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Keywords:

  • circumcision;
  • urinary tract infection;
  • vesico-ureteric reflux;
  • outcome

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVE

To evaluate whether circumcision during antireflux surgery can reduce the incidence of urinary tract infection (UTI) after successful ureteric reimplantation in patients with primary vesico-ureteric reflux (VUR).

PATIENTS AND METHODS

Children who had undergone antireflux surgery for primary VUR were divided into group 1 (27, circumcised at the time of antireflux surgery at the parents’ request) and group 2 (50, those not circumcised). All antireflux operations were by the Cohen method. Regular urine samples were cultured to detect UTI, which was defined as a single species with >105 colony-forming units/mL in a midstream voided specimen. Numbers of UTI episodes before and after surgery were compared between the groups, with 99mTc-dimercaptosuccinic acid (DMSA) renal scans also taken in all patients. Each scan was blindly reviewed in terms of the size, number and zonal location of cortical defects, based on morphology. Interval changes were categorised as improved, no change, progressed, and new scar formation, and compared between the groups. Prophylactic antibiotics were maintained until the follow-up studies at 4–6 months after surgery.

RESULTS

There was no significant difference between the groups in age at the time of operation (mean 42.4 vs 47.4 months), the age at the first documented UTI (mean 26.5 vs 29.3 months), reflux grade, or number of UTI episodes and renal parenchymal scarring on DMSA before surgery. There was no significant difference between the groups in the number of UTI episodes at a mean (range) follow-up of 151.3 (114–207) months after antireflux surgery. Also there was no significant morphological change on follow-up renal scans and no difference between the groups.

CONCLUSION

These findings suggest that circumcision during antireflux surgery has no effect on the incidence of postoperative UTI.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The continuing practice of circumcision of newborn male infants, other than as a religious and cultural rite, remains something of an enigma. In a summary of the scientific data in 1971, the American Academy of Pediatrics Committee on the Fetus and Newborn issued an advisory note that ‘there are no absolute medical indications for routine circumcision of the newborn.’[1]. In part, because of this consensus, the circumcision rate has declined; however, currently the link to UTI during infancy has renewed the debate about neonatal circumcision. From proponents of neonatal circumcision there are warnings that the intact prepuce invites bacterial colonization, leading to ascending urethral infection which, in turn, can sometimes result in acute pyelonephritis and permanent renal damage. On the opposing side there is no proof that uncircumcised infants who sustain a UTI will have urological problems in the future. Furthermore, routine circumcision is not necessarily a simple procedure; possible dangers include penile amputation or death.

In 1985 Wiswell et al.[2] reported the results of a study documenting the incidence of UTI during the first year of life in a large cohort of infants born at Brooke Army Medical Center over an 18-month period. They identified a significant association between circumcision status and risk of UTI in boys, and these findings prompted the American Academy of Pediatrics to reassess the issues involved in circumcision. In 1989, the Task Force on Circumcision issued a new statement, noting that the procedure had potential medical benefits and advantages, as well as disadvantages and risks [3]. However, many questions about the relationship between circumcision and UTI remain unanswered. In particular, few studies have evaluated whether circumcision can provide prophylaxis in children with disorders such as VUR that predispose them to UTI [2,4]. This disorder is found in 20–50% of children with UTI and at least a quarter of neonates and infants with VUR have had a UTI while receiving antimicrobial prophylaxis. In the series by Jodal [5] there was (after ureteric reimplantation) a striking reduction in the rate of episodes of acute pyelonephritis in patients with VUR, but the overall rate of symptomatic UTI was not reduced by surgery. We evaluated whether circumcision at the time of antireflux surgery can reduce the incidence of UTI after successful ureteric reimplantation in patients with primary VUR.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The study involved 77 patients with primary VUR who had had antireflux surgery at our institution between December 1985 and August 1993; their characteristics are shown in Table 1. Urine specimens were obtained by sterile technique before surgery. Group 1 comprised 27 boys who at the request of their parents had been circumcised at the end of cross-trigonal ureteric reimplantation. Group 2 consisted of 50 boys who had not been circumcised during antireflux surgery. Almost all antireflux surgery was by Cohen's method. The mean duration of prophylactic antibiotic treatment before surgery was 5.8 months in group 1 and 7.1 months in group 2; prophylactic antibiotics were maintained until follow-up studies (at 4–6 months) showed that the reflux had been corrected. Regular urine cultures were assessed and UTI diagnosed by the standard definition of bacteriuria (>105 colony-forming units/mL of a single species in a midstream specimen). There was no significant difference between the groups in age at operation, type and grade of VUR and renal scarring, as determined by a preoperative 99mTc-DMSA renal scan. The follow-up was from the date of surgery to date of the last visit. The mean follow-up was 152.4 months in group 1 and 150.4 months in group 2. Continuous data were compared statistically using Student's t-test, categorical variables using the chi-square test or linear-by-linear association test, with P < 0.05 taken to indicate significance in all.

