Commentary on chapter “Male circumcision protects against urinary tract infections”
Gitte M. Hvistendahl 2
1 Paediatric Urology Section, Department of Urology, Aarhus University Hospital, Aarhus, Denmark
2 Aarhus University Hospital, Aarhus, Denmark
Circumcision remains the most controversial surgery in human history and the foreskin undoubtedly “pound for pound” the most contentious body part. Not inasmuch due to any complexity with regards to the surgical procedure itself or elaborate function of the prepuce, but more with regards to the controversy, emotion, discussion, discourse, bickering, fundamentalism and partisanship these subjects stir. Neonatal routine/ritual/nontherapeutic circumcision is also one of the only topics which generates very conflicting outcomes and representations in the peer reviewed medical literature, allowing proponents and opponents to “cherry pick” studies, meta-analyses or parts hereof in support of their own view and agenda. Hence it has always been our practice to read, analyse and interpret the results of any such study with a “pinch of salt” and a fair amount of healthy skepticism. One of the documented and established facts however, is that the circumcised status decreases the risk of urinary tract infection especially in infancy. This in turn begs the question of whether this reduction in UTI risk is clinically significant and if so, if it outweighs the risk of harm which potentially befalls the non-consented patient. In the current chapter by Morris and Krieger the balance tips unreservedly in favour of circumcision especially when performed early in life, with the authors even equating circumcision with vaccination, and almost berating the decision not circumcise, and putting it on par with a decision not to vaccinate a child. Statements that are quite stinging in these “anti-vaxer” times.
The risk of UTI in male infants with normal urinary tracts is 1 to 2% and therefore classically it has been accepted that the number of normal infant boys needed to circumcise to prevent one UTI is about 100. Considering a conservatively set risk of surgical complications of 0.5% (some of which are catastrophic such as glans amputation) and an unquantifiable risk of harm to a non-consented patient, whilst also considering the fact that the overwhelming majority of these infections can be treated easily and adequately with antibiotics, the benefit to “risk of harm” scales heavily weigh against routine neonatal circumcision. On the other hand, when one considers boys born with congenital anomalies of the urinary tract, the number of infant boys needed to circumcise in order to prevent one case of UTI might be as low as 2, as in the case of posterior urethral valves, and hence prophylactic circumcision could here be considered justifiable.