22,335
edits
Changes
Jump to navigation
Jump to search
Created page with "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..."
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" /><ref>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>
== 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.<ref>Maskell, R. et al. Urinary Pathogens in the Male. British Journal of Urology, (1975) vol.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.
UTIs are usually associated with congenital abnormalities of the urinary tract.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref><ref>Amato D, Garduno-Espinosa J. [http://www.cirp.org/library/disease/UTI/amato/ Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis]. ''Bol Med Infant Mex'' Volume 49, Number 10, October 1992, 652-658.</ref><ref>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;149:170-3.</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 ===
In infant boys, UTIs originate from the external environment, strongly suggesting that these infections are iatrogenically caused.<ref>Maskell, R. et al. Urinary Pathogens in the Male. ''British Journal of Urology'', (1975) vol.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>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> which binds to the glans penis of the infant.<ref>Cunningham N. [http://www.cirp.org/library/disease/UTI/cunningham/ Circumcision and urinary tract infections]. (letter) ''Pediatrics'' 1986; 77(2):267.</ref> Urinary tract infections (UTI) are a complication of circumcision.<ref>Smith RM. [http://www.cirp.org/library/disease/UTI/smith1916/ Recent contributions to the study of pyelitis in infancy]. ''Am J Dis Child'' 1916;XII:235-43.</ref><ref>Cohen, H. ''et al.'' [http://www.cirp.org/library/disease/UTI/cohen/ Postcircumcision Urinary Tract Infection]. ''Clinical Pediatrics'' (1992), pp. 322-4.</ref><ref>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>Prais D. Shoov-Furman R, Amir J. Is circumcision a risk factor for neonatal urinary tract infections? ''Arch Dis Child'' Published Online First: 6 October 2008. doi:10.1136/adc.2008.144063 [http://adc.bmj.com/cgi/content/abstract/adc.2008.144063v1 Abstract]</ref>
== Treatment ==
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 UTI ==
Recurrent UTIs are associated with congenital abnormalities of the upper urinary tract.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref><ref>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><ref>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> McCracken recommends investigation with radiographic and/or sonography.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref>
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<ref>Berger A. [http://www.bmj.com/cgi/content/full/317/7171/1473 Burrowing bacteria may explain recurrent urinary tract infections]. ''BMJ'' 1998;317:1473 (Link to www.bmj.com)</ref> or forming pods,<ref>Anderson GG, Palermo JJ, Schilling JD, ''et al.'' [http://www.cirp.org/library/disease/UTI/anderson1/ Intracellular bacterial biofilm-like pods in urinary tract infections]. ''Science'' 2003; 301(5629):105-7.</ref> thus hiding from antibiotics.<ref>Berger A. [http://www.bmj.com/cgi/content/full/317/7171/1473 Burrowing bacteria may explain recurrent urinary tract infections]. ''BMJ'' 1998;317:1473 (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.
