Summary
Background
Uncircumcised males are at higher risk of urinary tract infection (UTI) in the first
year of life and circumcision is recommended as an option for males with vesicoureteral
reflux (VUR). Uncircumcised males treated successfully with topical corticosteroid
cream have decreased risk of UTI but the role of preputial management has not been
explored previously in males with VUR.
Objective
We hypothesized that among uncircumcised boys with VUR, those with retractable foreskin
would be at reduced risk of UTI compared to those with non-retractable foreskin.
Study design
Males less than one year of age with primary VUR were prospectively enrolled. Patients
with concomitant urologic diagnoses or less than one month of follow-up were excluded.
Phimosis severity was graded on a 0–5 scale. Primary outcome was UTI during follow-up.
Patients were divided into three groups for analysis: circumcised, low grade phimosis
(grades 0–3) and high grade phimosis (grades 4–5). Multivariable Cox proportional
hazards regression was used to estimate UTI risk adjusting for risk factors.
Results
One-hundred and five boys (24 circumcised and 81 uncircumcised) with VUR were included.
Median age at enrollment was 4.4 months (IQR 2.2–6.6) and median follow-up was 1.1
years (IQR 0.53–2.9). Males with phimosis grades 4–5 had a higher UTI rate (29%) compared
to phimosis grade 0–3 (4%). Based on Kaplan–Meier curves, boys with initial phimosis
grades 4–5 were significantly more likely to develop a UTI than boys who were circumcised
or had phimosis grades 0–3 (p = 0.005). On multivariable analysis, boys with phimosis
grades 4–5 were significantly more likely to develop UTI when compared to boys with
grades 0–3 phimosis (HR = 8.4, 95% CI: 1.1–64, p = 0.04).
Discussion
Males with a retractable prepuce had a lower UTI risk compared to males with non-retractable
prepuce (high grade phimosis) and this remained significant on multivariable analysis.
This is concordant with prior studies demonstrating that a retractable prepuce is
associated with decreased UTI risk. Limitations of our study include using phimosis
grade at time of study enrollment and heterogenous prophylactic antibiotic use in
our population.
Conclusions
Graphical AbstractKaplan–Meier survival plot for UTI risk for phimosis grades 4–5, phimosis grades 0–3,
and circumcised males.
Keywords
Abbreviations:
VUR (Vesicoureteral reflux), UTI (Urinary tract infection), RBUS (Renal bladder ultrasound), VCUG (Voiding cystourethrogram), CAP (Continuous antibiotic prophylaxis)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: January 09, 2021
Accepted:
January 7,
2021
Received in revised form:
December 29,
2020
Received:
October 14,
2020
Identification
Copyright
© 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
