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Wikify Thomas E. Wiswell; various formatting clean up, add conclusion.
== 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 ==
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 ColiCol''i, 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 ==
=== 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 ''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 ===
== The UTI scare ==
Drs. Charles Ginsburg and George McCracken 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/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."
== 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.
Prevention of UTI is not regarded as a reason to circumcise a boy.
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