== UTI and renal failure ==
In the past it was claimed that UTI could lead to renal failure, however, new evidence has disproved this claim.<ref>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><ref>Lane W, Robson M, Van Howe RS. [http://www.cirp.org/library/disease/UTI/robson1/ Circumcisions: Again]. ''Pediatrics'' 2001;108(2):522.</ref>
== 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.<ref>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>Pisacane A, ''et al.'' [http://www.cirp.org/library/disease/UTI/pisacane/ Breastfeeding and urinary tract infection]. ''The Lancet,'' July 7, 1990, p50.</ref><ref>Mårild S. [http://www.cirp.org/library/disease/UTI/marild/ Breastfeeding and Urinary Tract Infections]. ''Lancet'' 1990;336:942.</ref><ref>Coppa JV ''et al.'' [http://www.cirp.org/library/disease/UTI/coppa/ Preliminary Study of Breastfeeding and Bacterial Adhesion to Uroepithelial Cells]. The ''Lancet'' 1990;335:569-571.</ref><ref>Pisacane A, Graziano L, Mazzarella G, ''et al.'' [http://www.cirp.org/library/disease/UTI/pisacane1992/ Breast-feeding and urinary tract infection]. J Pediatr 1992;120:87-89.</ref><ref>Mårild S, Hansson S, Jodal U, Oden A, Svedberg K. [http://www.cirp.org/library/disease/UTI/marild4/ Protective effect of breastfeeding against urinary tract infection]. ''Acta Paediatr'' 2004;93(2):164-8.</ref><ref>Hanson LÅ. [http://www.cirp.org/library/disease/UTI/marild4/ Protective effects of breastfeeding against urinary tract infection]. ''Acta Paediatr Scand'' 2004;93(2);154-6.</ref> Outerbridge points out that breastfeeding is very effective in reducing incidence of UTI in both boys and girls.<ref>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>
=== 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>Gothefors L, Olling S, Winberg J. Breast feeding and biological properties of faecal E. coli strains. ''Acta Paediatr Scand'' 1975;64(6):807-12.</ref><ref>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>
=== 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 [[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>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. Recently, Fleiss et al. reviewed the immunological functions of the prepuce.<ref>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>Cunningham N. [http://www.cirp.org/library/disease/UTI/cunningham/ Circumcision and urinary tract infections]. (letter) ''Pediatrics'' 1986; 77(2):267.</ref> In addition, the sub-preputial moisture contains lysosyme, which has an anti-bacterial action.<ref>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'' 1990;336:942.</ref>
== American Academy of Pediatrics policy changes ==
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>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> 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.<ref>AAP Task Force on Circumcision. [http://www.cirp.org/library/statements/aap1999/ Circumcision Policy Statement]. ''Pediatrics'' 1999;103(3):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>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>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>AAP Task Force on Circumcision. [http://www.cirp.org/library/statements/aap1999/ Circumcision Policy Statement]. ''Pediatrics'' 1999;103(3):686-693.</ref>
== The UTI scare ==
Drs. Charles Ginsburg and George McCracken 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 <ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ 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>Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. ''Pediatrics'' 1985, 75: 901-903.</ref><ref>Wiswell TE. Circumcision and urinary tract infections. ''Pediatrics'' 1986; 77: 267-8.</ref><ref>Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants. ''Pediatrics'' 1986;78:96-99.</ref><ref>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: 338-42.</ref><ref>Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. ''Pediatrics'' 1989;83:1011-5.</ref><ref>Wiswell TE. Routine neonatal circumcision: a reappraisal. ''Am Fam Physician'' 1990; 41: 859-63.</ref><ref>Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. ''Clin Pediatr'' (Phila) 1993; 32: 130-4.</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>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.
=== 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,<ref>Wallerstein E. [http://www.cirp.org/library/general/wallerstein/ Circumcision: the uniquely American medical enigma]. ''Urol Clin North Am'' 1985;12(1):123-132.</ref> so the majority of its young male client population would have necessarily remained intact. The observation that 95% of the boys were not circumcised, therefore, indicated nothing more than that the majority of male infant patients at Parkland Hospital were not circumcised.
