Jezebel, May 19, 2009

Bubble baths

One significant cause of chronic UTIs in girls, that has never been acknowledged in boys, is bubble baths, especially low-cost brands such as "Mr Bubble". In 1987, the FDA required that all children's bubble bath products carry a warning label about the risk of irritation to the skin and urinary tract from prolonged exposure. In March 2009, Mr. Bubble introduced a new "pediatrician approved" formula.

Pediatrics. 1989 Jun;83(6):1011-5.

Risks from circumcision during the first month of life compared with those for uncircumcised boys.

Wiswell TE, Geschke DW.

Abstract

The records of 136,086 boys born in US Army hospitals from 1980 to 1985 were reviewed for indexed complications related to circumcision status during the first month of life. For 100,157 circumcised boys, there were 193 complications (0.19%). These included 62 local infections, eight cases of bacteremia, 83 incidences of hemorrhage (31 requiring ligature and three requiring transfusion), 25 instances of surgical trauma, and 20 urinary tract infections. There were no deaths or reported losses of the glans or entire penis. By contrast, the complications in the 35,929 uncircumcised infants were all related to urinary tract infections. Of the 88 boys with such infections (0.24%), 32 had concomitant bacteremia, three had meningitis, two had renal failure, and two died. The frequencies of urinary tract infection (P less than .0001) and bacteremia (P less than .0002) were significantly higher in the uncircumcised boys. [It goes without saying that the frequencies of local infections, haemorrhage and surgical trauma {how serious?} were infinitely higher in the circumcised boys.] Serious complications from routine prepuce removal are rare and relatively minor. Circumcision may be beneficial in reducing the occurrence of urinary tract infections and their associated sequelae.

20 out of of 100,157 (0.02%) circumcised boys got UTIs, compared with 88 out of 35,929 (0.244%) intact boys. If circumcising the 35,929 boys would have reduced the incidence from 0.244% to 0.02% (7 boys), the Number Needed to Treat is 35,929/(88-7) = 444 circumcisions to prevent one UTI.

The study evaluated charts of boys born at Army hospitals worldwide and looked at those who had urine cultures and whether they were circuncised or not. Wiswell, an Army neonatologist, decided that circumcised boys had fewer UTIs based on the greater number of positive cultures. In fact, the only variable was whether the boys were catheterised, since the circumcised boys' urine was obtained by clean catch bags, while the intact boys' urine was from catheterisation, thus growing whatever bacteria were hiding under the foreskin or on the skin of the glans itself - in other words, cultures were positive for harmless bacteria which were not causing infection, but were simply present, as they are on all of us. The cultures were irrelevant, but this started the whole claim that circumcision prevents UTI.

Prevalence of urinary symptoms in urban Australian men aged 40-69

J Epidemiol Biostat 2001;6(2):211-8 (ISSN: 1359-5229)
McCredie M; Staples M; Johnson W; English DR; Giles GG
Department of Preventive and Social Medicine, Dunedin Medical School, University of Otago, New Zealand.

BACKGROUND: This study was devised to determine the prevalence of urinary symptoms among men living in the Australian cities of Melbourne, Sydney or Perth, and to identify factors associated with the presence of moderate-to-severe urinary symptoms.

METHODS: The study comprised a population-based sample of 1,216 men, aged 40-69 years, whose names were obtained through electoral rolls and who participated as controls in a case-control study of risk factors for prostate cancer. As part of a structured face-to-face interview, the men completed the International Prostate Symptom Score (IPSS). Men with moderate (IPSS = 8-19) or severe (IPSS > or = 20) urinary symptoms were compared with those with mild or no symptoms (IPSS < 8) using unconditional logistic regression.

