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PEDIATRICS Vol. 107 No. 1 January 2001, pp. 210-214
To the Editor.
I commend Drs Schoen, Colby, and Ray for their recent article
that once again shows the vast majority (98%) of uncircumcised males
do not develop urinary tract infections (UTIs) in the first year of
life.1 Their data verifies that 52 circumcisions need to
be performed to prevent 1 UTI, and therefore 51 out of 52 circumcised
males do not benefit from their circumcision but instead only suffer pain and permanent disfigurement of their genitalia.
I also applaud them for showing that the cost of a UTI in an
uncircumcised male averages $1179. Because the charge for a
circumcision in our hospital is $382 (a reasonable amount given
physician time for the circumcision including getting consent and
checking for bleeding later, nursing time, lidocaine and EMLA,
sterilization of equipment, and use of nursery space), the cost to
perform 52 circumcisions is $19 864, making routine circumcision to
prevent UTIs 17 times more expensive than treating the exceedingly rare UTI and its sequelae.
Once again, looking at the data with logic and an unbiased eye confirms
that routine neonatal circumcisions should not be performed.
Division of Neonatology
University of California, San Francisco
San Francisco, CA 94143-0734
REFERENCE
To the Editor.
The article by Schoen et al1 discusses the need to present the benefits of newborn circumcision. It is essential that parents be fully informed before making a decision whether or not to circumcise their sons, and providing them with all the pertinent information is the responsibility of all health care providers.2 In discussing with parents the risks associated with circumcision, the focus is heavily weighted on the problems and complications in the immediate postoperative period, with some reference to the benefits of reduced UTIs and penile cancer. I would like to expand the discussion, beyond infancy and adulthood, to the complications of noncircumcision for the elderly dependent male and his caregiver.
As clinical nurse specialist in an extended care facility caring for an older male population, I would like to address the issue of circumcision from the gerontological perspective. We assume that parents make decisions about circumcision with the child's best interest in mind, but the information provided parents is inadequate because it does not address the question of what happens if that person is unable to care for his own hygiene needs. The geriatrics community has had little say and no input into the information that is presented to parents at the time they are deciding whether to circumcise their infant sons, yet the result of this decision is played out daily in nursing homes, in long-term care facilities, and in the homes of caregivers. Ultimately, it is the geriatrics community that is faced with care issues when one can no longer meet one's own care needs. Therefore, the information pediatricians present must include how this decision will affect the care, well-being, and comfort of an older male 70 or 80 years hence.
Good perineal-genital care for an uncircumcised male involves retracting the foreskin to expose the glans or head of the penis, washing and drying the glans, and replacing the foreskin. For younger patients who are unable to care for themselves, as a result of either trauma or disease, the need to have others perform this intimate care is embarrassing and stressful. The procedure of being cleaned is also emotionally difficult for the older uncircumcised patient. However, for the majority of older people who need this hygiene care performed because of a dementing illness, the reactions range from personally disturbing to disruptive behavior. Frequently, the patient misinterprets the care and strikes out in terror, kicking and scratching caregivers, whether family or nursing staff.
On the other hand, wives and daughters complain, in the security of support groups, that they do not even attempt to keep the patient clean, as their efforts are interpreted as an invitation of sexual activity. Thus, hygiene then becomes inadequate or nonexistent, a setup for inflammation and phimosis. As the population ages and more families are called on either to provide care or to institutionalize a member of the family, we in the field of health care must consider the effect of noncircumcision on all males and provide information and advice to those making the decision whether to circumcise an infant. Hopefully, that infant will grow up and always be able to care for himself, but in discussing this issue, we also need to consider the "what-ifs."
The pediatric community has long been in the forefront of preventive care. Pediatricians have led the way in educating the public to the need for infant immunizations, the need for proper diet and exercise, and the need for ongoing monitoring of growth and behavior patterns that contribute to a healthy childhood and adulthood. Among the aging, the fastest-growing segment of the population are those about 80 years of age, and as health care continues to improve, these numbers will continue to grow.
I suggest it is time to look at the decisions of circumcision as a preventive health concern for the later years with all pediatricians cognizant of how noncircumcision affects the elderly dependent male and his caregiver. I strongly urge my health care colleagues to include information from the gerontological perspective when providing information to parents contemplating circumcision.
VA Medical Center
Durham, NC 27705
REFERENCES
cause for concern. Pediatrics.
2000:105:620-623
To the Editor.
The recent article by Schoen et al1 adds little that is new to the body of work on increased UTIs in uncircumcised males, as noted in the excellent commentary by Wiswell, the originator of this line of investigation, which appears in the same issue.2
But as always, Dr Schoen persists in his advocacy of universal male circumcision. I note with interest that Dr Wiswell's commentary does not discuss this aspect of the article by Schoen et al, so I will take this opportunity to point out some issues.
