2init2=S.
|url=http://www.cirp.org/library/disease/UTI/sreenarasimhaiah1/
|title=Urinary tract infections per se do not cause end-stage kidney disease
}}</ref><ref>{{REFjournal
|last=Lane
|firstinit=W.
|last2=Robson
|first2init2=M.
|last3=Van Howe
|first3init3=R.S.RS
|author3-link=Robert Van Howe
|url=http://www.cirp.org/library/disease/UTI/robson1/
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
|firstinit=A.
|etal=yes
|url=http://www.cirp.org/library/disease/UTI/pisacane/
}}</ref><ref name="Marild 1990">{{REFjournal
|last=Mårild
|firstinit=S.
|url=http://www.cirp.org/library/disease/UTI/marild/
|title=Breastfeeding and Urinary Tract Infections
}}</ref><ref>{{REFjournal
|last=Coppa
|firstinit=J.V.JV
|etal=yes
|url=http://www.cirp.org/library/disease/UTI/coppa/
}}</ref><ref>{{REFjournal
|last=Pisacane
|firstinit=A.
|last2=Graziano
|first2init2=L.
|last3=Mazzarella
|first3init3=G.
|etal=yes
|url=http://www.cirp.org/library/disease/UTI/pisacane1992/
}}</ref><ref>{{REFjournal
|last=Mårild
|firstinit=S.
|last2=Hansson
|first2init2=S.
|last3=Jodal
|first3init3=U.
|last4=Oden
|first4init4=A.
|last5=Svedberg
|first5init5=K.
|url=http://www.cirp.org/library/disease/UTI/marild4/
|title=Protective effect of breastfeeding against urinary tract infection
}}</ref><ref>{{REFjournal
|last=Hanson
|firstinit=L.Å.LÅ
|url=http://www.cirp.org/library/disease/UTI/marild4/
|title=Protective effects of breastfeeding against urinary tract infection
}}</ref> Outerbridge points out that breastfeeding is very effective in reducing incidence of UTI in both boys and girls.<ref name="Outerbridge 1998">{{REFjournal
|last=Outerbridge
|firstinit=E.W.EW
|url=http://www.cirp.org/library/disease/UTI/outerbridge/
|title=Decreasing the risk of urinary tract infections (Letter)
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
|firstinit=L.
|last2=Olling
|first2init2=S.
|last3=Winberg
|first3init3=J.
|title=Breast feeding and biological properties of faecal ''E. coli'' strains
|journal=Acta Paediatr Scand
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
|firstinit=T.E.TE
|last2=Smith
|first2init2=F.R.FR
|last3=Bass
|first3init3=J.W.JW
|title=Decreased incidence of urinary tract infections in circumcised male infants
|journal=Pediatrics
}}</ref><ref>{{REFjournal
|last=Wiswell
|firstinit=T.E.TE
|title=Circumcision and urinary tract infections
|journal=Pediatrics
}}</ref><ref name="Wiswell 1986">{{REFjournal
|last=Wiswell
|firstinit=T.E.TE
|last2=Roscelli
|first2init2=J.D.JD
|title=Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants
|journal=Pediatrics
}}</ref><ref>{{REFjournal
|last=Wiswell
|firstinit=T.E.TE
|last2=Enzenauer
|first2=R.W.
}}</ref><ref>{{REFjournal
|last=Wiswell
|firstinit=T.E.TE
|last2=Geschke
|first2init2=D.W.DW
|title=Risks from circumcision during the first month of life compared with those for uncircumcised boys
|journal=Pediatrics
}}</ref><ref>{{REFjournal
|last=Wiswell
|firstinit=T.E.TE
|title=Routine neonatal circumcision: a reappraisal
|journal=Am Fam Physician
}}</ref><ref>{{REFjournal
|last=Wiswell
|firstinit=T.E.TE
|last2=Hachey
|first2init2=W.E.WE
|title=Urinary tract infections and the uncircumcised state: an update
|journal=Clin Pediatr (Phila)
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
|firstinit=E.
|url=http://www.cirp.org/library/general/wallerstein/
|title=Circumcision: the uniquely American medical enigma
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.
*Littlewood (1972) found an association of UTI with maternal infection, perinatal anoxia, and high or low birthweight.<ref>{{REFjournal
|last=Littlewood
|firstinit=J.M.JM
|url=http://www.cirp.org/library/disease/UTI/littlewood1/
|title=Infants with urinary tract infection in first month of life
}}</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
|firstinit=T.A.TA
|last2=Hendley
|first2init2=J.O.JO
|last3=Dudley
|first3init3=S.M.SM
|last4=Hayden
|first4init4=G.F.GF
|last5=Lohr
|first5init5=J.A.JA
|title=Explanation for false-positive urine cultures obtained by bag technique
|journal=Arch Pediatr Adolesc Med
}}</ref> There is a significant false-positive rate in diagnosing UTI when urine cultures alone are used.<ref name="Mueller 1997"/><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 1986"/>
*The hospital chart data used in the retrospective studies are unreliable. Hospitals frequently omit to record a circumcision on a baby's chart. In Atlanta, O'Brien found that circumcision was recorded only 84.3% of the time for circumcised boys.<ref>{{REFjournal
|last=O'Brien
|firstinit=T.R.TR
|last2=Calle
|first2init2=E.E.EE
|last3=Poole
|first3init3=W.K.WK
|title=Incidence of neonatal circumcision in Atlanta, 1985-1986
|journal=Southern Medical Journal
}}</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
|firstinit=R.S.RS
|author-link=Robert Van Howe
|url=http://www.cirp.org/library/disease/UTI/vanhowe/
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
|firstinit=T.
|last2=Agha
|first2init2=M.
|last3=Dick
|first3init3=P.T.PT
|etal=yes
|url=http://www.cirp.org/library/disease/UTI/to2/
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
|firstinit=M.S.MS
|url=http://www.cirp.org/library/disease/UTI/altschul1990/
|title=The circumcision controversy (editorial)
}}</ref><ref>{{REFjournal
|last=Thompson
|firstinit=R.S.RS
|url=http://www.cirp.org/library/disease/UTI/thompson/
|title=Does circumcision prevent urinary tract infection? An opposing view
}}</ref><ref>{{REFjournal
|last=Bollgren
|firstinit=I.
|last2=Winberg
|first2init2=J.
|url=http://www.cirp.org/library/disease/UTI/winberg-bollgren2/
|title=Rebuttal of Edgar J. Schoen
}}</ref><ref>{{REFjournal
|last=Chessare
|firstinit=J.B.JB
|url=http://www.cirp.org/library/disease/UTI/chessare/
|title=Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue?
}}</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
|firstinit=J.
|etal=yes
|url=https://jamanetwork.com/journals/jamapediatrics/article-abstract/513140
}}</ref><ref name="Cohen 1992"/><ref name="Goldman 1996"/><ref>{{REFjournal
|last=Van Howe
|firstinit=R.S.RS
|author-link=Robert Van Howe
|url=http://www.cirp.org/library/disease/UTI/vanhowe_uti2005/
}}</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
|firstinit=H.
|etal=yes
|url=http://www.cirp.org/library/normal/kayaba/
{{SEEALSO}}
* [[The Immunological and protective and hygienic function of the foreskin]]
{{LINKS}}