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Influence of circumcision technique on frequency of urinary tract infections in neonates

2002; Lippincott Williams & Wilkins; Volume: 21; Issue: 9 Linguagem: Inglês

10.1097/00006454-200209000-00020

1532-0987

Liora Harel, Rachel Straussberg, Shlomo Jackson, Jacob Amir,

Urologic and reproductive health conditions

An increase in urinary tract infection (UTI) during the first weeks after traditional Jewish circumcision has been reported. Circumcision can be performed by a nonmedical person (mohel) or by a physician, with the main difference being in hemostasis techniques. We assessed the effect of circumcision procedure on development of UTI in neonates. Circumcision performed by a mohel was associated with higher incidence of UTI compared with that by physicians. Hemostasis technique and shaft wrapping are postulated risk factors. Substantial evidence accumulated since the mid-1980s has confirmed the protective effect of circumcision against urinary tract infection (UTI) at all ages, 1 particularly in infancy. 2 An increase in the incidence of UTI during the first weeks after traditional Jewish circumcision has been reported in Israel. 3, 4 Most Jewish and Moslem children in Israel are circumcised, either at the age of 8 days (Jewish infants) or a few days later (Moslem infants). The Jewish ritual is traditionally performed by a mohel, an officially authorized, nonmedical person trained to perform circumcision. The aim of this study was to assess the effect of the circumcision technique and the performer on the development of UTI in the neonatal period. Methods. Traditional circumcision by a mohel is performed by sterile prepuce excision using a metal protector, without a clamp. Hemostasis is achieved by tightly wrapping the shaft of the penis with a strip of dry sterile gauze for several hours, usually overnight (Fig. 1). The mohel is the only one who unwraps the dressing on his follow-up visit. No manual pressure is used to stop the bleeding. No ointment or petrolatum is used. Circumcision by a physician is performed by an excision technique similar to that of the mohel, but hemostasis is achieved by local pressure (Bronstein clamping device) or by calcium-sodium alginate fiber (Kaltostat; Bristol Meyers-Squibb Company), a wound cavity dressing, that melts within 2 to 3 h. No ointment or dressing is applied.Fig. 1: Wrapping penis with a strip of gauze as used for hemostasis in traditional circumcision done by a mohel.The sample for this prospective study consisted of all Jewish circumcised neonates admitted to one pediatric department at the Schneider Children's Medical Center of Israel between July 1999 and July 2001 because of UTI. Only sick babies, 3 weeks or less after circumcision, were included. All had been circumcised on the eighth day after birth, according to Jewish practice, and none had medical problems warranting postponement of the procedure. The diagnosis of UTI was made by growth of one species of microorganism (105 or more colony-forming units) from urine obtained by suprapubic aspiration (16 patients), bladder catheterization (1 patient) or midstream specimen (38 patients). 5 The circumcision technique used, the person who performed the procedure and the duration of shaft wrapping were determined by parental interview at admission. All infants underwent renal ultrasound and postvoiding urethrocystography within 6 weeks after hospitalization. For the control we used two separate groups. Control Group 1 consisted of the first 100 families of all healthy full term male infants born during January and February 2000 at Schneider Children's Medical Center of Israel who were contacted by telephone in April 2000, when the infants were 2 to 4 months old. The parents were asked which circumcision technique was used, who performed the procedure and how long the shaft wrapping was left on. Control Group 2 consisted of the first 60 circumcised male neonates, 1 to 4 weeks old, admitted to the pediatric department between January and July 2000 for a sepsis workup and who had a negative urine culture. We compared the risk of UTI between mohels and physicians in the cases and the controls using the Mantel-Haenszel odds ratio. The association between continuous scale (duration of wrapping) was analyzed using the Student t test. Results. The study group included 55 Jewish male infants 9 to 30 days old (median, 17 days) with UTI. Most of the infants (90%) had fever, and the remainder had decreased feeding, vomiting, failure to gain weight or irritability. Leukocyturia was present in 95% of cases. Escherichia coli was isolated in 46 cases (84%), Klebsiella sp. in 7 patients (13%) and Enterobacter in 2 patients. In 10 infants the same microorganism was isolated from the blood. Forty-nine of 55 children in the study group (89%) had had a traditional circumcision by a mohel, and 6 (11%) had had a traditional procedure by a physician. Sixty-four of the 100 families contacted for the control group were available on the phone during working hours (Control Group 1). Forty-four infants (69%) had had a traditional circumcision by a mohel and 20 (31%) a procedure by a physician (odds ratio, 3.71; 95% confidence interval, 1.26 to 11.45, P = 0.007). In the second control group 37 infants (62%) had been circumcised by a mohel and 23 (38%) by a physician (odds ratio, 5.08; 95% confidence interval, 1.73 to 15.60;P = 0.0007). The odds ratio of UTI in children circumcised by a mohel compared with those circumcised a physician was 4.34 (95% confidence interval, 1.62 to 12.27;P = 0.001). The mean duration of hemostasis was 25.6 ± 21.8 h in the study group and 16.6 ± 12.7 h in the control group (P = 0.007). Renal ultrasound and postvoiding urethrocystography performed in all the infants in the study group revealed vesicoureteric reflux in eight (15%), one of whom also had duplication of the upper urinary tract. The severity of the reflux was Grade I in 3 children, Grade II in 3, Grade III in 1 and Grade IV in one infant. Five of the eight children with reflux (62%) had been circumcised by a mohel and three (38%) by a physician. Discussion. A metaanalysis of 9 published reports showed that the risk of urinary tract infection is 12 times higher among uncircumcised than among circumcised male infants. 6 According to a recent study, newborn circumcision resulted in a 9-fold decrease in the incidence of UTI during the first years of life as well as lower UTI-related medical costs and rate of hospital admissions. 7 Reports from Israel describe an increase in the incidence of UTI during the first few weeks after ritual Jewish circumcision. 3, 4 The majority of infants in Israel undergo traditional circumcision by a mohel, although in the last few years there was a growing trend among Jewish parents to opt for circumcision by a physician. In our study we found a significantly higher proportion of UTI in infants after traditional circumcision by a mohel than in infants circumcised by a physician. The main difference between these two procedures is the method and the mean duration of hemostasis, strengthening the hypothesis that urinary retention caused by gauze pressure could be a cause of UTI. The urine retention is probably partial, given that most infants are able to urinate during the first few hours postprocedure. Some support for this theory was provided by a Turkish study 8 in which circumcisions performed by medically trained and untrained operators were compared for complications. Circumcision by medically untrained persons accounted for 85% of all complications, some of which were severe, and urinary retention occurred in 3.6% of cases compared with only 0.3% of those undergoing a procedure done by medically trained operators. Differences in sterility of the procedure might also be a possible explanation, but the pathogens causing the UTI and lack of local skin infection in both groups were not different. Another possibility could be periurethral colonization postcircumcision worsened by shaft wrapping. The reported incidence of vesicoureteric reflux in children after first UTI is 30 to 50%. 9 The low rate of anomalies in our group (15%) further supports the possible role of circumcision in the occurrence of UTI. In conclusion our study shows that UTI apparently occurs more frequently after traditional circumcision by a mohel than after circumcision by a physician. The technique of hemostasis and duration of shaft wrapping are postulated risk factors. We speculate that change in the hemostasis technique or shortening the duration of the shaft wrapping might decrease the rate of UTI after Jewish ritual circumcision.