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Routine neonatal circumcision for the prevention of urinary tract infections in infancy

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Authors

Vanitha A Jagannath1, Zbys Fedorowicz2, Vikas Sud3, Abhishek Kumar Verma3, Sakineh Hajebrahimi4

Background - Methods - Results - Characteristics of Included Studies - References


1Department of Paediatrics, American Mission Hospital, Manama, Bahrain [top]
2UKCC (Bahrain Branch), The Cochrane Collaboration, Awali, Bahrain [top]
3MBBS, Kasturba Medical College, Manipal, India [top]
4Urology, Tabriz University of Medical Sciences, Tabriz, Iran [top]

Citation example: Jagannath VA, Fedorowicz Z, Sud V, Verma AKumar, Hajebrahimi S. Routine neonatal circumcision for the prevention of urinary tract infections in infancy. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD009129. DOI: 10.1002/14651858.CD009129.pub2.

Contact person

Zbys Fedorowicz

UKCC (Bahrain Branch)
The Cochrane Collaboration
Box 25438
Awali
Bahrain

E-mail: zbysfedorowicz@gmail.com

Dates

Assessed as Up-to-date: 30 August 2011
Date of Search: 30 June 2011
Next Stage Expected: 30 August 2013
Protocol First Published: Issue 5, 2011
Review First Published: Issue 11, 2012
Last Citation Issue: Issue 11, 2012

Abstract

Background

Neonatal circumcision is a fairly common surgical procedure that may be carried out for medical reasons, one of them being prevention of urinary tract infections (UTI) in male infants. Circumcision could help in reducing the incidence of UTI by reducing periurethral bacterial colonization, which is accepted as a potential risk factor in UTI. Evidence is needed to inform the benefits or harm for the routine use of this intervention.

Objectives

To assess the effectiveness and safety of routine neonatal circumcision for the prevention of UTIs in infancy.

Search methods

We searched the Cochrane Neonatal Review Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We completed this search 30 June 2011.

Selection criteria

Randomised controlled trials and quasi-randomised controlled trials.

Data collection and analysis

Two review authors had planned to independently screen studies, extract data and assess risk of bias using standard Cochrane Collaboration methodologies. We did not identify any studies for inclusion in this review.

Results

We did not identify any relevant studies after a comprehensive search of the literature.

Authors' conclusions

We were unable to identify any randomised controlled trials on the use of routine neonatal circumcision for prevention of UTI in male infants. Until further evidence becomes available, clinicians should continue to base their decisions on position statements and recommendations and in conjunction with the opinions of the children's parents.

Plain language summary

Newborn circumcision for the prevention of urinary tract infections in infancy

Routine neonatal circumcision is a fairly common surgical procedure that may be carried out for medical or religious reasons. The incidence of urinary tract infection (UTI) is greater in uncircumcised babies. Circumcision is a relatively simple procedure and is associated with minimal complications when carried out in neonates rather than in later life. We did not find any trials to support or refute the effectiveness of routine neonatal circumcision to prevent UTI in infancy. Although limited data from previous studies have shown that this intervention might be beneficial, questions regarding the safety and effectiveness of routine neonatal circumcision for the prevention of UTIs in infancy remain unanswered.

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Background

Routine neonatal circumcision is a fairly common surgical procedure (To 1998) that may be carried out for medical or religious reasons. The potential medical benefits include reduced occurrence of urinary tract infections (UTI) in infancy and a reduced risk of sexually transmitted diseases (STD) such as HIV, penile cancer, phimosis, human papilloma virus-related cervical cancer in female sexual partners in later life, HSV2, genital ulcers, and bacterial vaginosis (Alanis 2004). Circumcision is a relatively simple procedure and is in general associated with minimal complications (Wiswell 1990).

It has been suggested that newborn circumcision can be a valuable preventive health measure for UTI in infancy (Schoen 2000). A systematic review and meta-analysis (Amato 1992) of newborn circumcision concluded that the risk of UTI may decrease with circumcision but, given that the risk of UTI during the first year of life is itself low, a recommendation for routine circumcision may not be justified. The conclusions from a more recent review (Singh-Grewal 2005) indicated that although circumcision reduces the risk of UTI there was an attendant risk of complications and that the net clinical benefits are only achievable in boys at high risk of UTI. Regular foreskin hygiene is important for all males to prevent UTI (Robson 1992), but there is no evidence that many of the potential medical benefits of circumcision can be achieved by simple daily penile hygiene (Wiswell 1990; Tobian 2010). While the procedure appears to be beneficial in the prevention of UTI, a number of studies have shown that UTI may itself present as a complication of circumcision (Cohen 1992).