Wiswell's retrospective reviews of old hospital records failed to take a few factors into account:
*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>Littlewood JM. [http://www.cirp.org/library/disease/UTI/littlewood1/ Infants with urinary tract infection in first month of life]. ''Arch Dis Child'' 1972;47(252):218-26.</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>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;149:170-3.</ref> There is a significant false-positive rate in diagnosing UTI when urine cultures alone are used.<ref>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>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>O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. ''Southern Medical Journal'' 1995;88:411-5.</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>Van Howe RS. [http://www.cirp.org/library/disease/UTI/vanhowe/ To the Editor], ''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>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>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>
=== 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>To T, Agha M, Dick PT, ''et al.'' [http://www.cirp.org/library/disease/UTI/to2/ Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection]. ''Lancet'' 1998;352:1813-16.</ref>
=== 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.<ref>Altschul MS. [http://www.cirp.org/library/disease/UTI/altschul1990/ The circumcision controversy] (editorial). ''Am Fam Physician'' 1990;41:817-820.</ref><ref>Thompson RS: [http://www.cirp.org/library/disease/UTI/thompson/ Does circumcision prevent urinary tract infection? An opposing view]. ''J Fam Pract' 1990; 31: 189-96.</ref><ref>Bollgren I, Winberg J. Letter. ([http://www.cirp.org/library/disease/UTI/winberg-bollgren2/ Rebuttal of Edgar J. Schoen]) ''Acta Paediatrica Scandinavia'' 1991; 80:575-7.</ref><ref>Chessare JB. [http://www.cirp.org/library/disease/UTI/chessare/ Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue?] ''Clinical Pediatrics'' 31(2):100-4, Feb. 1992. 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>Amir J. ''et al.'' Circumcision and Urinary Tract Infections in Infants. ''Am J Dis Child'' (1986), vol. 140, p. 1092.</ref><ref>Cohen, H. ''et al.'' [http://www.cirp.org/library/disease/UTI/cohen/ Postcircumcision Urinary Tract Infection]. ''Clinical Pediatrics'' (1992), pp. 322-4.</ref><ref>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>Van Howe RS. [http://www.cirp.org/library/disease/UTI/vanhowe_uti2005/ Effect of confounding in the association between circumcision status and urinary tract infection]. ''J Infect'' 2005;51(1):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>Kayaba H ''et al.'' [http://www.cirp.org/library/normal/kayaba/ Analysis of shape and retractability of the prepuce in 603 Japanese boys]. ''J Urol'', 1996 Nov, V156 N5:1813-5.</ref> 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 ===
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.<ref>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.
{{REF}}
[[Category:From IntactWiki]]
== 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.<ref>Maskell, R. et al. Urinary Pathogens in the Male. British Journal of Urology, (1975) vol.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.
UTIs are usually associated with congenital abnormalities of the urinary tract.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref><ref>Amato D, Garduno-Espinosa J. [http://www.cirp.org/library/disease/UTI/amato/ Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis]. ''Bol Med Infant Mex'' Volume 49, Number 10, October 1992, 652-658.</ref><ref>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;149:170-3.</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 ===
In infant boys, UTIs originate from the external environment, strongly suggesting that these infections are iatrogenically caused.<ref>Maskell, R. et al. Urinary Pathogens in the Male. ''British Journal of Urology'', (1975) vol.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>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> which binds to the glans penis of the infant.<ref>Cunningham N. [http://www.cirp.org/library/disease/UTI/cunningham/ Circumcision and urinary tract infections]. (letter) ''Pediatrics'' 1986; 77(2):267.</ref> Urinary tract infections (UTI) are a complication of circumcision.<ref>Smith RM. [http://www.cirp.org/library/disease/UTI/smith1916/ Recent contributions to the study of pyelitis in infancy]. ''Am J Dis Child'' 1916;XII:235-43.</ref><ref>Cohen, H. ''et al.'' [http://www.cirp.org/library/disease/UTI/cohen/ Postcircumcision Urinary Tract Infection]. ''Clinical Pediatrics'' (1992), pp. 322-4.</ref><ref>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>Prais D. Shoov-Furman R, Amir J. Is circumcision a risk factor for neonatal urinary tract infections? ''Arch Dis Child'' Published Online First: 6 October 2008. doi:10.1136/adc.2008.144063 [http://adc.bmj.com/cgi/content/abstract/adc.2008.144063v1 Abstract]</ref>
== Treatment ==
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 UTI ==
Recurrent UTIs are associated with congenital abnormalities of the upper urinary tract.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref><ref>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><ref>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> McCracken recommends investigation with radiographic and/or sonography.<ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ Urinary tract infections in young infants]. ''Pediatrics'' 1982; 69:409-12.</ref>
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<ref>Berger A. [http://www.bmj.com/cgi/content/full/317/7171/1473 Burrowing bacteria may explain recurrent urinary tract infections]. ''BMJ'' 1998;317:1473 (Link to www.bmj.com)</ref> or forming pods,<ref>Anderson GG, Palermo JJ, Schilling JD, ''et al.'' [http://www.cirp.org/library/disease/UTI/anderson1/ Intracellular bacterial biofilm-like pods in urinary tract infections]. ''Science'' 2003; 301(5629):105-7.</ref> thus hiding from antibiotics.<ref>Berger A. [http://www.bmj.com/cgi/content/full/317/7171/1473 Burrowing bacteria may explain recurrent urinary tract infections]. ''BMJ'' 1998;317:1473 (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.
