Nessun rischio di infezioni al tratto urinario per bambini non circoncisi

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Posted on 4/8/2012, 20:43

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Research
Alexander Sasha Dubrovsky,
Bethany J. Foster,
Roman Jednak,
Elise Mok,
and David McGillivray
Visibility of the urethral meatus and risk of urinary tract infections in uncircumcised boys CMAJ cmaj.111372; published ahead of print July 9, 2012, doi:10.1503/cmaj.111372

Visibility of the urethral meatus and risk of urinary tract infections in uncircumcised boys

This study does not provide evidence that intact children have an increased risk of urinary tract infections (UTIs). To demonstrate an increased risk of UTIs, larger demographic data would be required. The intact-to-circumcised ratio of all children living within the hospital's catchment area would need to be determined and correlated with the results of the positive urine cultures. In addition, all UTIs diagnosed outside the emergency department would also need to be included, as well as the circumcision status of each of those children.

Abstract

Canadian Medical Association

Background: Uncircumcised boys are at higher risk for urinary tract infections than circumcised boys. Whether this risk varies with the visibility of the urethral meatus is not known. Our aim was to determine whether there is a hierarchy of risk among uncircumcised boys whose urethral meatuses are visible to differing degrees.

Methods: We conducted a prospective cross-sectional study in one pediatric emergency department. We screened 440 circumcised and uncircumcised boys. Of these, 393 boys who were not toilet trained and for whom the treating physician had requested a catheter urine culture were included in our analysis. At the time of catheter insertion, a nurse characterized the visibility of the urethral meatus (phimosis) using a 3-point scale (completely visible, partially visible or nonvisible). Our primary outcome was urinary tract infection, and our primary exposure variable was the degree of phimosis: completely visible versus partially or nonvisible urethral meatus.

Results: Cultures grew from urine samples from 30.0% of uncircumcised boys with a completely visible meatus, and from 23.8% of those with a partially or nonvisible meatus (p = 0.4). The unadjusted odds ratio (OR) for culture growth was 0.73 (95% confidence interval [CI] 0.35–1.52), and the adjusted OR was 0.41 (95% CI 0.17–0.95). Of the boys who were circumcised, 4.8% had urinary tract infections, which was significantly lower than the rate among uncircumcised boys with a completely visible urethral meatus (unadjusted OR 0.12 [95% CI 0.04–0.39], adjusted OR 0.07 [95% CI 0.02–0.26]).

Conclusion: We did not see variation in the risk of urinary tract infection with the visibility of the urethral meatus among uncircumcised boys.

Funding: This study received funding from the Montreal
Children’s Hospital Research Institute Clinical Projects Funding Competition for fellowship projects. The study sponsors had no role in the design of the study, the collection, analysis or interpretation of data, the writing of the report or the decision to submit the article for publication.

From the Divisions of Pediatric Emergency
Medicine (Dubrovsky, McGillivray), Pediatric Nephrology
(Foster), Pediatric Urology (Jednak), the Department of Epidemiology,
Biostatistics and Occupational Health (Foster)
and Montreal Children’s Hospital Clinical Research Centre
(Mok), Montréal Children’s Hospital, McGill University
Health Centre, Montréal, Que.

There are often complex psychological motivations among some physicians and researchers who compulsively search for "a priori" medical justifications in order to perpetuate infant circumcision. Even if circumcision provided 100% protection against UTIs, this practice could never be justified based on the ethical principle of proportionality - there are effective and less destructive therapies available for preventing and treating urinary tract infections which do not involve the prophylactic removal of healthy genital tissue.

Yes, little boys will sometimes develop UTIs. As with little girls, they should be treated appropriately with antibiotics, not with prophylactic surgery. Are we to believe that non-circumcising countries like Sweden, Finland, Denmark, Norway and Japan struggle with significant public health problems related to infant UTIs? If so, why aren't physicians from these nations promoting circumcision as an effective and ethical prevention strategy? Perhaps, they do not share the same irrational fear and loathing of the prepuce as some North American physicians? Circumcision prevents urinary tract infections the same way garlic prevents vampires.

Circumcision was only medicalized during the Victorian era as a misguided attempt to curb masturbation. It was widely promoted by physicians as a means of decreasing sexual pleasure and disrupting the normal gliding mechanism of the penis. We now understand that the prepuce is richly innervated, erogenous tissue which enhances sexual pleasure. In addition, the prepuce provides a unique linear gliding mechanism during sexual intercourse. As physicians, we have no right to amputate this functional tissue from powerless infants without medical urgency.

This study illustrates how our endless appetite for evidence-based medicine can sometimes distract us from the ethical and moral responsibilities of our profession. Prophylactic circumcision is medically unethical because it violates the child's fundamental human right to bodily integrity. Non-therapeutic circumcision is a disgrace to our profession. Canadian physicians have a moral obligation to oppose this cruel practice and properly educate the public about the sexual function and proper care of the prepuce. (Published July 19, 2012)

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