Newborn Circumcision Decreases Incidence and Costs of Urinary Tract Infections During the First Year of Life

I must apologise to Dr. TE Wiswell for misreading his references in his commentary to the Schoen article in my previous submission to P3R. The references of supportive articles subsequent to his meta-analysis was shown online as "14-8" which was actually "1, 4-8" in the printed paper. I have tried to read it as 12-18, and even backwards as references 14 to 8, and it didn't make sense. I apologise for claiming erroneously that those references were irrelevant and dated. The correctly read references are entirely appropriate in context.

My original criticism that the commentary did not mention methodological limitations still stands.

I congratulate the authors for publishing probably the only paper (reference 1) in the last decade in a major journal demonstrating a 9-fold increased risk of urinary tract infections (UTIs) in the uncircumcised male infants. Other similar papers either dated before the 1990's, or demonstrated a much smaller increase in risk (eg. 3.7 in reference 2).

However, on closer examination of the results, one found that amongst 52/154 chart reviews of the male infants diagnosed with a UTI, 5 (10%) were diagnosed without a documented positive urine culture, but on clinical grounds and positive urinalysis only. However, the latter is only 70% specific (range 60% - 92%) for the diagnosis (as reviewed in reference 3). This source of over-diagnosis contributes to only a small number, and probably applies both to the circumcised and the uncircumcised with no obvious bias. But for the remaining 47/52 charts reviewed, only 3(6%) were diagnosed with a positive suprapubic urine culture, while 11(21%) were diagnosed with a bag urine and 36(69%) with a catheterised urine, and in 2(4%) with an un-specified sample of urine. It was shown more than a decade ago that the uncircumcised male infant had an increased likelihood of harbouring uro-pathogens like E. coli, and in higher colony counts, in the urethral meatus (reference 4). It should be evident that urine collected by a catheter or urine collector bag are highly susceptible to contamination by such colonising uro-pathogens, compared to the circumcised male infant. It should thus be obvious that UTIs diagnosed by such urine collection methods will be strongly biased against the uncircumcised male due to possible contamination by peri- urethral uro-pathogenic colonisation. Can such bias be the explanation why this study demonstrated a 9.1-fold increased risk while a much more modest value of 3.7 was reported by another similar study (reference 2)?

Such shortcomings should not have precluded publication of this paper in a reputed journal like Pediatrics, but they should have been pointed out in an accompanying editorial or commentary, so that readers will appreciate the strength of the study, being a "large study on a relatively captive population" as well as the limitations of its conclusions due to methological bias. However, the accompanying commentary was written by TE Wiswell (reference 5), who co-authored a critical article (reference 6) against the American Academy of Pediatrics "Circumcision Policy Statement" (reference 7). In the editorial, he turned a blind eye to such obvious methodological bias described above, and reiterated the "body of evidence" supporting the increased risk of UTIs in the uncircumcised, which included the report of his own meta-analysis in 1993 (reference 8) and "numerous other supportive publications subsequent" to that report (references 14-18 in reference 5, numbered references 9-13 beneath). Two (references 11, 12) out of those five quoted papers actually antedated his report (and are thus not subsequent to his study). Jakobsson et al specifically mentioned that circumcision frequency was not noted in their study, and the procedure was rarely performed in Sweden (reference 9). The abstract of the article by Hoberman et al (reference 10) mentioned nothing about circumcision status and incidence of UTIs. Again, the abstract of Bachur and Caputo (reference 13) made no reference to the issue in question. The remaining two articles, one being a small cohort study (reference 12) and the other being Wiswell's study published in 1989 (reference 11), antedated the publication of his meta-analysis (reference 8). Far from having numerous supportive articles, these quoted papers are either irrelevant, small cohorts, or are traceable to Wiswell's US Army Hospitals data.

In summary, I think Schoen's paper is a useful paper with methodological limitations, and I think the editorial commentary by Wiswell has been too supportive. I believe circumcision confers a modest degree of protection against UTIs in infancy, and the decision to circumcision has to be made by the parents after "given accurate and unbiased information" pertaining to the benefits and risks, and it is legitimate to "take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision" (AAP policy statement, reference 7).

