Circumcision and urinary tract infection

This page indexes abstracts, full text articles, and other material about the relationship of circumcision status and the risk of contracting urinary tract infection (UTI).


Urinary tract infections (UTI) are a complication of circumcision. 1 38 40 63 They are bacterial infections of the urinary tract (kidneys, ureters, bladder and urethra). UTIs are usually associated with congenital abnormalities of the urinary tract.5 27 31 These infections can become serious if undetected, and may lead to permanent kidney damage. However, they are generally treated effectively with antibiotics.5,15

Studies have demonstrated that Escherichia coli (E. coli) bacteria, to which the infant has no passive immunity, can be colonized from the glans of circumcised infants and those infants whose foreskins have been forcibly retracted, tearing the protective synechia. Although E. coli is one of the most common bacteria on the surface of human skin, strains found in hospitals tend to be particularly virulent. In infant girls UTIs generally originate in the colon, whereas in infant boys they originate from the external environment, strongly suggesting that for boys such infections are iatrogenic.4 Premature retraction and circumcision expose boys to hospital strains of E. coli that can cause UTI.19

In order for the E. coli bacteria to bind to the glans penis of the infant, it needs an entry such as retraction of the adherent foreskin or circumcision.9 The intact boy has two physical lines of defense that his circumcised counterpart lacks: the preputial sphincter, which closes when a boy is not urinating; and a protected meatus (urinary opening), which is often inflamed and open in circumcised boys.9 In addition, the sub-preputial moisture contains lysosyme, which has an anti-bacterial action.47 Oligosaccharides excreted in the urine of breastfed babies prevent adhesion of pathogens to uroepithelial tissue.21

In the absence of a valid medical indication for circumcision, it would be unethical for physicians to perform it.29

The UTI Scare

Drs. Charles Ginsburg and George McCracken carried out a study of UTI in boys at Parkland Hospital in Dallas. They reported that 95 percent of the boys in their study were not circumcised.5 Parkland Hospital is a public hospital for indigent patients. Although it was not noticed at the time, the hospital did not perform non-therapeutic neonatal circumcisions,6 so most of its young male client population necessarily would have remained intact. The observation that 95 percent of the boys were not circumcised, therefore, signified nothing except that Parkland Hospital did not do unnecessary non-therapeutic circumcisions.

Thomas E. Wiswell, who was a U.S. Army pediatrician, read this study; he was impressed by Ginsburg and McCracken's erroneous observations about circumcision and UTI. In a determined search to show an association between lack-of-circumcision and UTI, Wiswell et al retrospectively examined charts of a number of boys born at U.S. military hospitals.7,11-13,17,25,39 Intact boys were reported to have a slightly higher rate of bacteriuria (bacteria in the urine) than circumcised boys during the first year of life.

Wiswell's sensational statistic, that circumcision resulted in a "ten to hundred times decrease in urinary tract infections in circumcised boys," has often been quoted; however, it is misleading. In fact, UTIs are so rare in any case that, using Wiswell's data, 50 to 100 healthy boys would have to be circumcised in order to prevent a UTI from developing in only one patient. (Using more recent data from a better-controlled study, the number of unnecessary operations needed to prevent one hospital admission for UTI would jump to 195.49)

Wiswell's findings generated a great deal of controversy at the time. The prepuce (foreskin) is a protective organ, and one would not normally expect the removal of a healthy organ to reduce the risk of infections.9 Nevertheless, the apparent correlation of intact foreskin to bacteriuria (and hence UTI) prompted the American Academy of Pediatrics (AAP) to review the evidence available in 1989.

Some points of fact:

A number of studies about post-circumcision UTIs, and the role of the surgery in possibly facilitating UTIs, were not able to recommend neonatal circumcision.23,24,26,37 Significantly, a number of recent Israeli studies have reported an increase in urinary tract infection rates in the period following ritual circumcision.10,38,40 62

In a prospective study, Kayaba et al. found a zero incidence of UTI in 603 intact boys, over a range of ages.41 Although this study did not focus on UTI, the Japanese researchers concluded: "Awareness of these findings will eliminate unnecessary circumcision in boys."