Dr Schoen gives us an analysis of the cost of early UTIs in
uncircumcised males, and, yes, there is a significant cost, but he
fails to analyze the situation in reversethe cost of circumcising all
males in relation to savings from preventing UTIs and serious complications.
Assume for the sake of argument the worst case of 10% bacteremia, quoted in Wiswell's commentary,2 as the highest likely complication rate, or about 13 of the 14 893 males in the original cohort (note that the actual number of proven bacteremia cases in the Schoen study is 2). Also assume a conservative cost of $100 for each circumcision (including no costs for complications after circumcision). Over $1.48 million would be spent to prevent 129 total preventable UTIs (without congenital anomalies) and 12 to 13 cases of potentially serious complications with a total short-term treatment cost of $155 628 (cost of the care for the 3 congenital anomaly cases not excluded). This means for each UTI prevented by universal circumcision, the cost is $11 545! For each complicated case averted, the cost is $114 561! With universal circumcision, the cost of averting a single complication is on par with total short-term cost of care for all UTIs in the uncircumcised.
Before such an approach can even be considered, one must ask if any alternative is more effective in reducing complications. Dr Wiswell's comments on more aggressive screening of febrile infants, at least for those <6 months of age, for UTI is one such approach.2
Two other possible approaches also need study:
using a probe to free
foreskin adhesions, allowing more retraction of the newborn foreskin to
facilitate hygiene.
All 3 options above are likely to be far more cost-effective than universal circumcision, and also preserve the penile foreskin.
Until it is determined that any of these alternative approaches will
not reduce the rate of UTIs and complications from them in young
uncircumcised males, Dr Schoen's continued insistence on universal
male circumcision makes no more sense than the other favorite operation
of the 1950sthe ubiquitous tonsillectomy. I will go further and opine
that advocating any surgical procedure be universal is counterintuitive
and highly unlikely to meet reasonable cost-effectiveness criteria.
From a "medical necessity" point of view, circumcision must be considered a cosmetic procedure, not a medically justified operation.
San Diego, CA 92131
REFERENCES
To the Editor.
Recent studies by Schoen et al1,2 made use of the extensive database at Kaiser Permanente Medical Care Program of Northern California. Numerous potential confounding epidemiologic factors were not taken into consideration in the analysis of the possible association between circumcision status and either UTI or penile cancer.
With the Kaiser database that could have controlled for these factors, we were disappointed that the investigators chose to provide only a case series1 and a comparison of raw data.2
The incidence of UTI is influenced by rooming in,3 race,4 breastfeeding,5-7 prenatal maternal UTI,8 level of parental education,9 hygienic practices,10 previously bacterial or viral infection,7 previous course of antibiotic,7 premature birth,11-13 urine collection method,14-16 and diagnostic criteria.17 Whether neonatal circumcision fits in among these factors has yet to be adequately addressed. A Canadian study eliminated infants with perinatal problems and controlled for socioeconomic status. The association between a normal foreskin and UTI was lower than reported in other studies.18 Controlling for other confounding factors might prove there is no association between the normal foreskin and UTI.
Penile cancer has been linked to genital warts, number of sexual partners, smoking, and penile rashes.19 Schoen et al could have used their database to establish cohort controls, matched for year of birth, race, and socioeconomic status. Because the neonatal circumcision rate steadily increased during the early part of the 20th century, it is impossible to render useful information from a case series without matched controls.
The claims made by the authors exaggerate what their study design permits. We encourage Schoen et al to revisit their database and look forward to further analysis.
Marshfield, WI 54449-5795
Hazelhurst, WI
REFERENCES
To the Editor.
As our general pediatric inpatient team was seeing patients, we began a discussion concerning a 9-month-old uncircumcised male hospitalized with his first episode of UTI. The parents of the child had asked whether circumcision would have been beneficial in preventing the occurrence of UTI. To answer the parent's question, the team formed the clinical question: Among uncircumcised male infants, what is the risk of UTI as compared with circumcised males and what are the associated costs/benefits of such intervention?
