Can’t you just take antibiotics? Circumcision and UTIs.

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.


6 responses to “Can’t you just take antibiotics? Circumcision and UTIs.

  • Bill Jordan

    Most UTIs in infants (85% is one figure) involves E-coli which is associated with feces. Wearing wet or dirty nappies increase UTIs. Nappy free time reduces UTIs. Breast feeding and teaching infants not to hold on can reduce the chances.

    Genetic abnormalities can increase the odds. If you sincerely want to reduce UTIs in infants, all these things and more need to be explored.

  • bilfus01

    You’re doing really good work here. I think it is imperative that any movement of group of people police their own rhetoric. One thing that is hard to convey about this kind of data regarding the prepuce and UTI’s is that am I the only one that can’t figure out why an intact penis is considered a “risk factor.” That is the kind of stuff that can’t be argued with studies, since this seems like more of a cultural implication. I can’t think of any other instance where normal healthy tissue is considered a risk factor. Even for healthy tissues that represent a much higher chance of future harm or conferred benefit. I am trying hard to combat this kind of language manipulation, but at this point, finding out how to combat this kind of stuff is extremely hard and usually lends itself to anecdotal or ad hominen attacks. I think this is where some intactivists have lost their way. Some of these studies rely on cultural assumptions, and are taken at face value. Yet, there are other studies that rely on assumptions touting the value of an anatomically correct penis that are usually ignored. There are some things that can be argued prima facie, yet intactivists are belittled for using them. I am not trying to excuse the behavior of people who go to extremes or who dismiss scientific studies that don’t agree with their viewpoint, but I am also trying to highlight the absurdity of the contours of the whole circ debate. For instance, couldn’t a prima facie case be made that based on the histological data we do have on the prepuce that its removal results in less nerves at the very least results in different if not lessened sensation? I understand the subjectivity of sensation and sensitivity, but can one not argue without a mountain of data that altering/removing part of the nerve and vascular system of the penis will indeed -on it’s face- alter the type of sensations the penis is able to feel and possibly how sensitive the penis is to those sensations? Long story short, I think that intactivists get a raw deal sometimes because due to our culture in the U.S., we are forced to defend and prove basic anatomical knowledge and basic principals of tissue excision and the harm and/or risks involved. I get tired of hearing the phrase “no causal link” only applied to studies that refute the benefits of circumcision. Who’s to say that the reduced incidence of UTI in circumcised males is due to the antiseptics applied pre-op and post-op to the neonate penis?

  • Nathan k

    Speaking as a circumcised male who was circumcised at birth I argue is quality of life not an important aspect to consider when making decisions about the long term health of a person? To most males, sexual pleasure and function is on an equal footing with being alive. I argue that the benefits preventing uti’s does not outweigh the psychological and neurological cost of permenant gentital mutilation.

  • Dreamer

    “This benefit seems to raise a lot of questions for anti-circumcision advocates” – Actually not only for anti-circumcision advocates, but also for some other medical organizations. The Royal Dutch Medical Association in their 2010 Viewpoint on Non Therapeutic Circumcision of Male Minors states: “Further, there is apparent evidence that circumcision offers protection against complaints such as HPV infection, urinary tract infections and penis cancer. However, these studies, too, are controversial.16 Moreover, urinary tract infections can be successfully treated with modern healthcare. Children with inborn abnormalities to the urinary tract can generally be successfully helped by a foreskin-widening operation, which makes the foreskin easier to clean.” “In response to the possible medical benefits, a large number of complications resulting from circumcision are described: infections, bleeding, sepsis, necrosis, fibrosis of the skin, urinary tract infections, meningitis, herpes infections, meatisis, meatal stenosis, necrosis and necrotising complications, all of which have led to the complete amputation of the penis.17 Deaths have also been reported.18 The AAFP estimates the number of deaths as 1 in 500,000.19 That would mean that in the United States, two children die each year as a result of the intervention.” “Alongside these direct medical complications, psychological problems20 and complications in the area of sexuality have also been reported,21 as have extreme pain experiences in newborns causing behavioural changes which are still apparent years later.22 23 Similarly, the high social costs of circumcision as a result of complications have been cited.24 Even if there were slight medical benefits connected with circumcision for medical preventative reasons, it is questionable whether these possible medical benefits would compensate for the risk of complications. Certainly when it comes to children, who cannot make this assessment themselves, the possible medical benefits should be significant and the risk of complications small for the intervention to be justifiable.” “It is a generally accepted moral principle that children may only be exposed to medical treatments if illness or abnormalities are present, or if it can be demonstrated that the medical intervention is in the interest of the child, as is the case for vaccinations, for example. In the case of preventative medical interventions, there needs to be a clear individual or public health benefit which cannot be achieved in another, less intrusive way.” “Thus circumcision as a preventative against urinary tract infections or HIV/AIDS would need to be weighed against other, less intrusive forms of prevention (such as antibiotics, condom use, sex education or behavioural changes) and a scientific cost/benefit analysis made. Only if the results of this cost/benefit analysis were positive should the intervention be offered to all parents of small boys on public health grounds.” http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm So yes, this point is not only debated by activists, but it’s also debated by other medical organizations.

    • paper0airplane

      The fact that its debated by other medical organizations does NOT mean, however, that it should simply be dismissed. Often many intactivists seem to miss that distinction. UTIs in male infants are serious and can be very harmful. I think this means in certain cases, the prophylaxis shouldn’t be dismissed off hand. I don’t think that means that every boy should be circumcised for this reason, but I also don’t believe that it’s an unreasonable thing to consider when parents make the choice.

      Your comments are going to spam, by the way. That’s why they spend so long in moderation.

      Also ‘truthful mother’ might have more to say on this I’m not sure. But I don’t believe she is truth’s master in any realm :).

    • veritasmater

      You’re right that the risk/benefit analysis of circumcision is hotly debated in the scientific community. I agree that there is controversy and that different people may weigh the evidence and come to very different conclusions. My post didn’t mean to be arguing that the benefits of protection against UTI are so overwhelming that they override any other consideration, but simply to correct the common argument that UTIs are unimportant, rare and can be easily treated. They are relatively rare, but not extremely rare, and in the neonatal period are very serious indeed.

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