Urinary Tract Infection Following Ritual Jewish Circumcsion

Urinary tract infection (UTI) in early infancy is often associated with septicemia^1-4, kidney scarring and occasionally renal failure^5,6. During early infancy, male are more commonly affected, but later on females predominate^7,8. Circumcision seems to reduce the overall incidence of UTI in male infants^1,2,9-11. In Jewish neonates, circumcision is performed routinely on the eighth day of life by a ritual circumciser who is usually not a physician. However, a few studies have suggested that ritual circumcision may be a disposing factor for UTI within the first 2 weeks following the surgical procedure^12-15. The aim of this study was to evaluate the possible association of UTI with ritual circumcision.

Methods

During a 4 year period, from April 1989 through April 1993, 82 infants under the age of 1 year were admitted with acute UTI to the pediatric department at Assaf Harofeh Medical Center. We included only Jewish females and circumcised male infants; all of the male infants had been circumcised on the eighth day of life. All infants had suprapubic aspiration, and UTI was defined as 10³ or more colony forming units of a single microorganism. Urosepsis was defined when blood and urine cultures were positive for an identical microorganism. Only infants who had both voiding cysto-urethrography and renal ultra-sound or intravenous pyelogram were included in the study.

Data were analyzed using Χ² analysis or Student's τ test. We considered a P value of <0.05 to be statistically significant.

Results

During the study period 82 hospitalized infants (55 females, 27 males) fulfilled our inclusion criteria. The mean age of the male infants was signifantly younger than that of the female infants (1.2 vs. 7 months, P<0.0001)(Fig. 1). The median age was 0.75 and 7.0, respectively. In the majority of males, UTI occurred during the first month of life (Fig. 2). The peak incidence was in the initial 13 days following circumcision), and 52% (14/27) of the UTI episodes occurred during that period. In females, the UTI episodes were distributed evenly throughout the first year of life.

Urine cultures revealed Escherichia coli in 84%, Klebsiella in 11%, and other bacteria (Proteus, Staphylococcus aureaus, Acienetobacter and Pseudomonas aeruginosa) in 5% (Fig. 3). When we compared the relative prevalence of E. coli versus other bacteria in males and females we found a significantly higher proportion of E. coli in females compared with males. (93 vs. 67%, P<0.01) (Fig. 4). The incidence of UTI induced by microorganisms other than E. coli was significantly higher (P<0.01) in male infants presenting within 2 weeks following circumcision (43%, 6/14) than in the remaining males (8%, 1/13) or in all female infants (7%, 4,55). Blood cultures were positive (identical microorganism as in urine culture) in 6/27 males and 2/55 females (P<0.01). All males with positive blood cultures were between 0.5 and 1.75 months old; four of them had positive cultures within the 2 weeks following circumcision. The two female infants were 4 and 8 months old.

Vesico-urethral reflux was demonstrated in 9/27 males and in 24/55 females. Seventeen males and 33 females had an intravenous pyelography (IVP). Hydronephosis with or without hydro-ureters was observed in 4/17 males and 6/33 females. A renal ultrasound (US) was performed in 22 males and 34 females. Hydronephosis was found in 6/22 males and 5/33 females. The only structural anomaly observed in our population with UTI was vesico-urethral reflux. Its incidence and severity (degree of reflux was similar in both sexes.

 

 

 

 

 

 

 

 

Discussion

Urinary tract infection is one of the most common diseases in infancy. During the neonatal period, males seem to be more commonly affected, whereas later on females predominate^6,7. In our study, 20 of 27 males, compared to only 2 of 55 females, suffered from UTI during the first 4 weeks of life. Four infants of each sex contracted UTI during the second month of life. Later on, female infants predominated by far. The higher incidence of neonatal UTI in males has been attributed by some authors to an increased incidence of structural abnormalities^16,17. In our study, the single urinary tract malformation observed was vesico-ureteral reflux, whose incidence and severity were similar in both sexes.

Based on epidemeologic studies, it has been suggested that neonatal circumcision may reduce the overall incidence of UTI early infancy^1,2,9-11. It has been hypothesized that the preputial fold, which is not amenable to ordinary cleaning, may harbor vast quantities of microorganisms that cause a contamination of the male urethra with fecal flora.

Circumcision is faithfully performed in Jewish infants. It is carried out on the eighth day of life unless medically contraindicated, and is performed by a ritual circumciser. Therefore, evaluating the incidence of UTI and its time of occurence in circumcised and uncircumcised populations is impossible in our area. However, comparing our data and those published by others in Israel^12-14 with studies performed in uncircumcised infants^7,18,19, it seems that UTI develops at a younger age in ritually circumcised infants than in intact ones. Wiswell et al.¹⁸ followed 1,919 circumcised male infants in whom 4 (0.21%) had UTI. The mean age of the infection was 1.4 and 1.7 months, respectively. In the present study, the mean age of UTI was 1.2 months. There was no clinical evidence of pre-existing infection prior to circumcision in any of the infants who developed UTI shortly after the procedure. The clustering of UTIs in the 2 weeks following the procedure may reflect a causal relationship between UTI and ritual circumcision relative to the non-sterile techniques used during the procedure, and may also be in part due to a pain-induced urine retention occurring immediately following circumcision. The significant difference in bacterial pathogens between male infants presenting with UTI within 2 weeks following circumcision and both the remaining male infants and the female population may also suggest a different etiology for the development of thedisease.

The combination of UTI and bacteremia is more common in the newborn than later on in infancy^3,7,20. The relatively common episodes of septicemia in male compared to female infants in our study may simply reflect the earlier appearance of the UTI. However a surgical procedure, albeit a minor one, performed under not strictly sterile conditions, in an area not amenable to ordinary cleaning and harboring great quantities of mainly fecal microorganisms may also predispose to the development of UTIand bacteremia.

In conclusion, it seems to us that the high incidence of UTIs following ritual Jewish circumcision, as well as the significant difference in bacterial etiology, may suggest a causal relationship between UTI and circumcision. A stricter sterile technique by the ritual circumciser may reduce the risk.

Address for correspondance: Dr. M. Aladjem, Department of Pediatrics B,  Assaf Harofeh Medical Center, 70300 Zerafin, Israel.

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