Neonatal circumcision rates vary widely at the global level, with rates as high as 64% in North America (American Academy of Pediatrics 1999), between 10% and 20% in Australia (Royal Australasian College of Physicians 2002), and much lower rates in Europe and Asia (American Academy of Pediatrics 1999). See Figure 1.

Neonatal circumcision continues to be a controversial subject. The American Academy of Pediatrics has revised its earlier policy, stating that newborn circumcision has potential benefits as well as risks, and emphasizes the need to explain these issues to parents who are considering the procedure so that an informed decision can be made (American Academy of Pediatrics 1999).

Many of the paediatric societies (Canadian Pediatric Society 1996; Royal Australasian College of Physicians 2002) oppose routine circumcision, but consider it an acceptable intervention for recurrent balanitis (inflammation of the glans penis), true phimosis (where the foreskin cannot be fully retracted over the glans penis) and UTI. Although American Academy of Pediatrics 1999 and American Urological Association 2007 have listed the advantages and disadvantages of neonatal circumcision they have left the onus on parents to make an informed decision.

Description of the condition

Urinary tract infections occur in 1% to 2% of neonates with a female:male ratio of 1:5 during infancy. Predisposing factors during infancy include anatomic abnormalities and obstructions of the urinary tract, pre-term birth and indwelling catheters (Barnett 1997). Most UTIs are caused by Escherichia coli (E. coli), and gram negative enterobacteria like Klebsiella, Proteus mirabilis, and Pseudomonas aeruginosa (Barnett 1997).

Antibiotics are the main stay of treatment (Rubin 1992). With careful management UTI rarely progresses to complications. However, repeated infections, especially in those with underlying urinary tract abnormalities, may cause renal scarring, hypertension and more rarely, lead to renal failure.

Description of the intervention

Circumcision is a surgical procedure in which the foreskin is removed from the penis, which can decrease microbial colonisation in the periurethral area and hence reduce the incidence of UTI (Wiswell 1988; Price 2010). It may also remove the protective sub-preputial moisture and antibacterial lysozyme (Fleiss 1998) and potentially be a source of UTI (Winberg 1989).

Usually circumcision is performed by either of the following two techniques. The first technique is a Plastibell circumcision device which is placed over the glans of a neonate and the foreskin is excised, the device falls off after five to seven days. This is the most commonly employed method. The second technique uses the Gomco Clamp in which the skin is clamped within the clamp and the circumcision occurs within five minutes. However, this technique has been almost completely replaced by the plastibell. Both of these techniques are performed under local anaesthesia.

The overall complication rate of circumcision is between 0.2% and 0.6% (American Academy of Pediatrics 1999), with most complications being categorised as minor (Griffiths 1985). Haemorrhage is the most frequent acute complication followed by infection, glandular ulceration, urethral fistula formation and even penile amputation. Long-term complications include meatal stenosis (narrowing of the opening of the urethra) and poor cosmetic results (Williams 1993).

How the intervention might work

The urethral meatus of uncircumcised male infants has been found to harbour more uropathogenic organisms than that of circumcised male infants, although this tends to decrease in both groups after the first six months. This would appear to be a biologically plausible explanation for a relationship between an intact foreskin and increased UTI during infancy (Wiswell 1988). These bacteria have also been shown to be more adherent to the mucosal surface of the foreskin than the keratinized surface (Fussell 1988). Circumcision could, therefore, help in reducing the incidence of UTI by reducing periurethral bacterial colonization, which is accepted as a potential risk factor in UTI.