A search was performed using PubMed1 and the keywords "UTI, uncircumcised, and children." In our search of the literature, the article by Schoen et al2 was reviewed. On initial inspection, this article seemed to provide overwhelming support of circumcision in decreasing the risk of UTI occurrence in male infants. However, from a cost-effective standpoint, we found that the savings from UTI prevention did not outweigh the cost of circumcision. According to the authors, the incidence of UTI in uncircumcised males is 1 in 39.6 control event rate (CER), as compared with 1 in 439.5 for circumcised male infants experimental event rate (EER). On further analysis of the data, we determined the absolute risk reduction (ARR) to be only 0.0230 (see Tables 1 and 2 for calculations). Using this information we determined that the number of male infants needing to be circumcised to prevent 1 episode of UTI was 43.5 (number needed to treat [NNT]). Using the authors' data that the cost of UTI is $1111 and our NNT of 43.5, we calculated that to make circumcision a cost-effective measure to decrease the incidence of UTI in males, the cost of circumcision would have to be >$25.54 per circumcision. This figure does not include the cost of complications occurring in circumcision. Similarly, we applied this data analysis to determine that the number of male infants needing to be circumcised to prevent 1 hospital admission is 146.
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Therefore, we conclude that although circumcision may be beneficial in decreasing the likelihood of UTI occurrence in male infants, it may be not a realistic or cost-effective strategy. We feel that this further analysis of the data presented by Schoen et al is needed to make a decision regarding the practice of performing circumcisions with the goal of preventing UTIs.
University of Cincinnati College of Medicine
Cincinnati, OH
Children's Hospital Medical Center
Cincinnati, OH
REFERENCES
To the Editor.
It's always invigorating to see old warriors remount old war horses. Dr Schoen, an unflagging advocate of routine male circumcision, is back, this time armed with statistics. Like the rest of us in this buck-shaving era of primary care, he's using dollars to prove why he's right. Let's take a closer look.
Like the abortion issue, assaying the truth goes beyond dollars, and circumcision policy isn't resolvable with a ledger. America's habituation to routine circumcision is not less aberrant viewed from a cost/benefit standpoint than it is looked at from a sociologic perspective. But, in terms of dollars expended, using Dr Schoen's current and credible figures, routine male circumcision is indefensible from a cost/benefit standpoint, as a standard of newborn care.
Examining the impressive follow-up of the large number of newborns studied, representing a contemporary population of infants in which a large proportion (35%) of the male newborns were not circumcised, Dr Schoen reiterates the figures first described by Wiswell et al: in the first year of life, baby boys born in California who retain their foreskins experience a 10-fold increase in UTI when compared with their circumcised peers.
Dr Schoen itemizes the cost of caring for 132 episodes of UTI in 5225 uncircumcised males, and notes that the cost of caring for the UTIs in the cohort of uncircumcised males exceeded the cost for caring for all the UTIs in their uncircumcised peers. Well and good. However, Dr Schoen doesn't bother to price out the other side of the circumcision coin.
Assuming it cost $250 to circumcise each boy, between supplies, nursing
care, and physician charges, it cost $2 417 000 to circumcise those
9668 baby boys, the 65% who experienced only 22 episodes of UTI.
Assuming a 10-fold reduction in UTI incidence, 120 of the 132 cases of
Schoen's figure of $1111 for the cost of caring for each male infant
diagnosed with UTI, circumcising all those boys who were left intact
would have saved $133 320 in male UTI care costs avoided. He fails to
mention it would have cost another $1 306 250 to do so. That'syou
bean counters$8.33 spent on circumcision for every $1 of UTI care
expense prevented. Such a deal! Considering all the time, pain, and
paperwork involved in routine circumcision in this country, it's no
wonder the rest of the civilized world of medical care looks at us and
just shakes it head. And, unlike the money our obstetrician colleagues
waste on routine fetal monitoring, we can't even blame it on the
lawyers.
Amherst Pediatrics
Amherst, NH 03031
In Reply.
Dr Bartman comments on the fact that infant urinary tract infections (IUTIs) develop in only 2% of uncircumcised male infants. This statement implies that infant circumcision is not an important health benefit because 98% of uncircumcised infants do not get IUTIs.
If all infant boys in the United States were left uncircumcised, that same annual incidence rate of 2% among 2 million newborn boys would represent 40 000 cases of IUTI in this country annually, making IUTI one of the most preventable diseases occurring in the first year of life.
Dr Bartman also states that circumcised men "suffer pain and permanent disfigurement." The 1999 American Academy of Pediatrics (AAP) Task Force Report on Circumcision1 documents that local methods of pain relief are safe and effective. As for appearance, if we accept Dr Bartman's assessment of the circumcised penis, the United States is home to >80 million permanently disfigured boys and men (ie, 70% of 120 million males). A study of sexually active women in middle America2 showed that about 75% preferred the circumcised penis, with 77% stating that it looked "more natural" (2:11) The well-known California writer, Anne Lamott (in her book Operating Instructions), decided to have her son circumcised because of ease of cleanliness and better appearance, believing that uncircumcised penises "look sort of marsupial, or like little rodents stuck in garden hoses" (3:25). Obviously, penile "beauty" versus "disfigurement" is in the eye of the beholder.