Moreover, studies show fairly conclusively that UTIs can be prevented far beyond the extent they are today. While hospital-borne strains of E. coli can attach to the glans and enter the urethra of circumcised boys and those whose foreskins have been retracted, infection can be resisted by certain measures to enhance the immunity of the infant to such pathogens:

Recently, Fleiss et al. reviewed the immunological functions of the prepuce.46 These functions suggest that the intact prepuce may offer protection against UTI if undisturbed.

Recurrent UTI. Some doctors recommend circumcision in cases of recurrent UTI. However, there is no medical evidence to support this recommendation. Recurrent UTIs are associated with congenital abnormalities of the upper urinary tract.5,15,28,32,35 McCracken recommends investigation with radiographic and/or sonography.5 In addition, a recent study of mice indicates that p-fimbriated Escherichia Coli, the organism responsible for about 85 percent of UTI, is capable of burrowing into the deeper tissue of the bladder48 or forming pods,56 thus hiding from antibiotics.48 Recurrent infections may actually be recurrence of the original infection, rather than a new infection ascending from the external genitals. If E. Coli behaves in a similar manner in humans, then circumcision would be of no benefit in preventing recurrence of these infections.

Congenital abnormalities of the urinary tract. The term vesicoureteral [ureterovesical] reflux refers to backflow of urine from the bladder to the ureters or kidneys. Ureteropelvic obstruction is a blockage or narrowing of part of the urinary tract. These kinds of congenital abnormalities are known to be the root cause of most UTI, as they may allow pathogens to flow upstream within the urinary tract. Obviously circumcision cannot prevent any such conditions. See Disorders of the Genitourinary Tract at Columbia University for more information.

Comparison of UTI incidence in boys and girls. A recent Scandinavian study found that girls and boys have about the same incidence of UTI in the first year of life. Girls have a four times higher incidence of UTI in the first six years of life than non-circumcised boys. No special concern is manifested regarding this much higher rate of infection in girls, yet surgery has not been proposed to reduce the incidence of UTI in girls.50

National Institutes of Health Recommendation

The National Kidney and Urologic Diseases Clearinghouse (NKUDIC), a service of the National Institutes of Health, maintains a comprehensive set of pages, listing the known causes of urinary tract infections in adults and children. NKUDIC does not suggest circumcision as a prevention or cure of urinary tract infection.

American Academy of Pediatrics Policy Changes

The American Academy of Pediatrics (AAP) has issued two statements which, when read together, constitute a substantial change in AAP policy toward the prevention of UTI in infants. First, in 1997, the AAP Workgroup on Breastfeeding recommended breastfeeding as highly beneficial in preventing a wide range of infections including UTI.45 Second, in 1999, The 1999 AAP Task Force on Circumcision abandoned the previous stance of the 1989 Task Force on Circumcision that circumcision may provide protection against UTI.53 The 1999 Task Force found that the bulk of the UTI studies were so methodologically flawed—by failing to control for confounding factors such as breastfeeding—that no meaningful conclusions could be drawn from them.53 The 1999 AAP Task Force on Circumcision could not, therefore, recommend circumcision to reduce incidence of UTI (or any other disease).

The 1999 AAP Task Force on Circumcision did, however, declare that breastfeeding produces a three fold reduction in UTI in infants. Two separate panels of the AAP, the Work Group on Breastfeeding and the 1999 Task Force on Circumcision, now recommend breastfeeding to reduce incidence of UTI.45,53 As Outerbridge points out, breastfeeding is very effective in reducing incidence of UTI in both boys and girls.46

The circumcision proponents now claim that circumcision is necessary to prevent UTI because UTI can cause renal failure.54 However, new evidence has disproved even that claim.52,54


The notion that circumcision is a useful prophylactic against disease has been laid to rest by the 1999 AAP Task Force on Circumcision.53 Instead, healthy, natural alternatives such as breastfeeding and rooming-in must be given favour. Breastfeeding offers a wide range of benefits for both mother and baby. Circumcision is surgery, and as such it has attendant risks. Furthermore, circumcision causes a great deal of pain, entails permanent loss of sexual function and sensation, which raises serious ethical questions concerning informed consent.32 Circumcision is not an operation to be performed lightly.