Why it is important to do this review

Male circumcision is a surgical procedure that has been performed for cultural, religious social, and medical reasons for a long time and whilst it continues to receive some attention the perceived benefits are still very much in dispute. Although there appear to be many benefits and a low risk of major complications with elective circumcision carried out during the neonatal period, some have argued that the complications outweigh the benefits (Pieretti 2010). A number of position statements have been developed on circumcision which conclude that there is insufficient evidence to recommend routine neonatal circumcision, but suggest that parents should be involved in the decision making process. At this point much of the data about the putative benefits and risks of neonatal circumcision to prevent UTI come from observational studies and the recommendations on this topic are based on them.

The policies and recommendations on this topic have transformed over time with accumulating evidence to support both the relative risks as well as benefits. As one of the suggested benefits of neonatal circumcision is prevention of UTI in male infants, we aim to evaluate this aspect in this systematic review.

Objectives

To assess the effectiveness and safety of routine neonatal circumcision for the prevention of UTIs in infancy.

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Methods

Criteria for considering studies for this review

Types of studies

We considered randomised controlled trials (RCT), quasi-randomised controlled trials and cluster-randomised trials as eligible for this study.

Types of participants

All male newborns with or without urogenital anomalies.

Types of interventions

Medical circumcision performed at the time of birth or within the first four weeks of life, compared with, as control, the uncircumcised state, with or without penile hygiene instructions provided by a healthcare provider.

The following comparisons were considered if studies were identified:

  • safety and effectiveness if the timing of the circumcision procedure is before three days and three days postnatal age;
  • effectiveness between groups defined by the presence or absence of urogenital anomalies;
  • safety and effectiveness between different techniques of the circumcision procedure.

Types of outcome measures

Primary outcomes

Urinary tract infection (UTI): a positive urine culture from a bag or clean-catch specimen/supra pubic puncture/urinary catheter collection in the presence of urinary symptoms or, for asymptomatic UTI, from any sample collected during the regular well baby visits or otherwise.

  1. Proportion of infants with UTI.
Secondary outcomes
  1. Total number of episodes of UTI in infancy.
  2. Proportion of infants with more than one episode of UTI.
  3. Complications of the intervention: proportion of infants.
  4. Infants who had complications (bleeding, infection, or other).
  5. Complications of UTI, proportion of infants who exhibited any of the complications of UTI:
    • renal scarring (renal parenchymal defects assessed with intravenous pyelogram (IVP) or dimercaptosuccinic acid (DMSA) scan);
    • renal failure (reported based on serum creatinine levels, glomerular filtration rate or urine output);
    • renal stones;
    • renal hypertension defined as an average systolic or diastolic blood pressure, or both, > 95th percentile for gender, age, and height on three or more separate occasions (Falkner 2004);
    • others, if any, in the follow-up of infants with UTI.

We planned to consider all outcome measures at three months, six months and one-year end points, while the complications of surgery were to be considered at or before three days, and later.

Search methods for identification of studies

Electronic searches

We used the standard search strategy of the Cochrane Neonatal Review Group, as outlined in The Cochrane Library. We did consider unpublished studies as eligible for this review.

We developed detailed search strategies for each database searched for the identification of studies to be included or considered for inclusion in this review. We based these search strategies on the search strategy developed for MEDLINE, but revised appropriately for each database.

Our search strategy included the following MeSH terms and text-words in our search of MEDLINE and PreMEDLINE (via the Ovid interphase): bleeding, circumcision, infant, newborn, neonate, routine, renal failure, renal scars, and urinary tract infections.

We searched the following databases:

  • Cochrane Neonatal Group Trials Register;
  • Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 6 2011);
  • MEDLINE (from 1950 to June 2011);
  • EMBASE (from1980 to June 2011).

For the MEDLINE search, we ran the subject search with the Cochrane highly sensitive search strategy (CHSSS) for identifying randomised trials in MEDLINE, sensitivity maximising version (2009 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 (updated March 2011) (Higgins 2011).

We limited searches to “randomised and quasi-randomised clinical trials”.

Searching other resources

We examined the reference lists of relevant articles and we handsearched journals in accordance with the recommendations of the Cochrane Neonatal Group.

We also searched clinical trials registries for ongoing or recently completed trials: (ClinicalTrials.gov, Controlled-Trials.com External Web Site Policy, and WHO International Clinical Trials Registry Platform (ICTRP) External Web Site Policy) in June 2011.