In his cost calculations, Dr Bartman fails to consider the point we
thought we made clear. Our cost figures simply represent the 10-fold
increased cost of IUTIs among uncircumcised boys during the first year
of life. Ours was not a cost-benefit study; such a study would require
determination of the lifetime medical benefits of circumcision and
would include calculation of the value of circumcision's preventive
effects not only on IUTI in the first year but on penile cancer, human
immunodeficiency virus (HIV), certain other sexually transmitted
diseases (STDs), balanoposthitis, penile dermatoses, phimosis,
andmost importanton the cost of postneonatal circumcision done for
whatever reason.
Circumcision done after the neonatal period costs about 10 times as
much as newborn circumcision done in the nursery before the infant is
discharged from the hospital. At our Kaiser Permanente (KP) hospitals,
the cost of circumcision for a newborn boy is about $200. (The figure
cited by Dr Bartman$382did not represent "costs" but instead
represented "charges," which can amount to whatever the free market
will bear). In the 3-year period 1996-1998, 573 postneonatal
circumcisions were done in KP-Northern California at a mean cost of
$1921 each. During this period, there were 11 149 uncircumcised
newborn boys, a postneonatal circumcision rate of 9.9%. Our costs for
neonatal and postneonatal circumcision are consistent with data of
Jayanthi et al.4 In Finland, which has a national health
care program in which routine newborn circumcision is not done, in the
period 1996 through 1998, 6438 postneonatal circumcisions were done
(generally for phimosis or balanoposthitis), during which time there
were 90 607 newborn boysa postneonatal circumcision rate of 7.1%
(M. Gissler, personal communication, February 7, 2000, National
Research and Development Centre for Welfare and Health [STAKES],
Helsinki, Finland).
The letters and calculations of Dr Goldenring, Dr Phelan and his 2 medical students, and Dr Canfield also confuse "cost differential" for treating IUTI in the first year of life with "cost benefit" of neonatal circumcision realized over a lifetime.
Despite the high risk ratios (RR) for invasive penile cancer and IUTI, Drs Cold and Storm raise the question of confounding factors. In studying IUTI and invasive penile cancer, all of the work comparing uncircumcised and circumcised men has found increased risk of disease in uncircumcised men. In cases of IUTI, the RR in uncircumcised men has varied from 3 to >50 times; and in cases of invasive penile cancer, the RR in uncircumcised men has varied from 3 times to an overwhelming multiple.5 Drs Cold and Storm chose studies with the lowest RR (ie, RR of about 3) in both conditions as examples of the effects of confounders.
A 300% increased risk is clinically significant, but both of the
studies chosen by Drs Cold and Storm are flawed in a way that could
explain the lower RR reported in those studies than in other studies.
Dr. Thomas Newman of the University of California, San Francisco, found
that IUTI is underdiagnosed because of failure of clinicians to obtain
urinalysis in febrile infants.6 Thus, a notable
observation is that easy access to laboratory facilities characterized
the studies that showed the greatest preventive effects of circumcision
against IUTI: a US military study,7 a study done in a
large health maintenance organization,8 and a study done
in an emergency department.9 In contrast, in the study by
To et al10which reported the experience of multiple
providers in various practice settingspoor laboratory availability
could have led to underestimation of IUTI incidence.
Our data clearly showed the invalidity of combining carcinoma in situ, a benign condition, with invasive penile cancer, a devastating disease: our comparison of uncircumcised and circumcised men showed an RR of 22 for invasive penile cancer and an RR of only 3 for carcinoma in situ.5 In Maden's study of penile cancer,11 carcinoma in situ and invasive penile cancer were analyzed together.
The comments of Ms Frank, a nurse at the Veterans Administration
Medical Center, raise the issue of genital hygiene later in life. These
comments supplement what we know about infant hygiene, ie, that proper
cleaning of the penis of an infant or a young boy can be difficult
because the foreskin may not physiologically separate from the glans
for monthsor even yearsand thus may leave secretions and bacteria
trapped. In men (especially many elderly men) who are physically unable
to care for themselves, inadequate hygiene in the presence of a
foreskin can result in major mechanical and psychologic problems. We
should thus be grateful to Ms Frank for another reminder that in
evaluating both the overall health value and cost benefits of newborn
circumcision, we must consider a lifetime of preventable health
effects. These include the combined effects of IUTIs in infancy; HIV
and other STD infections in young adults; penile cancer in older
adults; and phimosis, balanoposthitis, penile dermatoses, and genital
hygiene in boys and men of all ages.
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ACKNOWLEDGMENT |
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The Medical Editing Department, Kaiser Foundation Research Institute, provided editorial assistance.
Kaiser Permanente Medical Center
Oakland, CA 94611-5693
REFERENCES
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