THE CIRCUMCISION REFERENCE LIBRARY
Elizabeth R. Mueller, M.S.M.E.,
George Steinhardt M.D., F.A.A.P.,
Shahida Naseer M.D., F.A.A.P.,
Department of Surgery, Department of Pediatrics,
Saint Louis University School of Medicine,
St. Louis, Missouri.
Background: Numerous studies have implicated the presence of a foreskin as the major determinant of urinary tract infection (UTI) in newborn males. In the largest series of studies the contribution of underlying genitourinary (GU) structural abnormalities was not investigated. We report the results of an eight year prospective study examining the incidence of GU abnormalities in circumcised and uncircumcised boys who present with their first UTI by six months of age.
Methods: All male infants referred to our service with evidence of UTI were examined. Only infants less than or equal to six months of age with documented positive urine cultures were placed into the study. We categorized each infant by circumcision status, presenting symptoms, and race. The diagnosis of pyelonephritis was established on clinical grounds which required the presence of systemic complaints such as fever, lethargy, leukocytosis, and vomiting. All infants were evaluated with a renal ultrasound and voiding cystourethrogram. Genitourinary abnormalities were determined by the radiologic staff. Data were analyzed for statistical significance with χ2 analysis. P <.05 was considered to be significant.
Results: Complete information was obtained on 108 boys. Fifty-two of the boys were circumcised and had a presenting age of 2.4 ± 1.7 months (mean ± S.D.). Fifty-six of the boys were uncircumcised and presented at age 2.2 ± 1.6 months. The circumcision distribution by race were identical. Of the patients reviewed, 78.7% were Caucasians, 16.7% African Americans and 4.6% were Asian and Hispanic combined. Clinical pyelonephritis as opposed to uncomplicated UTI occurred in 67% of the boys, regardless of circumcision status. Twenty-six of the 108 boys had normal GU anatomy of which 46% were circumcised and 54% were uncircumcised. Abnormal anatomy was demonstrated in 76.9% of the circumcised boys and 75% of the uncircumcised boys. There was no statistical difference between the two groups. A breakdown of the anatomical abnormalities are shown in the following table.
_____________________________________________________ GU Abnormality Frequency (% of total) Reflux 70.0% Obstruction 21.0% Triad 4.0% Valves 3.0% Bladder Diverticulum 2.0% _____________________________________________________
Conclusion: Regardless of circumcision status, infants who present with their first UTI at 6 months or less are likely to have an underlying GU abnormality. In the remaining patients with normal underlying anatomy and UTI we found as many circumcised infants as those who retained their foreskin. Male infants presenting prior to 6 months of age with UTI should be examined for contributing anatomical abnormalities.
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