We did not apply any language restrictions on studies and if studies were identified in languages other than English, these would have been translated prior to assessment for eligibility.

Data collection and analysis

Selection of studies

Two review authors [Zbys Fedorowicz (ZF) and Vikas Sud (VS)] independently assessed the abstracts of studies resulting from the searches. We obtained full copies of all relevant and potentially relevant studies, those appearing to meet the inclusion criteria and for which there were insufficient data in the title and abstract to make a clear decision. Two review authors independently assessed the full text papers and any disagreements were resolved through discussion and consensus or, if necessary, through a third author Vanitha Jagannath (VJ). We did not find any eligible studies for inclusion.

Data extraction and management

If studies had been included in the review, the following details would have been entered into the table 'Characteristics of Included Studies'.

  1. Trial methods: (a) method of allocation; (b) allocation concealment (adequate, unclear, inadequate or not used); (c) masking of participants, trialists, and outcome assessors; (d) exclusion of participants after randomisation and proportion and reasons for losses at follow-up.
  2. Participants: (a) country of origin and study setting; (b) sample size; (c) breast feeding history; (d) urogenital anomalies; (e) inclusion and exclusion criteria.
  3. Intervention: (a) type of surgery; (b) day of life when surgery done; (c) duration of intervention in follow-up.
  4. Control: (a) If any blinding procedure is done.
  5. Outcomes: (a) primary and secondary outcomes mentioned in the Types of outcome measures section of this review, to include any reported adverse effects.

Assessment of risk of bias in included studies

Although no trials were identified for inclusion, we will apply the following methods for future updates. All eligible trials will be graded using a simple contingency form and follow the domain-based evaluation described in Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 (Higgins 2011). The evaluations will be compared and any inconsistencies in these evaluations between the review authors will be discussed and resolved.

The following domains will be assessed and categorised as 'low risk', 'unclear risk', or 'high' risk of bias:

  1. sequence generation;
  2. allocation concealment;
  3. blinding (of participants, personnel and outcome assessors);
  4. incomplete outcome data addressed;
  5. free of selective outcome reporting;
  6. free of other bias.

The overall risk of bias of any included trials will be categorised accordingly:

  • low risk of bias (plausible bias unlikely to seriously alter the results) if all criteria were met;
  • unclear risk of bias (plausible bias that raises some doubt about the results) if one or more criteria were assessed as unclear; or
  • high risk of bias (plausible bias that seriously weakens confidence in the results) if one or more criteria were not met.

Measures of treatment effect

We did not enter any data into the RevMan analysis, but if data are available in future updates, we will calculate risk ratios (RR) and their associated 95% confidence intervals (CIs) for dichotomous outcomes. For continuous outcomes, we will report the mean difference (MD) or the standardized mean difference (SMD) if different scales are used.

Unit of analysis issues

Unit of analysis issues that might arise may be as a result of recurrences or repeat episodes of UTI in a patient. If the studies had reported the proportion of participants with episodes of UTI or number of episodes of UTI per participant per unit time, they would have been compared and analysed accordingly. We would have followed the advice provided in Section 16.3.4 of the Cochrane Handbook for Systematic Reviews of Interventions(Higgins 2011).

No cluster-randomised trials were identified for inclusion in this review. In future updates, if cluster-randomised trials are included, we will follow the recommendations provided in Chapter 16.3 of the Cochrane Handbook for Systematic Reviews of Interventions(Higgins 2011).

Dealing with missing data

No trials were included in this review, but in future updates the following methods of dealing with missing data will apply. We will try to obtain missing data directly from the investigators of any of the included studies. When this is not possible, we will analyse the available data (that is ignoring the missing data) in addition to conducting further analyses by imputation (both best- and worst-case scenarios) and last observation carried forward (LOCF) to the final assessment, for dichotomous and continuous outcome data respectively.

For dichotomous outcomes, we will carry out both best- and worst-case scenarios and intention-to-treat (ITT) analyses. We will then compare results obtained from the two analysis options to enable a better understanding of the robustness of results relative to the different analytic approaches. We will consider an imputation approach of best-case scenarios (that is all missing participants in the intervention group did not experience poor outcomes (such as death, bronchopulmonary dysplasia (BPD) and all missing participants in the control group experienced poor outcomes) and worst-case scenarios (that is all missing participants in the intervention group experienced the event and all missing participants in the control condition did not). We would also conduct sensitivity analyses to compare results based on different imputation assumptions (that is best- versus worst-case scenarios).