References: 1. Schoen EJ, Colby CJ, Ray GT: Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Pediatrics 2000; 105:789-793. 2. To T, Agha M, Dick PT, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet 1998; 352: 1813 - 1816. 3. American Academy of Pediatrics, Committee on Quality Improvement. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics 1999; 103:843-851. 4. Wiswell TE, Miller GM, Gelston HM The effect of circumcision status on periurethral bacterial flora during the first year of life. J Pediatr 1988; 113: 442-446. 5. Wiswell TE. The Prepuce, Urinary Tract Infections, and the Consequences. Pediatrics April 2000; 105(4): 860-862. 6. Schoen EJ, Wiswell TE, Moses S. New policy on circumcision - cause for concern. Pediatrics 2000;105:620-623. 7. American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999;103:686-693. 8. Wiswell TE, Hachey WE: Urinary tract infections and the uncircumcised state: An update. Clin Pediatr 1993; 32:130-134. 9. Jakobsson B, Esbjörner E, Ehansson S. Minimum incidence and diagnostic rate of first urinary tract infection. Pediatrics 1999; 104:222 -226. 10. Hoberman A, Wald ER. Urinary tract infections in young febrile children. Pediatr Infect Dis J 1997; 16:11-17. 11. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989; 83:1011-1015. 12. Ginsburg CM, McCracken GH Jr. Urinary tract infections in young infants. Pediatrics 1982; 69:409-412. 13. Bachur R, Caputo GL. Bacteremia and meningitis among infants with urinary tract infections. Pediatr Emerg Care 1995; 11:280-284.

In a post of mine above, the URL of my third reference:

(3) Frisch M, Friis S, Kjear SK, Melbye M. Falling incidence of penis cancer in an

uncircumcised population (Denmark 1943-90). British Medical Journal

1995;311(7018):1471. http://www.cirp.org/library/diseas

got cut off.

It should have been: http://www.cirp.org/library/disease/cancer/frisch/

Dr. Schoen is mistaken as regards the American Cancer Society's (ACS) views on circumcision. In an article entitled "Dispelling Miscommunications," ACS News Today confirms that "circumcision is not of value in preventing cancer of the penis." The incidence of penile cancer in Denmark,² where circumcision is almost unknown, is lower than it is in the United States,³ where most men are circumcised.
 

Dr. Edgar Schoen does not accept Dennis Harrison's statement that the American Cancer Society does not accept Dr. Schoen's claim that neonatal circumcision is of value in preventing penile cancer.

Yet, The Penile Cancer Resource Center and ACS News Today, both part of the American Cancer Society's web site, continue to state:

"This practice [circumcision] has been suggested as giving some protection against cancer of the penis by contributing to improved hygiene.

"However, the penile cancer risk is low in some uncircumcised populations, and the practice of circumcision is strongly associated with socio-ethnic factors, which in turn are associated with lessened risk. The consensus among studies that have taken these other factors into account is circumcision is not of value in preventing cancer of the penis." (1, 2)

An example of a virtually non-circumcised developed-nation-setting population is Denmark. With the advent of increasing bathing facilities in homes in that country, the incidence of penile cancer has decreased to an incidence lower than that in the U.S., a country having a majoritarily circumcised male population. In the British Medical Journal, Frisch, Friis, Kjear and Melbye state:

"[T]he declining incidence of penis cancer in Denmark [from 1940 to 1990] cannot reasonably be attributed to an increased practice of neonatal circumcision...During the period under study, the proportion of Danish dwellings having a bath increased gradually from 35% in 1940 to 90% in 1990. It seems plausible that better penile hygiene resulting from this improvement in sanitary installations might have contributed to the observed trend." (3)

(1) The Penile Cancer Resource Center. http://www3.cancer.org/cancerinfo/load_cont.asp?st=pr&ct=35

(2) ACS News Today. http://www2.cancer.org/ezineCFML/dsp_storyIndex.cfm?fn=/001_11051998_0.html

(3) Frisch M, Friis S, Kjear SK, Melbye M. Falling incidence of penis cancer in an uncircumcised population (Denmark 1943-90). British Medical Journal 1995;311(7018):1471. http://www.cirp.org/library/diseas

Response to Dennis Harrison Regarding Circumcision and Male Infant Urinary Tract Infection (IUTI).