Table 1.  The patients’ characteristics
 Group 1Group 2P
N 27 50 
Mean (range):
age at surgery, months 42.4 (4.2–134.7) 47.4 (5.1–173.7)0.612
follow-up, months152.4 (114–207)150.4 (114–207)0.769
N (%) according to age at operation:  0.273
≤1 year  5 (19) 15 (30) 
>1 year 22 (82) 35 (70) 
N (%) type of VUR  0.281
Unilateral 21 (78) 33 (66) 
Bilateral  6 (22) 17 (34) 
N (%) highest grade of VUR (%):  0.528
Grade I  0  2 (4) 
Grade II  1 (4)  1 (2) 
Grade III  4 (15)  5 (10) 
Grade IV  9 (33) 23 (46) 
Grade V 13 (48) 19 (38) 
N (%) renal findings on DMSA before surgery  0.113
No scar  3 (11)  11 (22) 
Unilateral scar  9 (33) 20 (40) 
Bilateral scar 15 (56) 19 (38) 

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The number of UTI episodes before surgery between the groups was compared according to age at surgery (Table 2); there was no difference in recurrence rates of UTI between the groups, nor in the recurrence rate of UTI after surgery. In group 1 and 2, 21 (78%) and 32 (64%) patients had no UTI after surgery. In addition, in patients aged ≤1 or >1 year, the recurrence rate of UTI in group 1 after surgery was no different from that in group 2, at three and 18 (82%) in group 1, and eight and 24 (69%), in group 2 had no UTI, respectively. Irrespective of circumcision, the number of UTI episodes after surgery in patients aged ≤1 year was not significantly different from that in patients >1 year, respectively (not shown). The follow-up DMSA renal scans in all patients at the last visit showed no difference in findings between groups 1 and 2 (P = 0.773), with 14% and 10% having a new scar, 74% (both) having no change, and 11% and 16% improving, respectively.

Table 2.  Comparison of numbers (and % where the total is >20) of UTI episodes in the two groups before and after surgery
Age group UTI categoryBeforeAfter
Group 1Group 2P*Group 1Group 2P*
  • *

    Linear-by-linear association test.

≤1 year  0.847  0.370
0–1 2 7  5 11 
2–4 2 7  0 4 
5–8 1 1  0 0 
Total 515  515 
>1 year  0.157  0.142
0–1 11 (50)13 (37) 20 (91)28 (80) 
2–4 11 (50)20 (57)  2 (9) 7 (20) 
5–8 0 2 (6)  0 0 
Total22 (100)35 (100) 22 (100)35 (100) 
Overall age  0.241  0.069
0–113 (48)20 (40) 25 (93)39 (78) 
2–413 (48)27 (54)  2 (7) 11 (22) 
5–8 1 (4) 3 (6)  0 0 
Total27 (100)50 (100) 27 (100)50 (100) 

In patients aged >1 year the mean number of analgesic injections to control pain after surgery (and circumcision) was not significantly different from that in the uncircumcised group (at 0.86 and 0.40, respectively, P = 0.221).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

UTI is a common disorder of childhood, occurring more often during the first year of life than at any other age [6,7], which is the only period in life when males are more likely to be affected than females. UTI during infancy usually consists of acute pyelonephritis; the infant kidney is more prone to damage (scarring) than that of older children or adults, and up to 10–15% of children aged <1 year with UTI will have such scarring. Up to 25% of infants with scarring will later develop long-term sequelae involving renal insufficiency and hypertension [7–9]. Also, more acute complications of UTI can occur during early infancy; 20–25% of children aged <3 months with these infections will have concomitant bacteraemia [10], and up to 11% of those aged <1 month with UTI will die [11]. Preventing UTI should be one of the goals of healthcare providers.

Whether circumcision in neonates can reduce the incidence of UTI is controversial. In the report by Wiswell et al.[2] in 1985, based on circumcision status, it was reported that 4% of uncircumcised males had a UTI in the first year of life, compared with 0.21% of circumcised males and 0.47% of females. The second study in 1986 [4] analysed UTI in infants born at Brooke Army Medical Center, Fort Sam Houston, Texas, over a 4-year period. Once again, the incidence of confirmed infection in the first year of life was significantly higher in uncircumcised than in circumcised males.

