Statistics from Altmetric.com
Commentary on the paper by Singh-Grewel et al (see page 853)
Circumcision is the commonest surgical procedure carried out in boys and it probably originated 15 000 years ago.1 It was initially done for religious, ritualistic, and cultural reasons and it was not until the 19th century that the procedure was “medicalised”. The original therapeutic circumcisions were performed for phimosis and since then indications for surgery have altered with the trends of the day. In some countries these trends turned to dogma, resulting in the virtual routine circumcision of newborn boys. It was estimated that 61% of all boys born in the USA in 1987 were circumcised.2 It is also fascinating to observe how this dogma can pervade other cultures. Traditionally Koreans did not circumcise their boys until their exposure to many thousands of American troops during the Korean War; now Korea is the only country in that region practising routine circumcision.3 This high rate of routine newborn circumcision generated concern, and in the USA the American Academy of Pediatrics issued various circumcision policy statements, the most recent being in 1999; this concluded,“Existing scientific evidence demonstrates potential benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision”.4 Medical indications for circumcision can be subdivided into absolute and relative, with the absolute indications generally accepted as phimosis secondary to balanitis xerotica obliterans and recurrent balanoposthitis, occurring in 1.5% and 1% of boys, respectively.5 There are many relative indications including the prevention of penile and cervical cancer, the prevention of sexually transmitted disease, particularly HIV/AIDS, and the prevention of urinary tract infection (UTI), but are the benefits for these indications of such degree to justify a policy of routine circumcision? The prevention of UTI remains the most interesting and perhaps the most persuasive relative indication for male circumcision and continues to provoke controversy, but the question must be asked whether this is an argument to justify the continuation of the lucrative practice of routine circumcision or whether there is truly a medical benefit.
The association between UTI and the uncircumcised state was first recognised in 1982.6 Since then there have been numerous observational and case–control cohort studies and these have shown a three to seven times increased risk of UTI in uncircumcised compared with circumcised infants, with the greatest risk in infants under 1 year of age.4 There were many methodological problems with these studies, making their relevance difficult to assess and thus making it impossible to establish firm evidence based guidelines. In a report in this issue, Singh-Grewal and colleagues undertook a meta-analysis of 12 studies assessing the association between UTI and circumcision and applied stringent criteria before accepting any study into their analysis.7 However, in reaching their conclusions they had to make various assumptions based on the results of other studies, particularly with respect to the recurrence rate of UTI in preschool children in the absence of a urinary tract anomaly and the recurrence rate in patients with vesicoureteric reflux (VUR) of grade 3 and above. These assumptions detracted from a solid evidence base but the conclusions of the study still represented a reasonable consensus view to guide clinical practice at the present time.
Singh-Grewal et al concluded that 111 circumcisions would be required to prevent one UTI, and in the UK at the present time this would cost the NHS approximately £55 000.7 It is doubtful that a cost–benefit analysis could ever justify routine circumcision under those circumstances. However the same study estimated that only 11 circumcisions would be required in boys with recurrent UTI and four in boys with grade 3 or more VUR to prevent a single UTI, making the cost–benefit analysis much more acceptable and attractive. It is interesting to note that this approach to circumcision has been adopted empirically by many paediatric urologists over the past decade, and from personal communications it would be difficult to find a urologist who would not offer a circumcision to a boy with recurrent UTI or a boy who developed a UTI despite conservative treatment in the presence of a serious underlying abnormality of the urinary tract such as VUR, posterior urethral valves, neuropathic bladder, and many other conditions. In my experience many boys troubled with recurrent UTI in the clinical settings described above have been “cured” by a circumcision. It is an intervention that should always be considered. However, a note of caution must be struck on assessing the benefit of circumcision even in the presence of an underlying abnormality of the urinary tract. In a recent interesting controlled trial, Kwak et al could find no benefit for circumcision when it was done at the same time as anti-reflux surgery for severe VUR, irrespective of the age of the patient.8
One further note of caution must be raised before completely dismissing the role of routine circumcision in reducing the risk of UTI. The cost–benefit of preventing a single UTI is questionable, but what is the cost–benefit of preventing renal scarring? In the only randomised controlled trial on circumcision and UTI, Nayir found DMSA evidence of renal parenchymal abnormalities in 18% of 88 boys presenting with UTI.9 This study went on to show a significant reduction in further infection following circumcision, but if the circumcision had been done in the newborn period would the kidneys have been protected from damage in the first instance? This is a question that neither this or any other study can answer at the present time, and the recommendation of Singh-Grewal et al for a randomised controlled trial must be supported. Surely, however, we must not just limit such a study to UTI but include an assessment of renal scarring as well.7
Commentary on the paper by Singh-Grewel et al (see page 853)
Competing interests: none declared