Fujiwara Memorial Hospital
47 Tennoh Kamiegawa
13 December 1996
Dear Mr Falk,
Thank you for your letter of 23 November.
As an author of the article which you have read in the Journal of Urology, I reply to your question about the incidence of urinary tract infection among the subjects in the article. The statement that "no boy had a urinary tract infection" means that none had a symptomatic UTI, at least, at the time of examination. Though, there were no clinical evidence of UTI described in patient's records describing their clinical history, there remains the possibility of undiagnosed or subclinical UTI. One boy aged 2 years included in this study had UTI (non-bacterial acute cystitis) after the accomplishment of our study. The true incidence of urinary tract infection in a population is not easy to know. When I have a febrile child in our out patient clinic, I do not always order urinalysis. Pharyngitis, tonsillitis, bronchitis, pneumonia, colitis and generalized viral infection are the cause of fever in the majority of cases.
I believe that the incidence of UTI in boys is very low compared to those of URI or other infective disease, but there remains the possibility that some patients receive medication before accurate diagnosis of UTI is made. When I suspect UTI as a cause of fever, I observe urinary sediments obtained from spontaneously voided urine. I do not prefer invasive diagnostic procedure as catheterization of puncture of the urinary bladder which Dr. Wiswell described in his paper. One may criticize me that the diagnosis of UTI is inaccurate and its incidence may be underestimated. It is not a main purpose of our work to cal- culate the incidence of UTI nor to criticize the result of the paper by Dr. Wiswell. You should be aware of the difference of the age distribution of the subjects and of the method between the studies by Dr.Wiswell and me. It needs more strict study, dealing with a large number of subjects in the same social class, comparing the incidence of UTI between circumcised and uncircum- cised boys to criticize (or support) the results reported by Dr. Wiswell.
As a pediatric surgeon, I believe that all the children should be protected from unnecessary surgery. The controversy on circum- cision lasting for these decades in USA may be indicating that neonatal circumcision is not a scientific surgery but a cultural one. It is an enigma that USA, one of the most sophisticated countries criticizing some African people performing clitoridectomy to young girls, has many neonates whose prepuce are circumcised in hospitals. It will take a long time to break with a custom, and need long lasting activity of CIRP.
I would like to know the reason why the sculpture of David by Michelangelo (1475-1564) has no evidence of surgery on his prepuce. Please let me know if you have any information.
I hope that things are going well for CIRP.
Department of Pediatric Surgery
Fujiwara Memorial Hospital
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