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Urethra Visibility Does Not Change UTI Risk


July 9, 2012 — All uncircumcised boys have a higher risk for acquiring a urinary tract infection, regardless of the degree of urethral meatus visibility (phimosis), according to a recent prospective cross-sectional study published online July 9 in theCanadian Medical Association Journal.
Alexander Sasha Dubrovsky, MDCM, a physician in the Division of Pediatric Emergency Medicine at Montreal Children's Hospital, McGill University Health Centre, Quebec, Canada, and colleagues explain that urinary tract infections are much more common in uncircumcised boys than in circumcised boys, and that some believe that the visibility of the urethral meatus (phimosis) plays a role, with the highest risk being in boys whose meatus is partially visible or nonvisible.
Dr. Dubrovsky and colleagues conducted a prospective cross-sectional study in a tertiary care pediatric emergency department of boys aged 3 years or younger who were not yet toilet trained and who had catheter-obtained urine culture ordered. Patients were screened for enrollment between April 2007 and December 2009 and were excluded if they had received antibiotics within 72 hours before their emergency department visit, catheter insertion within the previous 7 days, or any genitourinary anomalies that prevented catheter insertion.
Study participants were placed into 1 of 3 groups: circumcised boys, uncircumcised boys with a partially or nonvisible urethral meatus, and uncircumcised boys with an entirely visible meatus.
Participant Characteristics
Of the 404 patients enrolled in the study, urine culture results were available for 393 boys. Of those children, 40 boys were uncircumcised with a completely visible meatus, 106 had a partially visible meatus, 163 had a nonvisible meatus, and 84 were circumcised. Phimosis was assessed by the nurse at the time of catheterization.
The median age of the participants was 3.9 months (interquartile range [IQR], 1.5 - 11.2 months); 44.0% (173/393) of the boys were younger than 3 months. Uncircumcised boys with a completely visible meatus were older (11.6 months; IQR, 2.8 - 18.5 months) than the boys with a partially or nonvisible meatus (3.4 months; IQR, 1.4 - 8.9 months).
The meatus was completely visible in only 7.9% (11/140) of uncircumcised boys younger than 3 months compared with 32.3% (20/62) of boys aged 12 months or older.
Caution Urged
A total of 80/393 boys (20.4%) had urinary tract infections. Of those with a completely visible meatus, 30.0% (12/40) had urinary tract infection compared with 23.8% (64/269) of boys with a partially or nonvisible meatus (P = .4).
The unadjusted odds ratio for urinary tract infection in boys with a partially or nonvisible meatus compared with those with a completely visible meatus was 0.73 (95% confidence interval [CI], 0.35 - 1.52).
The only variable the researchers retained in their multivariable logistic regression was age. The adjusted odds ratio was 0.41 (95% CI, 0.17 - 0.95; P = .04). This suggests the possibility that the risk for urinary tract infection is significantly lower among boys with a partially or nonvisible meatus compared with boys with a completely visible meatus, the authors write.
"Although we cannot exclude the possibility that [boys with a completely visible meatus are] truly at higher risk (contrary to our hypothesis), this result should be interpreted with caution given the small number of participants in the completely visible group," the authors write. "Furthermore, no previous studies suggest such an association, nor is there an apparent physiologic mechanism to explain this finding."
All Uncircumcised Boys at Higher Risk
"Our results suggest that uncircumcised boys presenting with clinical symptoms or signs suggesting urinary tract infection are at equal risk for urinary tract infection irrespective of the visibility of the urethra. Clinicians should continue to use circumcision status alone, not the degree of phimosis, to decide which boys should undergo investigation for urinary tract infection," the authors conclude.
This study was funded by the Montreal Children's Hospital Research Institute Clinical Projects Funding Competition for fellowship projects. All of the authors are members of the Research Institute of the McGill University Health Centre, which is supported by the Fonds de Recherche du Québec–Santé. The authors have disclosed no other relevant financial relationships.

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