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Retractable foreskin reduces urinary tract infections in infant boys with vesicoureteral reflux

Published:January 09, 2021DOI:https://doi.org/10.1016/j.jpurol.2021.01.007

      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

      Summary Figure
      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)
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      References

        • Schoen E.J.
        • Colby C.J.
        • Ray G.T.
        Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life.
        Pediatrics. 2000; 105: 789-793
        • Craig J.C.
        • Knight J.F.
        • Sureshkumar P.
        • Mantz E.
        • Roy L.P.
        Effect of circumcision on incidence of urinary tract infection in preschool boys.
        J Pediatr. 1996; 128: 23-27
        • Hiraoka M.
        • Tsukahara H.
        • Ohshima Y.
        • Mayumi M.
        Meatus tightly covered by the prepuce is associated with urinary infection.
        Pediatr Int. 2002; 44: 658-662
        • Bader M.
        • McCarthy L.
        What is the efficacy of circumcision in boys with complex urinary tract abnormalities?.
        Pediatr Nephrol. 2013; 28: 2267-2272
        • Wiswell T.E.
        • Miller G.M.
        • Gelston Jr., H.M.
        • Jones S.K.
        • Clemmings A.F.
        Effect of circumcision status on periurethral bacterial flora during the first year of life.
        J Pediatr. 1988; 113: 442-446
        • Fussell E.N.
        • Kaack M.B.
        • Cherry R.
        • Roberts J.A.
        Adherence of bacteria to human foreskins.
        J Urol. 1988; 140: 997-1001
        • Oster J.
        Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys.
        Arch Dis Child. 1968; 43: 200-203
        • Esposito C.
        • Centonze A.
        • Alicchio F.
        • Savanelli A.
        • Settimi A.
        Topical steroid application versus circumcision in pediatric patients with phimosis: a prospective randomized placebo controlled clinical trial.
        World J Urol. 2008; 26: 187-190
        • Berdeu D.
        • Sauze L.
        • Ha-Vinh P.
        • Blum-Boisgard C.
        Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect.
        BJU Int. 2001; 87: 239-244
        • Lee J.W.
        • Cho S.J.
        • Park E.A.
        • Lee S.J.
        Topical hydrocortisone and physiotherapy for nonretractile physiologic phimosis in infants.
        Pediatr Nephrol. 2006; 21: 1127-1130
        • Moreno G.
        • Corbalan J.
        • Penaloza B.
        • Pantoja T.
        Topical corticosteroids for treating phimosis in boys.
        Cochrane Database Syst Rev. 2014; : CD008973
        • Peters C.A.
        • Skoog S.J.
        • Arant Jr., B.S.
        • Copp H.L.
        • Elder J.S.
        • Hudson R.G.
        • et al.
        Summary of the AUA guideline on management of primary vesicoureteral reflux in children.
        J Urol. 2010; 184: 1134-1144
        • Chamberlin J.D.
        • Dorgalli C.
        • Abdelhalim A.
        • Davis-Dao C.A.
        • Chalmers C.L.
        • Kelly M.S.
        • et al.
        Randomized open-label trial comparing topical prescription triamcinolone to over-the-counter hydrocortisone for the treatment of phimosis.
        J Pediatr Urol. 2019; 15: 388 e1-e5
        • Sookpotarom P.
        • Asawutmangkul C.
        • Srinithiwat B.
        • Leethochawalit S.
        • Vejchapipat P.
        Is half strength of 0.05 % betamethasone valerate cream still effective in the treatment of phimosis in young children?.
        Pediatr Surg Int. 2013; 29: 393-396
      1. Subcommittee on urinary tract infection. Reaffirmation of AAP clinical practice guideline: the diagnosis and management of the initial urinary tract infection in febrile infants and young children 2-24 Months of age.
        Pediatrics. 2016; 138
        • Roberts K.B.
        Revised AAP guideline on UTI in febrile infants and young children.
        Am Fam Physician. 2012; 86: 940-946
        • Radmayr C.
        • Bogaert G.
        • Dogan H.S.
        • Nijman R.
        • Silay M.S.
        • Stein R.
        • et al.
        EAU guidelines on paediatric Urology 2020.
        (European Association of Urology Guidelines 2020 Edition) European Association of Urology Guidelines Office, Arnhem, The Netherlands2020
        • Chen C.J.
        • Satyanarayan A.
        • Schlomer B.J.
        The use of steroid cream for physiologic phimosis in male infants with a history of UTI and normal renal ultrasound is associated with decreased risk of recurrent UTI.
        J Pediatr Urol. 2019; 15: 472 e1-e6
        • Hoberman A.
        • Greenfield S.
        • Mattoo T.K.
        • Keren R.
        • Mathews R.
        • et al.
        • RIVUR Trial Investigators
        Antimicrobial prophylaxis for children with vesicoureteral reflux.
        N Engl J Med. 2014; 371: 1072-1073
        • Singh-Grewal D.
        • Macdessi J.
        • Craig J.
        Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomized trials and observational studies.
        Arch Dis Child. 2005; 90: 853-858
        • Wijesinha S.S.
        • Atkins B.L.
        • Dudley N.E.
        • Tam P.K.
        Does circumcision alter the periurethral bacterial flora?.
        Pediatr Surg Int. 1998; 13: 146-148
        • American Academy of Pediatrics Task Force on C
        Circumcision policy statement.
        Pediatrics. 2012; 130: 585-586
        • Weiss H.A.
        • Larke N.
        • Halperin D.
        • Schenker I.
        Complications of circumcision in male neonates, infants and children: a systematic review.
        BMC Urol. 2010; 10: 2
        • Schoen E.J.
        • Colby C.J.
        • To T.T.
        Cost analysis of neonatal circumcision in a large health maintenance organization.
        J Urol. 2006; 175: 1111-1115
        • Hart-Cooper G.D.
        • Tao G.
        • Stock J.A.
        • Hoover K.W.
        Circumcision of privately insured males aged 0 to 18 years in the United States.
        Pediatrics. 2014; 134: 950-956
        • Shirley P.J.
        • Thompson N.
        • Kenward M.
        • Johnston G.
        Parental anxiety before elective surgery in children. A British perspective.
        Anaesthesia. 1998; 53: 956-959
        • Frisch M.
        • Aigrain Y.
        • Barauskas V.
        • Bjarnason R.
        • Boddy S.A.
        • Czauderna P.
        • et al.
        Cultural bias in the AAP's 2012 technical report and policy statement on male circumcision.
        Pediatrics. 2013; 131: 796-800
        • Morris B.J.
        • Wamai R.G.
        • Henebeng E.B.
        • Tobian A.A.
        • Klausner J.D.
        • Banerjee J.
        • et al.
        Estimation of country-specific and global prevalence of male circumcision.
        Popul Health Metr. 2016; 14: 4
        • Wang Z.T.
        • Wehbi E.
        • Alam Y.
        • Khoury A.
        A reanalysis of the RIVUR trial using a risk classification system.
        J Urol. 2018; 199: 1608-1614
        • Koff S.A.
        • Wagner T.T.
        • Jayanthi V.R.
        The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children.
        J Urol. 1998; 160: 1019-1022