Library Holdings

Holdings are listed in the chronological order of publication

  1. Smith RM. Recent contributions to the study of pyelitis in infancy. Am J Dis Child 1916;XII:235-43.
  2. Littlewood JM. Infants with urinary tract infection in first month of life. Arch Dis Child 1972;47(252):218-26.
  3. Gothefors L, Olling S, Winberg J. Breast feeding and biological properties of faecal E. coli strains. Acta Paediatr Scand 1975;64(6):807-12.
  4. Maskell, R. et al. Urinary Pathogens in the Male. British Journal of Urology, (1975) vol.47.
  5. Ginsburg CM, McCracken GH. Urinary tract infections in young infants. Pediatrics 1982; 69:409-12.
  6. Wallerstein E. Circumcision: the uniquely American medical enigma. Urol Clin North Am 1985;12(1):123-132.
  7. Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985, 75: 901-903.
  8. Anderson GF, Smey P. Current concepts in the management of common urologic problems in infants and children. Pediatr Clin North Am 1985; 32:1133-47.
  9. Cunningham N. Circumcision and urinary tract infections. (letter) Pediatrics 1986; 77(2):267.
  10. Amir J. et al. Circumcision and Urinary Tract Infections in Infants. Am J Dis Child (1986), vol. 140, p. 1092.
  11. Wiswell TE. Circumcision and urinary tract infections. Pediatrics 1986; 77: 267-8.
  12. Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants. Pediatrics 1986;78:96-99.
  13. Wiswell TE, Enzenauer RW, Holton ME, Cornish JD, Hankins CT. Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy. Pediatrics 1987; 79: 338-42.
  14. Watson SJ. Care of uncircumcised penis. Pediatrics 1987;80(5):765.
  15. McCracken GH. Options in antimicrobial management of urinary tract infections in infants and children. Pediatr Infect Dis J 8(8), Aug 1989; 552-555.
  16. Herzog LW. Urinary tract infections and circumcision: a case-control study. Am J Dis Child 1989:143:348-50.
  17. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989;83:1011-5.
  18. Canadian Paediatric Society Supplemental Statement. Ottawa, 1989.
  19. Winberg J et al. The Prepuce: A Mistake of Nature? Lancet 1989, pp.598-99.
  20. Pisacane A, et al. Breastfeeding and urinary tract infection. The Lancet, July 7, 1990, p50.
  21. Mårild S. Breastfeeding and Urinary Tract Infections. Lancet 1990;336:942.
  22. Coppa JV et al. Preliminary Study of Breastfeeding and Bacterial Adhesion to Uroepithelial Cells. The Lancet 1990;335:569-571.
  23. Altschul MS. The circumcision controversy (editorial). Am Fam Physician 1990;41:817-820.
  24. Thompson RS: Does circumcision prevent urinary tract infection? An opposing view. J Fam Pract 1990; 31: 189-96.
  25. Wiswell TE. Routine neonatal circumcision: a reappraisal. Am Fam Physician 1990; 41: 859-63.
  26. Bollgren I, Winberg J. Letter. [Rebuttal of Edgar J. Schoen] Acta Paediatrica Scandinavia 1991; 80:575-7.
  27. Amato D, Garduno-Espinosa J. Circumcision of the newborn male and the risk of urinary tract infection during the first year: A meta-analysis. Bol Med Infant Mex Volume 49, Number 10, October 1992, 652-658.
  28. Craig JC et al. Effect of circumcision on incidence of urinary tract infection in preschool boys. From the Department of Nephrology, Royal Alexandra Hospital for Children, Sydney, Australia.
  29. American Academy of Pediatrics, Committee on Bioethics. Informed Consent, Parental Permission, and Assent in Pediatric Practice. Pediatrics 1995 Vol. 95 No. 2, February 1995.
  30. Chaban C et al. Urinary tract infection in childhood. Infect Urol 8(4), 111, 114-120, 1995.
  31. Schlager TA, Hendley JO, Dudley SM, Hayden GF, Lohr JA. Explanation for false-positive urine cultures obtained by bag technique. Arch Pediatr Adolesc Med 1995;149:170-3.
  32. Mueller ER, Steinhardt G, Naseer S. The incidence of genitourinary abnormalities in circumcised and uncircumcised boys presenting with an initial urinary tract infection by 6 months of age. Pediatrics, September 1997, Vol. 100, page 580 (supplement)