RESULTS: The age-specific prevalence of moderate-to-severe urinary symptoms (IPSS > or = 8) in men aged 40-49, 50-59, 60-69 years was 16%, 23% and 28%, respectively. Compared with men with no or mild urinary symptoms (IPSS < 8), men with moderate-to-severe symptoms were more likely to report not currently living as married [odds ratio (OR) = 1.5; 95% confidence interval (CI) 1.1-2.0] and being circumcised (OR = 1.5; 95% Cl 1.2-2.0). The increased likelihood associated with drinking an average of > 60g per day of alcohol in the 2 years before interview was of marginal statistical significance (OR = 1.6; 1.0-2.6). There were no significant differences between men with IPSS > or = 8 and those with IPSS < 8 with respect to body mass index, education level, having had a vasectomy, or cigarette smoking.

CONCLUSION: Among Australian men, being circumcised, or not currently living as married, were associated with increased prevalence of urinary symptoms.

A[rchives of]Diseases of ]C[hildren] Online
September, 2008

Is ritual circumcision a risk factor for neonatal urinary tract infections?

Dario Prais, Rachel Shoov-Furman and Jacob Amir

Schneider Children's Medical Center of Israel, Israel

Objective: Although circumcision is commonly believed to protect against urinary tract infection (UTI), it is not unusual in neonates in Israel, where almost all male infants are circumcised. The aim of the study was to evaluate the burden of neonatal UTI in Israel and its relationship to circumcision.

Design: Medical records of neonates (?T2 months old) hospitalized with UTI were reviewed and demographic and clinical data were collected. The second part of the study consisting of a telephone survey to assess timing and details concerning the circumcision, included two groups: the study group consisting of parents of male infants, aged 8-30 days, hospitalized with UTI and a control group consisting of healthy neonates.

Results: 162 neonates (108 males, 54 females) were hospitalized with UTI. Mean age at admission was significantly lower in males (27.5 vs 37.7 days, p=0.0002). The incidence of UTI in males peaked at 2-4 weeks of age, i.e. the period immediately following circumcision. In females, the incidence tended to rise with age. Accordingly, male predominance disappeared at 7 weeks and the male-to-female ratio reversed. In the second part of the study, 111 males (?T1 month old) were included: 48 post-UTI and 63 as a control group. While evaluating the impact of circumcision technique, we found that UTI occurred in 6 of the 24 infants circumcised by a physician (25%), and in 42 of the 87 infants (48%) circumcised by a religious authority; the calculated odds ratio for contracting UTI was 2.8 (95% CI: 1-9.4).

Conclusions: There was a higher preponderance of UTI among male neonates. Its incidence peaked during the early post-circumcision period, as opposed to the age-related rise in females. UTI seems to occur more frequently after traditional circumcision than after physician performed circumcision. We speculate that changes in the hemostasis technique or shortening the duration of the shaft wrapping might decrease the rate of infection after Jewish ritual circumcision.

[Conclusion: Not circumcising would decrease the rate of Unrinary Tract Infection.]

BJU Int. 2004 Sep;94(4):627-9.

Effect of circumcision on urinary tract infection after successful antireflux surgery.

Kwak C, Oh SJ, Lee A, Choi H.

Abstract

OBJECTIVE:
To evaluate whether circumcision during antireflux surgery can reduce the incidence of urinary tract infection (UTI) after successful ureteric reimplantation in patients with primary vesico-ureteric reflux (VUR).

PATIENTS AND METHODS:
Children who had undergone antireflux surgery for primary VUR were divided into group 1 (27, circumcised at the time of antireflux surgery at the parents' request) and group 2 (50, those not circumcised). All antireflux operations were by the Cohen method. Regular urine samples were cultured to detect UTI, which was defined as a single species with >10(5) colony-forming units/mL in a midstream voided specimen. Numbers of UTI episodes before and after surgery were compared between the groups, with (99m)Tc-dimercaptosuccinic acid (DMSA) renal scans also taken in all patients. Each scan was blindly reviewed in terms of the size, number and zonal location of cortical defects, based on morphology. Interval changes were categorised as improved, no change, progressed, and new scar formation, and compared between the groups. Prophylactic antibiotics were maintained until the follow-up studies at 4-6 months after surgery.