== UTI and renal failure ==
In the past it was claimed that UTI could lead to renal failure, however, new evidence has disproved this claim.<ref>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><ref>Lane W, Robson M, Van Howe RS. [http://www.cirp.org/library/disease/UTI/robson1/ Circumcisions: Again]. ''Pediatrics'' 2001;108(2):522.</ref>
== 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.<ref>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>Pisacane A, ''et al.'' [http://www.cirp.org/library/disease/UTI/pisacane/ Breastfeeding and urinary tract infection]. ''The Lancet,'' July 7, 1990, p50.</ref><ref>Mårild S. [http://www.cirp.org/library/disease/UTI/marild/ Breastfeeding and Urinary Tract Infections]. ''Lancet'' 1990;336:942.</ref><ref>Coppa JV ''et al.'' [http://www.cirp.org/library/disease/UTI/coppa/ Preliminary Study of Breastfeeding and Bacterial Adhesion to Uroepithelial Cells]. The ''Lancet'' 1990;335:569-571.</ref><ref>Pisacane A, Graziano L, Mazzarella G, ''et al.'' [http://www.cirp.org/library/disease/UTI/pisacane1992/ Breast-feeding and urinary tract infection]. J Pediatr 1992;120:87-89.</ref><ref>Mårild S, Hansson S, Jodal U, Oden A, Svedberg K. [http://www.cirp.org/library/disease/UTI/marild4/ Protective effect of breastfeeding against urinary tract infection]. ''Acta Paediatr'' 2004;93(2):164-8.</ref><ref>Hanson LÅ. [http://www.cirp.org/library/disease/UTI/marild4/ Protective effects of breastfeeding against urinary tract infection]. ''Acta Paediatr Scand'' 2004;93(2);154-6.</ref> Outerbridge points out that breastfeeding is very effective in reducing incidence of UTI in both boys and girls.<ref>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>
=== 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>Gothefors L, Olling S, Winberg J. Breast feeding and biological properties of faecal E. coli strains. ''Acta Paediatr Scand'' 1975;64(6):807-12.</ref><ref>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>
=== 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 [[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>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. Recently, Fleiss et al. reviewed the immunological functions of the prepuce.<ref>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>Cunningham N. [http://www.cirp.org/library/disease/UTI/cunningham/ Circumcision and urinary tract infections]. (letter) ''Pediatrics'' 1986; 77(2):267.</ref> In addition, the sub-preputial moisture contains lysosyme, which has an anti-bacterial action.<ref>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'' 1990;336:942.</ref>
== American Academy of Pediatrics policy changes ==
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>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> 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.<ref>AAP Task Force on Circumcision. [http://www.cirp.org/library/statements/aap1999/ Circumcision Policy Statement]. ''Pediatrics'' 1999;103(3):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>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>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>AAP Task Force on Circumcision. [http://www.cirp.org/library/statements/aap1999/ Circumcision Policy Statement]. ''Pediatrics'' 1999;103(3):686-693.</ref>
== The UTI scare ==
Drs. Charles Ginsburg and George McCracken 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 <ref>Ginsburg CM, McCracken GH. [http://www.cirp.org/library/disease/UTI/ginsburg/ 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>Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. ''Pediatrics'' 1985, 75: 901-903.</ref><ref>Wiswell TE. Circumcision and urinary tract infections. ''Pediatrics'' 1986; 77: 267-8.</ref><ref>Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants. ''Pediatrics'' 1986;78:96-99.</ref><ref>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: 338-42.</ref><ref>Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. ''Pediatrics'' 1989;83:1011-5.</ref><ref>Wiswell TE. Routine neonatal circumcision: a reappraisal. ''Am Fam Physician'' 1990; 41: 859-63.</ref><ref>Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. ''Clin Pediatr'' (Phila) 1993; 32: 130-4.</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>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.