In the past 13 years about 15 major studies all have shown marked increase in IUTI in uncircumcised boys. The risk ratios have varied from a low of threefold in the Canadian study by To et al, (the only one cited by Mr. Harrison), to more than 50 times increased risk in the Boston study by Herzog et al; the average increased risk for IUTI in uncircumcised boys from all the studies is about tenfold. Recently Dr. Tom Newman of the University of California in San Francisco, found that IUTI are underdiagnosed because of the failure of the provider in many cases to get urine specimens in febrile infants. I suspect that is the explanation for the apparent low prevalence in the Canadian report. Wiswell's study from the Armed Forces and ours from Kaiser Permanente, were performed in large, organized group settings with easy laboratory access, while To's data reflected the experience of many physicians in various practice settings some with limited laboratory availability. In febrile infants, no urinalysis no IUTI diagnosis, even if IUTI is present.

As for penile cancer no one can seriously doubt the great preponderance in uncircumcised men. In our recent study (Pediatrics, March 2000) we found a 22 times increased risk in uncircumcised men. Six earlier series in the United States, beginning in 1932 from major academic and cancer institutions, showed an even more overwhelming role of the foreskin in penile invasive cancer, with all of the 592 cases occurring in uncircumcised men. The sole report with a lower risk ratio (threefold risk) is suspect since it lumped together carcinoma-in-situ, a benign condition, with invasive penile cancer, a devastating disease. The quote by Mr. Harrison concerning the position of the American Cancer Society (ACS) was from a letter written by 2 former employees of the American Cancer Society and does not represent either credible evidence or the official position of the ACS. Recent publications of the ACS clearly allude to the protective role of the foreskin in invasive penile cancer.

Edgar J. Schoen, MD Oakland, California

A cohort study conducted in the province of Ontario found that the protective effect of neonatal circumcision against UTI was only a fraction of that reported by Schoen et al. (1)

Dr. Schoen's opinion that circumcision protects against penile cancer is not shared by the American Cancer Society, which advises that "circumcision is not of value in preventing cancer of the penis." (2)

References:

(1) To T, Agha M, Dick PT et al. A cohort study on male neonatal circumcision and the subsequent risk of urinary tract infection. Paediatr Child Health 1997;2 (suppl A): 55A.

(2) http://www2.cancer.org/ezineCFML/dsp_storyIndex.cfm?fn=/001_11051998_0.html

Dr. Hopper is correct in suggesting that the cost savings due to circumcision in infant urinary tract infections (IUTI) in the first year do not equal the cost of circumcision, which is about $200 in this area. But it must be pointed out that our IUTI study was not a cost benefit study. In order to do a full cost benefit analysis one would have to determine the cost savings attributed to circumcision over a lifetime. This would include protection against not only IUTI, but against balanoposthitis, phimosis, heterosexual HIV and other sexually transmitted diseases, penile cancer, and penile dermatoses, all of which are more common in uncircumcised males. Further, since post-neonatal circumcision costs about $2000 in our experience, about 10 times as much as neonatal circumcision, the percentage of uncircumcised males receiving post-neonatal circumcision , for whatever reason (including personal preference and improved hygiene), is the main factor in cost benefit analysis.

The reason why the cost per UTI is higher in uncircumcised than in circumcised males is that the uncircumcised boys were sicker, younger and more likely to be hospitalized.

Finally , it should be emphasized that from the standpoint of the parent's choice, it is likely that the multiple medical benefits of newborn circumcision plays a larger role in the decision than do cost benefits.

Edgar J. Schoen, MD

Oakland, Ca.

