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Is routine circumcision advised in boys with obstructive uropathy in order to prevent urinary tract infection?

Uncircumcised males run a 10 times higher risk of getting early infantile symptomatic urinary tract infection (UTI) than circumcised ones [1]. these figures have been used to advocate circumcision of all newborns. However, this is not a biological approach to a biological problem [2]. There is also an ethical aspect to this question: is it justifiable to operate on 100 babies to prevent infection in 1, and is it justifiable to operate on 1000 babies to prevent renal scarring in 1 or 2 (assuming that 1/5 or 1/10 of those infected will develop a scar)?

The situation is different in babies at high risk of infection and severe renal damage, i.e. those with low obstructions such as urethral valves or ureterocele or with grade IV - V vesico-ureteral reflux, especially when associated with intrarenal reflux. These conditions are now diagnosed with increasing frequency as a consequence of antenatal ultrasound examinations of the babies with dilatation of the upper urinary tract.

The abundant Escherichia coli colonization of the prepuce, encouraged by bacterial adhesion to its inside [3], is associated with increased risk of urethral E.coli colonization [1], and from there ascent of uropathogenic strains to the urinary tract. This might in this selected group of patients constitute a sizeable risk. Since extirpation of the prepuce breaks an important link in the chain of events leading to UTI, I feel that it would be worth while to consider circumcision in these instances. If this could be done as a controlled multi-centre study we might avoid all the mistakes and ill-supported statements, which have lined our attempts to prevent UTI and scarring.

There is still another ethical aspect. When mass circumcision is applied, caution or even reluctance to use anaesthesia has been advocated -- the risks (and costs?) would be too big [4]. If circumcision is used in a few selected cases, as suggested above, appropriate pain relief can be given. Thus the human right not to be subjected to unnecessary pain will be recognized and defended also in the newborn, who as a matter of fact reacts more intensively [sic] to painful stimuli than do other age groups [5,6].

Jan Winberg
Department of Paediatrics
Karolinska Hospital
Stockholm, Sweden

References

  1. Wiswell TE, Miller GM, Gelston HM, Jones SK, Clemmings AF (1988) Effect of circumcision status on periurethral bacterial flora during the first year of life. J Pediatr 113: 442-446
  2. Winberg J, Bollgren I, Gothefors L, Herthelius M, Tullus K (1989) The prepuce: a mistake of Nature? Lancet I: 598-599
  3. Fussell EN, Kaack B, Cherry R, Roberts JA (1988) Adherence of bacteria to human foreskins. J Urol 140: 997-1001
  4. Schoen EJ (1990) Sounding board. The status of circumcision of newborns. N Engl J Med 322: 1308-1312
  5. Fitzgerald M, Millard C, McIntosh N (1989) Cutaneous hypersensitivity following peripheral tissue damage in newborn infants and its reversal with topical anaesthesia. Pain 39: 31-36
  6. Fitzgerald M, McIntosh N (1989) Pain and analgesia in the newborn. Arch dis Child 64: 441-443