We will analyse missing continuous data on an end point basis, including only participants with a final assessment or analysed using LOCF if the trial authors reported any LOCF data.

If unsuccessful, or if the discrepancies are significant, we will provide a narrative synthesis of the data as presented in the individual reports.

Assessment of heterogeneity

As no studies were included, we were unable to assess clinical heterogeneity. In future updates we will assess heterogeneity by examining the characteristics of the studies, the similarity between the types of participants, the interventions, and the outcomes as specified in the criteria for included studies. Statistical heterogeneity will be assessed using a Chi2 test and the I2statistic, where I2 values of 30% to 50% indicate moderate to high, 50% to 75% substantial, and 75% to 100% considerable heterogeneity. We will consider heterogeneity to be significant when the P value is less than 0.10 (Higgins 2003).

Assessment of reporting biases

If sufficient trials had been identified for inclusion in this review, publication bias would be assessed according to the recommendations on testing for funnel plot asymmetry (Egger 1997) as described in section 10.4.3.1 of the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 (updated March 2011) (Higgins 2011). If asymmetry had been identified, we would have tried to assess other possible causes of asymmetry and these would have been explored in the discussion, if appropriate.

Data synthesis

We planned that two review authors (ZF and VS) would have analysed the data as specified in Chapter 9 of the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 (Higgins 2011). No studies were included but in future updates the following methods of data synthesis will apply. If a sufficient number of studies investigating similar interventions are included, analysis will be conducted in RevMan (RevMan 2011). If adequate data are available, we will calculate a pooled estimate of effect of specific interventions together with the corresponding 95% CIs.

In general the fixed-effect method should be used for the meta-analysis but if significant heterogeneity is found between the studies, a meta-analysis may not be undertaken. In the event that there are insufficient clinically homogenous trials, or insufficient data for pooling, the results of the individual trials will be presented and only a descriptive analysis will be performed.

Subgroup analysis and investigation of heterogeneity

If a sufficient number of studies of moderate, substantial, or considerable heterogeneity (as defined above) are identified in future updates, we will carry out subgroup analyses in the following categories:

  • timing of circumcision: < 3 days or after 3 days (post natal days);
  • presence or absence of urogenital anomalies;
  • technique of circumcision (Mogen clamp, Gomco clamp, or Plastibell device);
  • method of sample collection for urine analysis (bag, catheter, or suprapubic).

Sensitivity analysis

As no studies were included, we were unable to undertake a sensitivity analysis. In future updates the robustness of our review results will be assessed by repeating the analysis with the following adjustments: exclusion of studies with unclear or inadequate allocation concealment, unclear or inadequate blinding of outcomes assessment or completeness of follow-up.

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Results

Description of studies

No eligible studies were identified in the comprehensive searches undertaken for this review .

Risk of bias in included studies

No studies were included in this review.

Effects of interventions

No studies were included in this review.

Discussion

The comprehensive search used in this review provided no references to relevant studies. The lack of relevant randomised controlled trials, as well as any robust evidence to support or refute the use of routine neonatal circumcision for prevention of UTI in infancy, highlighted the lack of sound evidence on the subject, hence the guidelines advocated by professional agencies may not have an adequate scientific basis. Over the last 10 years there have been several observational studies and reviews evaluating the effectiveness of routine neonatal circumcision for prevention of UTI in infancy (Amato 1992; Singh-Grewal 2005). Although these studies have provided some limited data, questions still remain unanswered as to whether treatment options based on this intervention can be considered both effective and safe for routine and universal recommendation.

Agreements and disagreements with other studies or reviews

We identified a systematic review (Singh-Grewal 2005) that reviewed the effect of circumcision on the risk of UTI in boys. This review identified 12 studies with data on 402, 908 children and included studies with a variety of designs (one randomised controlled trial, four cohort studies, and seven case–control studies). The only RCT (Nayir 2001) studied the effect of circumcision on boys with microbiologically confirmed UTI. Seventy uncircumcised patients age three months to 10 years with proven UTI were recruited and then randomised into circumcision and non-circumcision groups.