Ginsberg and McCracken [12] were the first to note that a high proportion of boys with UTI were uncircumcised; however, they did not compare the frequency of such infections in boys with and without foreskins. During a prospective investigation of the causes of fever during early infancy, Wiswell et al.[2] found that the risk of UTI was 20 times higher in uncircumcised boys than in those who had been circumcised. They subsequently documented a frequency of UTI at least 10 times greater among uncircumcised boys in a population of >400 000 children [4]. Several studies have shown that among uncircumcised boys, the risk of developing a UTI is five to 89 times greater than among those who have been circumcised [2,4,9,10,13,14].

The association of UTI with an intact foreskin is not unique to infancy. In a study of boys aged 1–14 years, Wiswell [15] found a greater frequency of UTI. Stang et al.[16] found a similar increase in boys aged 1–16 years, and Spach et al.[17] found that an intact foreskin increased the risk of UTI in adult men. Wiswell [18] believed that the presence of a foreskin affects two factors; bacterial colonization and bacterial adherence.

However, in the present results there was no significant difference in the recurrence rate of UTI after surgery between the uncircumcised and circumcised groups, regardless of age at operation; this suggests that the prepuce might not influence the development of UTI. In addition, there was no significant difference in the incidence of UTI before or after surgery between patients aged <1 or >1 year at operation. These findings suggest that age at surgery is not an important factor in the development of UTI.

Although some reports suggested that infection rates are initially higher in uncircumcised infants there is little to show that this leads to urological problems [2,4,9,10,13,14]. The reported rate of complications arising from circumcision is 0.2–0.6%[19], although if minor complications are also considered, the incidence may be as high as 35%. The mortality rate is 1 in 500 000 procedures [20]. Comparing the risks and benefits of circumcision, and in view of the lack of difference in UTI recurrence rates, we do not think that circumcision during antireflux surgery is beneficial.

In conclusion, the current evidence suggests that circumcision during antireflux surgery has no effect on the incidence of UTI afterward, and the age at operation is not an important factor in the development of this infection.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
  • 1
    American Academy of Pediatrics. Committee on Fetus and Newborn: Standards and Recommendations for Hospital Care of Newborn Infants, 5th edn. Evanston, Illinois: American Academy of Pediatrics, 1971: 110
  • 2
    Wiswell TE, Smith FR, Bass J. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985; 75: 9013
  • 3
    Schoen EJ, Anderson G, Bohon C, Poland R. Report of the Ad Hoc Task Force on Circumcision. Pediatrics 1989; 84: 38891
  • 4
    Wiswell TE, Rochelli JD. Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1986; 78: 969
  • 5
    Jodal U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am 1987; 1: 71329
  • 6
    Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in febrile infants. J Pediatr 1993; 123: 1723
  • 7
    Smellie JM. Reflections on 30 years of treating children with urinary tract infections. J Urol 1991; 146: 6658
  • 8
    Piercey KR, Khoury AE, McLorie GA, Churchill BM. Diagnosis and management of pediatric urinary tract infection. Curr Opin Urol 1993; 3: 259
  • 9
    Rushton HG. Pyelonephritis in male infants: How important is the foreskin? J Urol 1992; 148: 7336
  • 10
    Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: An update. Clin Pediatr 1993; 32: 1304
  • 11
    Littlewood JM. 66 infants with urinary tract infection in the first month of life. Arch Dis Child 1972; 47: 21826
  • 12
    Ginsberg CM, McCracken GH Jr. Urinary tract infections in young infants. Pediatrics 1982; 69: 40911
  • 13
    Herzog LW. Urinary tract infections and circumcision. A case-control study. Am J Dis Child 1989; 143: 34850
  • 14
    Kashani IA, Faraday R. The risk of urinary tract infection in uncircumcised male infants. Int Pediatr 1989; 4: 445
  • 15
    Wiswell TE. The circumcision debate. Pediatrics 1987; 79: 64950
  • 16
    Stang HJ, Snellman LW, Stang JM. Influence of circumcision status on urinary tract infections in pediatric males. Am J Dis Child 1992; 146: 491
  • 17
    Spach DH, Stapleton AE, Stamm WE. Lack of circumcision increases the risk of urinary tract infection in young men. JAMA 1992; 267: 67981
  • 18
    Wiswell TE. Circumcision and urinary tract infection. Cur Opin Urol 1994; 4: 503
  • 19
    American Academy of Pediatrics. Report of the task Force on Circumcision. Pediatrics 1989; 84: 38891
  • 20
    Kaplan GW. Circumcision: an overview. Curr Probl Pediatr 1977; 7: 133