One of the most well grounded benefits of neonatal circumcision is a 90% reduction in the incidence of urinary tract infection (UTI) in boys in the first year of life. This benefit seems to raise a lot of questions for anti-circumcision advocates. One example can be seen in this response to the new AAP guidelines,
The AAP report inflates the benefits by stating in its summary, for example, that circumcision “prevents” urinary tract infection (UTI). The report text states, “Given that the risk of UTI among this population [boys under age 2] is approximately 1%, the number needed to circumcise to prevent UTI is approximately 100.” Therefore, 99 boys out of 100 receive no UTI “benefit” from circumcision. UTI is treatable with antibiotics. Good medical practice requires the least intrusive form of effective treatment. All the claimed “preventive health benefits” are debatable and insignificant.
There are numerous other arguments made against circumcision to prevent infection, one common claim is that that UTIs are “several times commoner” in girls, yet we aren’t considering surgical alteration to prevent their rate of infection. Sometimes the grounds for the claim in reduction itself are challenged, although this has become less frequent as the claims have become better and better supported by evidence. Do these arguments undermine this benefit?
The first thing to establish is what exactly we are talking about when we speak of a UTI in an infant boy. A UTI in an infant is a very different beast to a bladder infection in an older child or adult. The primary symptoms are not burning pain and discomfort, but instead a prolonged fever and irritability with no other obvious cause. The majority of UTIs in infancy involve the upper urinary tract, the kidneys, and not merely the bladder as is more common in older children and adults. It poses the very real risks of kidney damage or the development of sepsis, a blood infection, although these have become less common as better antibiotics have been developed. Mortality was once a real danger from a UTI in infancy although this is now extremely rare. While antibiotics are an essential part of the treatment of such a urinary tract infection, treatment is not as easy as going and taking an oral medication. Hospitalization and the use of IV antibiotics are common and unfortunately antibiotic resistance is becoming common among the pathogens in these UTIs. Even if response to the antibiotics is good, imaging follow up to look for urinary tract abnormalities and damage will often be necessary.
Contrary to the repeated claims that UTI is more common in girls, in early infancy it is in fact several times more likely in an uncircumcised boy than in a girl. This early period, under three months or so, is also the time of greatest risk overall for a febrile UTI. Within a few months, the prevalence of UTI in an uncircumcised boy is equal to that in girls, and soon the risk in girls surpasses the risk in boys. The most prevalent form of UTI also changes, as bladder infections become more common than the more serious kidney infections that are seen in early infancy.
Studies consistently show that circumcision reduces the risk of UTI significantly, with an overall reduction in risk of nearly 90%. Considering that what is being prevented is a serious infection and not a minor issue, is this alone sufficient reason to circumcise? A recent review determined that it would require 111 circumcisions to prevent one urinary tract infection, and assuming that the complications of circumcision are about 2%, concluded that this wasn’t sufficient to recommend routine circumcision. However, for certain subpopulations at greater risk of infection, the benefits would more clearly outweigh the risks. Moreover, if any of their assumptions about the complication rate of circumcision or the severity of the morbidity associate with UTI or circumcision were wrong, the numbers needed to treat might be quite different. The review didn’t consider any other potential benefits of circumcision besides the risk of UTI, so this might be only one piece to consider when making this decision.