Holzman Sarah A, Chamberlin Joshua D, Davis-Dao Carol A, Le Dao T, Delgado Vincent A, Macaraeg Amanda M, Dorgalli Crystal, Chuang Kai-Wen, Stephany Heidi A, Wehbi Elias J, Khoury Antoine E
UC Irvine and Children's Hospital of Orange County Department of Pediatric Urology, Orange, CA, USA.
Loma Linda Department of Pediatric Urology, Loma Linda, CA, USA.
J Pediatr Urol. 2021 Apr;17(2):209.e1-209.e6. doi: 10.1016/j.jpurol.2021.01.007. Epub 2021 Jan 9.
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.
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.
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.
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).
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.
Retractable foreskin reduces UTI risk in uncircumcised boys less than one year of age with VUR. Medical phimosis treatment to achieve a retractable prepuce offers an alternative and less invasive modality to reduce UTI risk in males with VUR.
未行包皮环切术的男性在出生后第一年发生尿路感染（UTI）的风险较高，对于患有膀胱输尿管反流（VUR）的男性，建议行包皮环切术。局部使用皮质类固醇乳膏成功治疗的未行包皮环切术男性发生UTI的风险降低，但对于患有VUR的男性，包皮处理的作用此前尚未得到探讨。
我们假设，在患有VUR的未行包皮环切术男孩中，包皮可上翻的男孩发生UTI的风险低于包皮不可上翻的男孩。
前瞻性纳入年龄小于1岁的原发性VUR男性。排除伴有其他泌尿系统诊断或随访时间少于1个月的患者。 phimosis严重程度按0-5级进行分级。主要结局为随访期间发生的UTI。患者分为三组进行分析：包皮环切组、轻度 phimosis（0-3级）和重度phimosis（4-5级）。采用多变量Cox比例风险回归分析来估计UTI风险，并对风险因素进行校正。
纳入105例患有VUR的男孩（24例行包皮环切术，81例未行包皮环切术）。入组时的中位年龄为4.4个月（四分位间距IQR 2.2-6.6），中位随访时间为1.1年（IQR 0.53-2.9）。phimosis 4-5级的男性UTI发生率（29%）高于phimosis 0-3级（4%）。根据Kaplan-Meier曲线，初始phimosis为4-5级的男孩发生UTI的可能性显著高于行包皮环切术或phimosis为0-3级的男孩（p = 0.005）。多变量分析显示，与phimosis 0-3级的男孩相比，phimosis 4-5级的男孩发生UTI的可能性显著更高（风险比HR = 8.4，95%置信区间CI：1.1-64，p = 0.04）。
与包皮不可上翻（重度phimosis）的男性相比，包皮可上翻的男性发生UTI的风险较低，多变量分析显示这一差异仍具有统计学意义。这与先前的研究结果一致，即包皮可上翻与UTI风险降低相关。我们研究的局限性包括在研究入组时使用phimosis分级以及我们研究人群中预防性抗生素使用的异质性。
包皮可上翻可降低年龄小于1岁、患有VUR的未行包皮环切术男孩发生UTI的风险。通过医学手段治疗phimosis以实现包皮可上翻，为降低患有VUR的男性发生UTI的风险提供了一种替代的、侵入性较小的方法。