=== 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,<ref>Wallerstein E. [http://www.cirp.org/library/general/wallerstein/ Circumcision: the uniquely American medical enigma]. ''Urol Clin North Am'' 1985;12(1):123-132.</ref> so the majority of its young male client population would have necessarily remained intact. The observation that 95% of the boys were not circumcised, therefore, indicated nothing more than that the majority of male infant patients at Parkland Hospital were not circumcised.
Wiswell's retrospective reviews of old hospital records failed to take a few factors into account:
*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>Littlewood JM. [http://www.cirp.org/library/disease/UTI/littlewood1/ Infants with urinary tract infection in first month of life]. ''Arch Dis Child'' 1972;47(252):218-26.</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>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;149:170-3.</ref> There is a significant false-positive rate in diagnosing UTI when urine cultures alone are used.<ref>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>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>O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. ''Southern Medical Journal'' 1995;88:411-5.</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>Van Howe RS. [http://www.cirp.org/library/disease/UTI/vanhowe/ To the Editor], ''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>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>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>
=== 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>To T, Agha M, Dick PT, ''et al.'' [http://www.cirp.org/library/disease/UTI/to2/ Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection]. ''Lancet'' 1998;352:1813-16.</ref>
=== 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.<ref>Altschul MS. [http://www.cirp.org/library/disease/UTI/altschul1990/ The circumcision controversy] (editorial). ''Am Fam Physician'' 1990;41:817-820.</ref><ref>Thompson RS: [http://www.cirp.org/library/disease/UTI/thompson/ Does circumcision prevent urinary tract infection? An opposing view]. ''J Fam Pract' 1990; 31: 189-96.</ref><ref>Bollgren I, Winberg J. Letter. ([http://www.cirp.org/library/disease/UTI/winberg-bollgren2/ Rebuttal of Edgar J. Schoen]) ''Acta Paediatrica Scandinavia'' 1991; 80:575-7.</ref><ref>Chessare JB. [http://www.cirp.org/library/disease/UTI/chessare/ Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue?] ''Clinical Pediatrics'' 31(2):100-4, Feb. 1992. 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>Amir J. ''et al.'' Circumcision and Urinary Tract Infections in Infants. ''Am J Dis Child'' (1986), vol. 140, p. 1092.</ref><ref>Cohen, H. ''et al.'' [http://www.cirp.org/library/disease/UTI/cohen/ Postcircumcision Urinary Tract Infection]. ''Clinical Pediatrics'' (1992), pp. 322-4.</ref><ref>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>Van Howe RS. [http://www.cirp.org/library/disease/UTI/vanhowe_uti2005/ Effect of confounding in the association between circumcision status and urinary tract infection]. ''J Infect'' 2005;51(1):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>Kayaba H ''et al.'' [http://www.cirp.org/library/normal/kayaba/ Analysis of shape and retractability of the prepuce in 603 Japanese boys]. ''J Urol'', 1996 Nov, V156 N5:1813-5.</ref> 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 ===
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.<ref>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.
{{REF}}
[[Category:From IntactWiki]]