An article which analyses "cost" would not be complete without this calculation: From this article the incidence of UTIs in males of 0.2% (circumcised) and 2.5% (uncircumcised) and the cost per UTI is $1179 (Uncircumcumcised) and $703 (circumcised) then for, say, 1000 procedures, UTIs would cost $1400 (circ) and $29500 (uncirc). In other words, the savings on treatment of UTIs in the first year of life would be, on average, $28 per circumcision per patient. What does a circumcision cost in the US?

On another point, why does the treatment cost for UTIs in uncircumcised males cost more per UTI? Are they sicker? Do they stay longer? Are there any negative data in this study to answer thwese questions?

Using the jargon of the organized lay anti-circumcision groups, Mr. Mermer refers to newborn circumcision as "genital mutilation." He acknowledges the overwhelming evidence that newborn circumcision protects against infant urinary tract infection (UTI), an effect previously denied by the anti-circumcisionists in spite of convincing evidence for over a decade. However, he seems to be unaware of the high morbidity, including hospitalization, of UTIs in young infants (1, 2), as well as the data showing reflux and kidney scarring following UTI (2).

The 1999 Task Force report referred to the complications of newborn circumcision as "rare and usually minor" (3), in contradiction of Mermer's claims. The information he cites regarding sexual enjoyment was collected by an anti-circumcision couple who surveyed a select group of those with their own beliefs and lacks credibility.

Finally, Mr. Mermer fails to mention the other lifetime health advantages of newborn circumcision, 6 of which, including UTI prevention, were cited in the 1999 Task Force report (3). These include protection against penile cancer, HIV infection, balanoposthitis, and phimosis, as well as ease of genital hygiene. A recent publication (4) adds the lower risk of dermatological disease in circumcised males to this list of benefits. All in all, a pretty compelling array of evidence favoring the medical advantages of newborn circumcision.

References 1. Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Pediatrics 2000; 105:789-93. 2. Wiswell TE. The prepuce, urinary tract infections, and the consequences (Commentary). Pediatrics 2000; 105:860-62. 3. American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999; 103:686-93. 4. Mallon E, Hawkins D, Dinneen Metal. Circumcision and genital dermatoses. Arch Dermatol 2000; 136:350-54.

The study by Schoen et al (1) confirms what I thought to be the already established fact that newborn circumcision is highly protective of Urinary Tract Infection (UTI). However, does this benefit necessarily mean that circumcision should therefore be a universal practice, serving as a form of UTI prophylaxis?

UTI's are not associated with high mortality or with significant long -term sequelae. Combine this with the fact that circumcision has been shown to have an immediate complication rate of 4% (2) or 3.1% (3). Although many of these complications are minor with no known long-term sequelae, there are also instances of serious and devastating results, such as amputation of the glans penis and/or urethra (4) or other form of genital mutilation. Additionally it has been reported that 13% of circumcised newborns experience minor complications at a later time (2).

Even if the risk of complications were zero there is an additional and rarely discussed issue, which if people were aware of could profoundly impact their decision regarding circumcision. I am referring to the fact that, in a recently published study, a majority of women who have had sexual partners who were both circumcised and uncircumcised reported that they experienced more enjoyment with uncircumcised partners (5). Considering the fact that most men consider sexual performance an important aspect of their life, it seems like a very high price to pay to avoid the small risk of UTI.

References:

1. Schoen EJ, Colby CJ, Ray GT. Newborn Circumcision Decreases Incidence and Costs of Urinary Tract Infections During the First Year of Life. Pediatrics 2000; 105: 789-793.

2. Metcalf TJ, Osborn LM, Mariani EM. Circumcision: a study of current practices. Clin Pediatr (Phila) 1983; 22: 575-579.

3. O'Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. South Med J 1995; 88: 411-415.

4. Sherman J, Borer JG, Horowitz M, Glassberg KI. Circumcision: successful glanular reconstruction and survival following traumatic amputation. J Urol 1996; 156: 842-844.

5. O'Hara K, O'Hara J. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int 1999; 83: Suppl 1 79-84.