NEW YORK (Reuters Health) - Results of a meta-analysis confirm that male circumcision reduces the risk of urinary tract infections (UTIs) -- but more than 100 boys need to be circumcised to prevent one UTI. While the authors of the analysis would reserve circumcision for boys at high risk of UTI, this view is not universally held, commentators suggest.

A reduced incidence of UTI is the most frequently cited benefit of circumcision, Dr. Jonathan Craig and his team at the Children's Hospital at Westmead in Sydney, Australia, indicate in their report, published in the August Archives of Disease in Childhood.

The investigators searched databases to identify studies published between 1987 and 2001 that reported on circumcision and UTI outcomes. Their meta-analysis included 12 articles (one randomized controlled trial, four cohort studies and seven case-control studies), documenting outcomes for approximately 403,000 children and 1953 episodes of UTI. Maximum follow-up was 3 years.

Circumcision was associated with a significantly reduced risk of UTI, with an odds ratio of 0.13 (p < 0.001). "An OR of 0.13 reflects a substantial reduction and makes residual confounding an unlikely source of the observed association," the authors note.

They calculate that "the number-needed-to-treat to prevent one UTI is 111" in normal boys.

Also, they add, circumcision is associated with a 2% to 10% complication rate, while the rate of sequelae of UTI is unknown.

Dr. Craig and colleagues estimate the risk of UTI to be 1% in normal boys, 10% in boys with a history of UTI, and 30% in boys with high-grade vesicoureteric reflux. Therefore, they conclude, "circumcision should be considered in boys with a past history of recurrent UTI or high grade (grade 3 and above) vesicoureteric reflux, as the benefit outweighs the risk of complications in these cases."

Reflecting a "North American view," Dr. Edgar J. Schoen, from Kaiser Permanente Medical Center in Oakland, California, suggests in a related commentary that the researchers' interpretation of their findings is flawed.

For example, he notes, circumcision is ideally performed in newborns, where the complication rate is approximately 0.2% to 0.6%. He also advocates its use because of multiple other lifetime health benefits, such as prevention of penile cancer, some sexually transmitted diseases and HIV.

But in a second commentary giving a "European View," Dr. Padraig S. J. Malone, from Southampton University Hospitals NHS Trust in the UK, remarks that "it is doubtful that a cost-benefit analysis could ever justify routine circumcision" to prevent UTIs. He does, however, recommend controlled trials to assess the benefit of routine circumcision in preventing renal scarring.

Arch Dis Child 2005;90:772-774,853-858

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