  33. Saez-Llorens X. et al. Bacterial contamination rates for non-clean-catch and clean-catch midstream urine collections in uncircumcised boys. From the Department of Pediatrics. Hospital Nacional de Ninos, San Jose, Costa Rica, and the Department of Pediatrics, the Children's Medical Center of the University of Virginia, Charlottesville VA.
  34. O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. Southern Medical Journal 1995;88:411-5.
  35. Van Howe RS. To the Editor, Southern Medical Journal (unpublished).
  36. Pisacane A, Graziano L, Mazzarella G, et al. Breast-feeding and urinary tract infection. J Pediatr 1992;120:87-89.
  37. Chessare JB. Circumcision: Is the Risk of Urinary Tract Infection Really the Pivotal Issue? Clinical Pediatrics 31(2):100-4, Feb. 1992. Department of Pediatrics, Medical College of Ohio, Toledo 43699.
  38. Cohen, H. et al. Postcircumcision Urinary Tract Infection. Clinical Pediatrics (1992), pp. 322-4.
  39. Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an update. Clin Pediatr (Phila) 1993; 32: 130-4.
  40. Goldman M, Barr J, Bistritzer T, Aladjem M. Urinary tract infection following ritual jewish circumcision. Israel Journal of Medical Sciences 1996;32(11),1098-102.
  41. Kayaba H et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol, 1996 Nov, V156 N5:1813-5.
  42. Editorial. British Journal of Urology 77, June 1996, p. 924.
  43. See for instance Fleiss P. The case against circumcision. Mothering, Winter 1997, pp. 36-45.
  44. To T, Agha M, Dick PT. et al. A cohort study on male neonatal circumcision and the subsequent risk of urinary tract infection. Paediatr Child Health 1997;2 suppl. A: 55A.
  45. AAP Workgroup on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100(6)1035-1039.
  46. Outerbridge EW. Decreasing the risk of urinary tract infections. (Letter). Paediatr Child Health 1998; 3(1):19.
  47. Fleiss PM, Hodges FM, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998: 364-367.
  48. Berger A. Burrowing bacteria may explain recurrent urinary tract infections. BMJ 1998;317:1473 (Link to
  49. To T, Agha M, Dick PT, et al. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet 1998;352:1813-16.
  50. Urinary tract infections in children. Healthtouch Online.
  51. Mårild S, Jodal U. Incidence rate of first-time symptomatic urinary tract infection in children under 6 years of age. Acta Paediatr 1998;87(5):549-52.
  52. Sreenarasimhaiah S, Hellerstein S. Urinary tract infections per se do not cause end-stage kidney disease. Pediatr Nephrol 1998;12(3):210-3.
  53. AAP Task Force on Circumcision. Circumcision Policy Statement. Pediatrics 1999;103(3):686-693.
  54. Lane W, Robson M, Van Howe RS. Circumcisions: Again. Pediatrics 2001;108(2):522.
  55. Newman TB. Circumcisions: Again. Pediatrics 2001;108(2):522-523.
  56. Anderson GG, Palermo JJ, Schilling JD, et al. Intracellular bacterial biofilm-like pods in urinary tract infections. Science 2003; 301(5629):105-7.
  57. Justice SS, Hung C, Theirot JA, Fletcher DA, Anderson GG, Footer MJ, Hultgren SJ. Differentiation and developmental pathways of uropathogenic Escheria coli in urinary tract pathogenesis. Proceedings of the National Academy of Sciences, early online edition, week of Jan. 19-23, 2004.
  58. Mårild S, Hansson S, Jodal U, Oden A, Svedberg K. Protective effect of breastfeeding against urinary tract infection. Acta Paediatr 2004;93(2):164-8.
  59. Hanson LÅ. Protective effects of breastfeeding against urinary tract infection. Acta Paediatr Scand 2004;93(2);154-6.
  60. Kwak C, Oh SJ, Lee A, Choi H. Effect of circumcision on urinary tract infection after successful antireflux surgery. BJU Int 2004;94(4):627-9.
  61. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomized trials and observational studies. Arch Dis Child 2005;90:853-8.
  62. Van Howe RS. Effect of confounding in the association between circumcision status and urinary tract infection. J Infect 2005;51(1):59-68.
  63. Prais D. Shoov-Furman R, Amir J. Is circumcision a risk factor for neonatal urinary tract infections? Arch Dis Child Published Online First: 6 October 2008. doi:10.1136/adc.2008.144063 [Abstract]

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(Last revised: 2 February 2009)