Overall, the analysis reported that circumcision was associated with a significantly reduced risk of UTI (OR  =  0.13; 95% CI, 0.08 to 0.20) with the same odds ratio (0.13) for all three types of study design (Singh-Grewal 2005). However, the above mentioned studies do not address the effect of routine neonatal circumcision on UTI in infant boys.

Authors' conclusions

Implications for practice

The evidence from this review does not at present allow confident decision-making about the use of routine neonatal circumcision for prevention of UTI in infancy, since there were no included studies in the review. Until further evidence becomes available, clinicians should continue to base their decisions on regional position statement recommendations (American Academy of Pediatrics 1999; American Urological Association 2007) in conjunction with the parents' opinions in individual circumstances.

Implications for research

As this review provided no evidence, there is a need for further randomised controlled trials which can help provide better insight into the potential benefits and harms associated with this intervention.

These RCTs should be adequately powered, multi-centred and with a focus on outcomes that are meaningful to parents to assist them in making choices. Future trials should assess not only the benefit but also the safety of the procedure. They will need to be rigorous in design and delivery, with subsequent reporting to include high quality descriptions of all aspects of methodology to enable appraisal and interpretation of results, and conform to the Consolidated Standards of Reporting Trials (CONSORT External Web Site Policy) statement.

Acknowledgements

The authors would like to acknowledge the help they have received in developing this review from the Cochrane Neonatal Review group.

Editorial support of the Cochrane Neonatal Review Group has been funded with Federal funds from the Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA, under Contract No. HHSN267200603418C

Contributions of authors

Vanitha Jagannath (VJ), Zbys Fedorowicz (ZF), Vikas Sud (VS), Abhishek Kumar Verma(AV), Sakineh Hajebrahimi (SH) were responsible for:

  • organising the retrieval of papers;
  • writing to authors of papers for additional information;
  • screening search results;
  • screening retrieved papers against inclusion criteria;
  • appraising the quality of papers;
  • data collection for the review;
  • extracting data from papers;
  • obtaining and screening data on unpublished studies.

ZF and VJ were responsible for entering data into RevMan and will be responsible for analysis and interpretation of the data in future updates of the review.
All review authors contributed to writing the review.
All review authors were responsible for designing and co-ordinating the review and for data management for the review.
ZF, VJ, and VS conceived the idea for the review and are the guarantors for the review.

Declarations of interest

There are no financial conflicts of interest and the review authors declare that they do not have any associations with any parties who may have vested interests in the results of this review.

Potential conflict of interest

  • None noted.

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Characteristics of studies

Characteristics of Included Studies

  • None noted.

Characteristics of excluded studies

Singh-Grewal 2005

Reason for exclusion

This review studies the effect of circumcision on boys of ages 3 months to 12 years with confirmed UTI and evaluates recurrent episodes of UTI as the outcome.

Footnotes

UTI: urinary tract infection

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References to studies

Included studies

  • None noted.

Excluded studies

Singh-Grewal 2005

Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Archives of Disease in Childhood 2005;90(8):853-8.

Studies awaiting classification

  • None noted.

Ongoing studies

  • None noted.

Other references

Additional references

Alanis 2004

Alanis MC, Lucidi, RS. Neonatal circumcision: a review of the world's oldest and most controversial operation. Obstetrical and Gynecological Survey 2004;59(5):379-95.

Amato 1992

Amato D, Garduno-Espinosa J. Circumcision in the newborn child and risk of urinary tract infection during the first year of life. A meta-analysis [Circuncision en el nino recien nacido y el riesgo de presentar infeccion de vias urinarias durante el primer ano de vida. Un meta-analisis.]. Boletin medico del Hospital Infantil de Mexico 1992;49(10):652-8.

American Academy of Pediatrics 1999

American Academy of Pediatrics. Task Force on Circumcision. Circumcision policy statement. Pediatrics 1999;103(3):686-93.

American Urological Association 2007

Circumcision Policy Statement. http://www.auanet.org/content/guidelines-and-quality-care/policy-statements/c/circumcision.cfm.

