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Commentary on the paper by Singh-Grewal et al (see page 853)
Almost 20 years ago, Wiswell and colleagues1 found that uncircumcised infant boys had a 10-fold greater likelihood of having urinary tract infection (UTI) in the first year of life than boys who had been circumcised as newborns. That finding has been repeatedly confirmed, and the protective effect of newborn circumcision against UTI is well established, as documented in a 1992 meta-analysis of nine separate studies.1 A report from Sweden—where newborn circumcision is unusual—showed a preponderance of UTI in male infants,2 although UTI is much more common in older girls. The procedure at issue is newborn circumcision, because the younger the infant, the more likely and severe is the UTI and the greater the danger of sepsis and death. UTIs in infants manifest as pyelonephritis with high fever, usually requiring hospital admission and parenteral therapy, whereas UTI which develops later in life (usually cystitis) is milder and more easily treated. Imaging studies conducted after UTI in infants has resolved often show evidence of renal damage with scarring.3 In a 1997 Commentary in this journal, I indicated that Europe, in opposing circumcision, was ignoring compelling medical evidence.4 The reply concerning UTI was the unsubstantiated claim that infant UTI—except when associated with renal tract anomalies—is rarely seen in the United Kingdom.4
In this issue of the journal, Singh-Grewal et al5 from Australia reviewed 12 studies and concluded, as did the earlier meta-analysis by Wiswell,1 that circumcision substantially reduces the risk of UTI. Wiswell1 reported that UTI developed in about 1% of uncircumcised normal boys without renal anomalies; circumcision reduced the risk of UTI by 90%. Instead of using this significant benefit as an argument in favour of routine newborn circumcision, Singh-Grewal et al argue that the data support circumcision not in normal boys but in boys with recurrent UTI or vesicoureteric reflux. This interpretation of the findings is flawed for several reasons:
Newborn circumcision prevents UTI. Waiting for a UTI to develop before making the decision to circumcise risks the possibility of allowing renal damage in immature kidneys, and vesicoureteric reflux may result from pyelonephritis. The strategy of waiting for a UTI to develop is analogous to postponing immunisation of an infant until the child is exposed to the pathogen or is diagnosed with the disease.
The immediate newborn period offers a “window of opportunity” for circumcision because the infant is programmed for stress and quickly recovers, stress hormones are increased, healing is rapid, and the thinness of the foreskin eliminates the need for sutures.
Circumcision in the newborn nursery is about 10 times less expensive than if the procedure is performed postneonatally. Local anaesthesia is the standard of care in newborn circumcision.
Although the dangers and high prevalence of UTI occur mainly in the first year of life, studies of older children and adults are inappropriately included in the analysis. That the prevalence of UTI in boys decreases with increasing age may explain why the odds ratio in boys is not as favourable as in earlier studies. The 2% complication rate mentioned is high. In a 1999 report,6 the American Academy of Pediatrics stated that complications of newborn circumcision are “rare and usually minor” and that complications occur at a rate of 0.2% to 0.6%—3 to 10 times lower than the rate cited by Singh-Grewal et al.
In discussing the rationale for routine newborn circumcision, Singh-Grewal and colleagues overlook a key point: Preventing infant UTI is only one of the many lifetime benefits of newborn circumcision.6,7 During infancy and childhood, circumcision prevents phimosis and balanoposthitis and facilitates cleanliness. In young men, circumcision helps prevent certain sexually transmitted diseases8 and (because of improved genital hygiene) encourages more varied sexual activity. More than 40 separate studies (mainly from subSaharan Africa) have shown that circumcised men are two to seven times less likely to acquire HIV after exposure than are men with foreskins.9 The foreskin has specialised cells that bind the AIDS virus and allow it to enter the body.10 Human papilloma virus (HPV) is diagnosed three times more often in uncircumcised men than in circumcised men.11 HPV is the causative agent of both penile cancer and cervical cancer. Penile cancer is seen almost exclusively in uncircumcised men, and women with uncircumcised partners are more likely to acquire cervical cancer.11
In concluding that preventing UTI in normal boys is not a sufficient reason to recommend routine circumcision, the authors neglect not only the multiple preventive health benefits listed above but the role of the parents in making the decision. Medical policy today is not for the physician to tell parents and patients what to do; instead, physicians engage in “non-directional counselling.” Parents of infants should be told of the benefits and risks of the procedure in an objective manner to allow for truly informed consent so that the parents, not the physician, make the decision. This scenario assumes that the physician is knowledgeable on the topic and presents a valid picture.
The USA and Europe are at opposite ends of the practice spectrum regarding routine newborn circumcision: Unlike the situation in Europe, most boys born in the USA are circumcised. This statistic includes not only the 64% of circumcision procedures recorded on the newborn discharge form but also those not recorded on the discharge form and those done after the newborn period. Thus the total circumcision rate in the USA is 75–80% as measured by actual surveys. In contrast, circumcision in Europe is not a routine secular medical procedure; except for men circumcised for medical reasons, the rare circumcised man in Europe can be assumed to be Jewish or Muslim. Most uncircumcised males in the USA are immigrants or sons of recent immigrants, most commonly Latino/Hispanic. Perhaps, as the growing evidence on the multiple proven preventive health benefits of newborn circumcision becomes more widely known and accepted, European practice will change; acknowledging the role of circumcision in protecting against UTI is a good start.
The Kaiser Foundation Hospitals Medical Editing Department provided editorial assistance.
Commentary on the paper by Singh-Grewal et al (see page 853)
Competing interests: none declared
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