RESULTS:
There was no significant difference between the groups in age at the time of operation (mean 42.4 vs 47.4 months), the age at the first documented UTI (mean 26.5 vs 29.3 months), reflux grade, or number of UTI episodes and renal parenchymal scarring on DMSA before surgery. There was no significant difference between the groups in the number of UTI episodes at a mean (range) follow-up of 151.3 (114-207) months after antireflux surgery. Also there was no significant morphological change on follow-up renal scans and no difference between the groups.

CONCLUSION:<.br>These findings suggest that circumcision during antireflux surgery has no effect on the incidence of postoperative UTI.

A statistician comments:

It is not possible to evaluate whether a treatment is worthwhile based on its Relative Risk Reduction. While a 90% reduction may sound impressive, 90% of a tiny amount is an even tinier amount. The Number Needed to Treat (NNT) is a much better indicator, because it makes it possible to compare the cost of the treatment with the benefit of the treatment.

The lower the incidence of a condition, the higher the NNT required to prevent that condition. Because the incidence of UTI is low, the NNT will be high irrespective of the relative risk reduction of the treatment. Even when the relative risk reduction is 90% the NNT is very high. The lower the relative risk reduction, the higher the NNT (and when the relative risk reduction is zero, even an infinite number of treatments will not prevent a UTI).

Even though we are not given either

• the circumcision status of 32 of the 68 boys with a UTI, or
• among the young males in the general population to which the subjects belonged

we can calculate NNTs for various values of these variables.

Of the 68 boys, we know that 26 were intact and 10 were circumcised, so the total number of intact boys must be between 26 and 58. If the circumcision statuses of an intact boy and a circumcised boy were equally likely to have been noted, then 49 of the 68 boys with a UTI were intact. However, where the circumcision rate is very high, it is plausible that intact status would be considered more noteworthy than circumcised status and thus more likely to have been noted, in which case the intact:circumcised ratio among the 68 boys with UTIs would be lower than the 26:10 ratio among the 36 boys whose statuses were noted.

It seems likely that the children in the study came from Ohio, Pennsylvania and one other (possibly adjoining) state in which the circumcision rates are very high.

A number of US studies have observed that UTI incidence among circumcised boys was lower than that among intact boys. They have failed to establish whether that is because circumcision reduced the incidence, or because improper care of the intact penis in the US elevates the incidence in intact boys (or both, or neither). Whatever the cause, conventional wisdom has it that the incidence is about 90% lower in circumcised boys.

Based on the data in the Conway study, it can be calculated that

• if circumcision reduces UTI incidence by 90%, and
• if the circumcision rate of young boys in the general population to which the study subjects belonged is in the range 78% to 87.5%,

then

• it probably requires between 133 and 186 circumcisions to prevent a single UTI (almost always successfully treatable with antibiotics) and
• it requires between 600 and 1,577 circumcisions to prevent a recurrent UTI.

It is possible that a large number of UTIs in intact boys in the US are caused by improper care of the intact penis, i.e., that the difference, if any, between the UTI incidence in intact boys and circumcised boys would be much smaller than has been observed in US studies if physicians and parents knew how to care for the intact penis. If we assume that 50% of the UTIs observed in intact males in the study were caused by improper care, and, if circumcision reduces UTI incidence by 80%, we can calculate that

• it probably requires somewhere between 300 and 417 circumcisions to prevent a single UTI and
• it requires between 1,200 and 3,548 circumcisions to prevent a recurrent UTI.

If this is the case, and if one costs a circumcision at $300 (and ignores the cost of re-circumcisions, treatment of complications and any consideration of long-term damage), it costs

• of the order of $100,000 to prevent a single UTI (which can be treated by a ~$20 course of antibiotics), and
• $300,000 to $1,000,000 to prevent a recurrent UTI.

The UTI incidence among young girls in the study was 1.48%, while the highest credible UTI incidence among intact young boys was 0.83% -- i.e., the rate anong girls was at least 78% higher than the rate among intact boys -- hardly a comparison upon which to base advocating prophylactic surgery on boys.