Barnett 1997

Barnett BJ, Stephens DS. Urinary tract infection: an overview. American Journal of the Medical Sciences 1997;314(4):245-9.

Canadian Pediatric Society 1996

Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. Canadian Medical Association Journal 1996;154(6):769-80.

Cohen 1992

Cohen HA, Drucker MM, Vainer S, Ashkenasi A, Amir J, Frydman M, et al. Postcircumcision urinary tract infection. Clinical Pediatrics 1992;31(6):322-4.

Egger 1997

Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315(7109):629-34.

Falkner 2004

Falkner B, Daniels SR. Summary of the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Hypertension 2004;44(4):387-8.

Fleiss 1998

Fleiss PM, Hodges FM, Van Howe RS. Immunological functions of the human prepuce. Sexually Transmitted Infections 1998;74(5):364-7.

Fussell 1988

Fussell EN, Kaack MB, Cherry R, Roberts JA. Adherence of bacteria to human foreskins. Journal of Urology 1988;140(5):997-1001.

Griffiths 1985

Griffiths DM, Atwell JD, Freeman NV. A prospective survey of the indications and morbidity of circumcision in children. European Urology 1985;11(3):184-7.

Higgins 2003

Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327(7414):557-60.

Higgins 2011

Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.

Nayir 2001

Nayir A. Circumcision for the prevention of significant bacteriuria in boys. Pediatric Nephrology 2001;16(12):1129-34. [PubMed: 11793114]

Pieretti 2010

Pieretti RV, Goldstein AM, Pieretti-Vanmarcke R. Late complications of newborn circumcision: a common and avoidable problem. Pediatric Surgery International 2010;26(5):515-8.

Price 2010

Price LB, Liu CM, Johnson KE, Aziz M, Lau MK, Bowers J, et al. The effects of circumcision on the penis microbiome. PloS One 2010;5(1):e8422. [PubMed: 20066050]

RevMan 2011

Review Manager (RevMan) [Computer program]. Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.

Robson 1992

Robson WL, Leung AK. The circumcision question. Postgraduate Medicine 1992;91(6):237-42, 244.

Royal Australasian College of Physicians 2002

Paediatrics and Child Health Division. Policy statement on circumcision. www.racp.edu.au/hpu/paed/circumcision/index.htm#toc 2002.

Rubin 1992

Rubin RH, Shapiro ED, Andriole VT, Davis RJ, Stamm WE. Evaluation of new anti-infective drugs for the treatment of urinary tract infection. Infectious Diseases Society of America and the Food and Drug Administration. Clinical Infectious Diseases 1992;15 Suppl(1):216-27.

Schoen 2000

Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Pediatrics 2000;105(4 Pt 1):789-93.

To 1998

To T, Agha M, Dick PT, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet 1998;352(9143):1813-6.

Tobian 2010

Tobian AA, Gray RH, Quinn TC. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Archives of Pediatrics & Adolescent Medicine 2010;164(1):78-84. [PubMed: 20048246]

Williams 1993

Williams N, Kapila L. Complications of circumcision. The British Journal of Surgery 1993;80(10):1231-6.

Winberg 1989

Winberg J, Bollgren I, Gothefors L, Herthelius M, Tullus K. The prepuce: a mistake of nature? Lancet 1989;1(8638):598-9.

Wiswell 1988

Wiswell TE, Miller GM, Gelston HM Jr, Jones SK, Clemmings AF. Effect of circumcision status on periurethral bacterial flora during the first year of life. Journal of Pediatrics 1988;113(3):442-6.

Wiswell 1990

Wiswell TE. Routine neonatal circumcision: a reappraisal. American Family Physician 1990;41(3):859-63.

Other published versions of this review

  • None noted.

Classification pending references

  • None noted.

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Figures

Figure 1

Refer to figure 1 caption below.

Global prevalence of circumcision (Figure 1 description)

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Sources of support

Internal sources

  • No sources of support provided.

External sources

  • Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA
  • Editorial support of the Cochrane Neonatal Review Group has been funded with Federal funds from the Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA, under Contract No. HHSN275201100016C

This review is published as a Cochrane review in The Cochrane Library, Issue 11, 2012 (see http://www.thecochranelibrary.com External Web Site Policy for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback. The Cochrane Library should be consulted for the most recent version of the review.