Effect of circumcision on incidence of urinary tract infection in preschool boys,☆☆,,★★

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Abstract

OBJECTIVE: To determine whether circumcision decreases the risk of symptomatic urinary tract infection (UTI) in boys less than 5 years of age. STUDY DESIGN: A case-control study (1993 to 1995) in the setting of a large ambulatory pediatric service. Case subjects and control subjects were drawn from the same population. One hundred forty-four boys less than 5 years of age (median age, 5.8 months) who had a microbiologically proven symptomatic UTI (case subjects), were compared with 742 boys (median age, 21.0 months) who did not have a UTI (control subjects). The proportion of case and control subjects who were circumcised in each group was compared with the use of the chi-square test, with the strength of association between circumcision and UTI expressed in terms of an odds ratio. To determine whether age was a confounder or an effect-modifier, we stratified the groups by age (<1 year; 1 year) and analyzed by the method of Mantel-Haenszel. RESULTS: Of the 144 preschool boys with UTI, 2 (1.4%) were circumcised, compared with 47 (6.3%) of the 742 control subjects (chi-square value = 5.6; p = 0.02; odds ratio, 0.21; 95% confidence intervals, 0.06 to 0.76). There was no evidence that age was a confounder or modified the protective effect of circumcision on the development of UTI (Mantel-Haenszel chi-square value = 6.0; p = 0.01; combined odds ratio, 0.18; 95% confidence intervals, 0.05 to 0.71; Breslow-Day test of homogeneity chi-square value = 0.6; p = 0.4). CONCLUSIONS: Circumcision decreases the risk of symptomatic UTI in preschool boys. The protective effect is independent of age. (J PEDIATR 1996;128:23-7)

Section snippets

Case selection

To identify cases of UTI in boys less than 5 years of age, we prospectively reviewed all urine cultures that were obtained from eligible boys attending the ambulatory pediatric department of the Royal Alexandra Hospital for Children, Sydney, from March 1, 1993, to Dec. 17, 1994. All urine samples were inoculated onto blood agar and MacConkey medium with a 1 μl calibrated loop. Our case criteria were a colony-forming unit count of more than 106/L from urine obtained from a suprapubic tap or

Clinical findings

One hundred forty-four cases of UTI were identified. The method of urine collection and of counting colony-forming units are given in Table I. Escherichia coli was the pathogenic organism in 124 (86.1%), Proteus sp. in 11 (7.6%), Klebsiella sp. and Escherichia faecalis in four each (2.8%), and Corynebacterium minutissimum in a single case (0.7%).13 The median age was 5.8 months, with a range of 0.3 to 54.5 months (Table II). Fever, the commonest initial symptom, was present in 111 boys (77.1%).

DISCUSSION

The association between circumcision and UTI was first recognized by Ginsberg and McCracken3 in 1982 in a cross-sectional study of 100 hospitalized infants with UTI. Despite differences in study populations and design, all subsequent studies have consistently demonstrated an association between an uncircumcised state and UTI.

The strongest evidence of a causal link between an intact foreskin and UTI comes from the series of retrospective cohort studies from Wiswell and colleagues.5, 9, 10 When

Acknowledgements

We thank Professor Geoffrey Berry for assistance with the statistical analysis; Ralph Hanson, Audrey Chan, and Peter Greenacre for technical assistance; and associate professor Les Irwig for comments on earlier drafts.

References (20)

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    Concerning the prevalence of UTI, there is one prospective randomized study demonstrating reduction in the episodes of symptomatic fUTI, although statistically the data in the study were not significant.13 In addition, there have been numerous nonrandomized studies reporting a decreased rate of fUTI in circumcised boys compared with noncircumcised boys, including cohort studies from Canada,14 Australia,15 and the United States,16–18 a series of epidemiological studies from the United States,19–22 and three meta-analyses (2 from the United States22,23 and 1 from Australia24). There are also two studies comparing the incidence of fUTI before and after circumcision, one from Turkey25 and the other from the United States.26

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    Wijesinha et al. reported that most boys harbor uropathogenic organisms in their preputial flora prior to circumcision, which are replaced by skin commensals after removal of the foreskin Ref. [20]. In these studies the organisms most commonly isolated post circumcision were coagulase-negative Staphylococci [18,21], which is similar to what was observed in the present study: an increase in culture positivity from 29% (baseline) to 66% (post circumcision). The general finding was that children in groups 2 and 3 (circumcised) had lower positive urethral swab rates compared to children in groups 1 and 4.

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From the Department of Nephrology, Royal Alexandra Hospital for Children, Sydney, Australia

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Supported by the National Health and Medical Research Council, the Children's Hospital Research Fund, and the Manildra Group of Companies.

Reprint requests: J. C. Craig, MBChB, DCH, FRACP, Department of Nephrology, Royal Alexandra Hospital for Children, PO Box 3515, Parramatta, New South Wales 2124, Australia.

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