Being uncircumcised - not foreskin tightness - key risk for urinary infection

TORONTO -- Urinary tract infections are far more common in uncircumcised boys than in their circumcised counterparts, but whether their foreskin is tight or more retractable makes no difference in how prone they are to becoming infected, a study suggests.

Data has shown that uncircumcised boys have a 10-fold higher risk of getting a urinary tract infection (UTI), compared to those who have had their foreskins removed.

Some previous research has suggested that the increased risk might not be related only to a boy being uncircumcised, but also to whether his foreskin is tight or more retractable. A new study, led by Montreal's Dr. Sasha Dubrovsky, set out to find out if there is any correlation.

The study found the risk of getting a urinary tract infection was pretty much equal among uncircumcised boys, no matter the state of their foreskin, said Dubrovsky, a pediatrician at Montreal Children's Hospital.

"So whether they had a tight foreskin or not a tight foreskin, it didn't change that risk."

The issue is of particular importance for doctors when diagnosing children brought to the emergency department with symptoms of a possible UTI, one of the most common and serious bacterial infections in children, say the authors, whose study was published Monday in the Canadian Medical Association Journal.

"The interesting part of the article is that many of us were under the misconception that it was the covered penis, and primarily the urethra, that was responsible for infant males' urinary tract infections," said Dr. Martin Koyle, a pediatric urologist at Toronto's Hospital for Sick Children.

"And we thought that once the foreskin retracted, that risk was no longer there. This article seems to refute that."

If left untreated, UTIs can cause a potentially fatal infection of the blood; repeated untreated infections over time can leave the kidneys scarred, potentially leading to renal failure in adulthood.

When young children are brought to the ER with persistent fever, doctors must consider whether they are dealing with a cold or other virus that will likely run its course or a potentially serious bacterial infection requiring treatment, Dubrovsky said from Montreal.

"And nowadays, in the post-vaccine era, the most common serious bacterial infection is the urinary tract infection," he said. "So we'd like to have some methods of figuring out who is that high-risk kid when we're seeing them."

There are a number of guidelines on how to stratify the risk, among them circumcision status, Dubrovsky said.

"Our study just confirms that it is uncircumcised, period, not uncircumcised boys with a tight foreskin. So one does not need to consider the retractability of the foreskin or how tight it is. That has no bearing on it."

He said uncircumcised boys are more prone to UTIs because the bacteria that cause them tend to stick to area and multiply, especially when children are in diapers that hold in heat and moisture.

"The kids who do get urinary tract infections, it's not a question of cleanliness versus not cleanliness. It's a part of life, it's just one of those things that happen," he said, offering this advice to parents of uncircumcised boys:

"You give them their bath, you don't need to retract anything, pull anything. Nothing should ever hurt when washing that area. And people need to be aware that it is normal for the foreskin to be tight when they're very young children, and as they get older, into the three or four years of age, that's when they start to get more retractable.

"So to be aware of that and not to think that there's a problem with their very normal child."

Koyle said it's considered normal for the foreskin to cover the head of the penis for at least the first four years of life.

The foreskin is naturally tight at birth -- less than 10 per cent of newborns have movable foreskins -- but by age four, more than 90 per cent of boys' foreskins are retractable, he said.

To conduct the study, researchers compared infection rates in 393 boys, ranging in age from one to 18 months old, who visited an emergency department with symptoms of a possible UTI. Of the 393 boys, 309 were uncircumcised and had various degrees of foreskin tightness; 84 were circumcised.

One-fifth of all the subjects were diagnosed with a UTI; only one circumcised boy was admitted to hospital for the infection, compared with 26 -- or 8.4 per cent -- of uncircumcised youngsters.

But Dubrovsky cautioned that parents should not base a decision on whether to circumcise their infant -- an issue that remains controversial for many people -- on the study's findings.

"I wouldn't draw any conclusions on routine neonatal circumcision for the prevention of urinary tract infections," he said. "Our study didn't look at any of those issues.

"Our study has a very specific group of patients who have symptoms of urinary tract infection, so it's not generalizable to the general public to guide a decision on whether to circumcise or not circumcise."

Based on reviews of scientific evidence both for and against the surgery, the Canadian Paediatric Society does not recommend routine circumcision for newborn boys. The CPS advises parents considering the surgery for religious, social or cultural reasons to speak to their doctors about its medical risks and benefits.

Koyle said the American Academy of Pediatrics' policy mirrors that of its Canadian counterpart. However, the AAP position is under review and could be revised, based on studies showing that circumcised males have a markedly lower risk of contracting HIV or other sexually transmitted infections.