Lifetime reduction in UTI risk by male circumcision, "Beyond the Abstract," by Brian J. Morris, DSc, PhD, FAHA

BERKELEY, CA (UroToday.com) - A meta-analysis published in the June 2013 issue of Journal of Urology  has determined, for the first time, the risk of urinary tract infection (UTI) over the lifetimes of males.[1] In particular, it showed the level of strong protection that circumcision confers across different age categories. Brian Morris at the University of Sydney and Thomas Wiswell a neonatologist in Orlando concluded that, over the lifetime, the single risk factor of the foreskin confers a 1-in-4 chance of getting a UTI during the male lifetime. This represented the difference between lifetime UTI prevalence in uncircumcised males (1-in-3) and lifetime prevalence in circumcised males (1-in-8).

It was found that circumcision reduced the risk of an infant getting a UTI by 10-fold. For boys aged 1 to 16 years, the protective effect was 6.6-fold. And for males aged 16 through adulthood, the risk reduction was 3.4-fold. Thus, of any single period of life, prevalence of a male UTI is highest in infancy. The most thorough study to date has shown that 1-in-50 baby boys succumb to a UTI if they are not circumcised.[2] As a result, one of the strongest arguments in favor of infant male circumcision is the prevention of UTI. But the new study highlights the fact that UTI does not suddenly go away after infancy, as many believe.

For a febrile male infant, lack of circumcision should alert the physician to the possibility of a UTI. For several months post-partum, the kidney is still growing. As a result, when bacteria from a UTI ascend the ureter and urethra to infect the kidney, it causes renal parenchymal disease in half of cases.[3] The inflammatory marker most predictive of upper versus lower UTI, and thus renal scarring, is procalcitonin.[4] Bacteria enter the bloodstream in 4 to 12% of UTI cases, causing sepsis.[5, 6] Meningitis occurs in 0.3% of cases and is perhaps the most serious consequence of a UTI.[6] Lumbar puncture would be required to rule this out.

Severe fever and pain, as well as other febrile symptoms, generally result in a visit to an emergency department. This is often followed by hospital admission. While oral antibiotics can be given, intravenous antibiotic administration is often required (see NHS Guidelines).

In older males, diagnosis is easier because the boy or man can communicate the source of his pain. Of particular concern, however, is UTI in an elderly man, especially when he is in a nursing home and when the infection is associated with dementia. There are a number of reasons for this, not the least of which is the higher risk of complications in frail individuals.

There have been warnings recently that UTI is set to be caused increasingly by gram- negative bacilli resistant to conventional antibiotics.[7] Therefore, the emergence of “superbugs” increases the risk of UTI becoming a far more serious condition than it is at present. Even now, a UTI poses risks that require medical practitioners' attention and diligence to reduce the risk of complications.

The high lifetime risk of UTI documented by the recent meta-analysis forms an important component of risk-benefit analyses that have found half of all males will suffer an adverse medical condition during their lives, if left uncircumcised.[8, 9] Given new affirmative pediatric policies advocating infant male circumcision,[9, 10] the ability of infant male circumcision to reduce UTI treatment costs substantially,[11] and support for evidence-based decision making in clinical practice, good medical practice supports the promotion and practice of neonatal male circumcision as a simple, safe intervention with a lifetime of benefits. These benefits include prevention of deaths from genital cancers, whilst having no adverse impact on sexual function or pleasure.[8, 9, 10]

References:

  1. Morris BJ, Wiswell TE. Circumcision and lifetime risk of urinary tract infections: A systematic review and meta-analysis. J Urol 2013:189:2118-24.
  2. Simforoosh N, Tabibi A, Khalili SA, et al. Neonatal circumcision reduces the incidence of asymptomatic urinary tract infection: A large prospective study with long-term follow up using Plastibell. J Pediatr Urol 2012;8:320-3.
  3. Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev 2005;18:417-22.
  4. Kowalsky RH, Shah NB. Update on urinary tract infections in the emergency department. Curr Opin Pediatr 2013;25:317-22.
  5. Tebruegge M, Pantazidou A, Curtis N. Question 1. How common is co-existing meningitis in infants with urinary tract infection? Arch Dis Child 2011;96:602-6.
  6. Schnadower D, Kuppermann N, Macias CG, et al. Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics 2010;126:1074-83.
  7. Looke DFM, Thomas Gottlieb T, Jones CA, Paterson DL. Gram-negative resistance: can we combat the coming of a new “Red Plague”? Med J Aust 2013;198:243-4.
  8. Morris BJ, Waskett JH, Banerjee J, et al. A ‘snip’ in time: what is the best age to circumcise? BMC Pediatr 2012;12(article20):1-15.
  9. Morris BJ, Wodak AD, Mindel A, et al. Infant male circumcision: An evidence-based policy statement. Open J Prevent Med 2012;2:79-82.
  10. American AP. American Academy of Pediatrics. Circumcision policy statement. Task Force on Circumcision. Pediatrics 2012;130:e756-e85.
  11. Kacker S, Frick KD, Gaydos CA, Tobian AA. Costs and effectiveness of neonatal male circumcision. Arch Pediatr Adolesc Med 2012;166:910-8.

Written by:
Brian J. Morris, DSc, PhD, FAHA as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Professor, School of Medical Sciences, Building F13, Sydney Medical School, University of Sydney, NSW 2006, Australia. Email:

Circumcision and lifetime risk of urinary tract infection: A systematic review and meta-analysis - Abstract

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