Circumcision and Urinary Tract Infections

Some evidence shows that circumcised boys have a lower chance of developing urinary tract infections (UTIs) in their first years of life, but the added protection  may be miniscule, say Dr. Elias Wehbi, a CHOC pediatric urologist, and Maryellen Kelly, CHOC nurse practitioner.

CHOC Children's Urology Center

Learn more about circumcision’s possible effects on UTI rates and get answers to other questions about this common ailment in the following Q & A.

Does circumcision help boys reduce the risk of UTIs?

One study that looked at the amount and type of bacteria around the penis before and after circumcision found a significantly greater amount of bacteria under the foreskin in uncircumcised boys. These bacteria are precisely the kinds of germs that can make their way into the urinary tract and cause an infection.

Some studies show a three- to ten-fold decrease in UTI rates in circumcised boys. However, because the rates of UTIs are already relatively low in boys, that finding means 50 to 100 boys would need to be circumcised to prevent one UTI in one boy, who might not have otherwise developed an infection.

Considering this, the decision to circumcise boys should be made with both the family and the physician working closely together to evaluate all the cultural and medical issues.

Are UTIs more common in boys or girls?

During the first year of life, boys and girls get UTIs at about the same frequency. After age 1, females are more likely to have a UTI because of the channel from their bladder to the exterior, or the urethra, is shorter. Another theory for higher risk of infections in females is that increased moist tissue and folds of females’ genitals might allow bacteria to colonize the area more easily.

What symptoms could indicate a UTI?

Identifying a UTI in young children can be difficult because they aren’t vocal. In many infants, a high-grade fever will be their first or only symptom. Older children might complain of abdominal pain; painful urination; burning when urinating; increased frequency and urgency of urination; blood in their urine; or urinary incontinence. These symptoms are the same for boys and girls.

How are UTIs treated?

Children with UTIs should be treated with appropriate antibiotics that are specific to the bacterium that has infected their bladder. Following treatment, parents and children should receive education about preventing infections.

Baby boys with a very tight foreskin and recurrent UTIs may be offered a circumcision or a topical steroid cream to try to loosen their foreskin so that better hygiene can be conducted to reduce their risk or a another infection.

How can UTIs be prevented in children?

Hydration is important in preventing UTIs. All children should drink at least one 8 ounce glass of water for each year of age until they are 8. For example, a 4-year-old should drink four glasses of water daily.

We also encourage children to urinate frequently, about once every two to three hours. Holding of urine is a major risk factor for more UTIs. Bacteria in a bladder doubles in quantity every 30 minutes, so it is important children don’t hold their urine for extended time periods.

Constipation is another risk factor. Families should focus on eating high-fiber foods and drinking plenty of water to help children achieve daily soft bowel movements that will reduce their likelihood of UTIs.

Learn more about urology services at CHOC.

Four Ways to Prevent Urinary Tract Infections in Children

Urinary tract infections are a common and painful ailment for children, but a few simple strategies can go a long way toward keeping the problUTI_Prevention_Tips_CHOCem at bay, says Dr. Antoine Khoury, medical director of urology at CHOC.

Dr. Khoury offers four measures parents and children can take to promote good urinary tract health in kids.

Drink lots of water

Parents should encourage children to stay hydrated.

“Water is really important,” explains Dr. Khoury. “Drinking water increases the volume of urine. This helps the child flush bacteria from their bladder out.”

A dehydrated body conserves water, which can prompt constipation and reduce the frequency of urination, and the flushing of bacteria, Dr. Khoury says.

“Constipation also stops the bladder from emptying completely,” he says. “This results in retention of some bacteria in there that will start multiplying as soon as the child stops peeing.”

Dr. Khoury also says that children should examine their urine to ensure proper hydration.

“If it’s yellow, it’s concentrated so they haven’t had enough water to drink,” he says. “It should be the same color as the water in the toilet bowl, which is clear.”

Urinate frequently

Ensure children urinate every two to three hours or at least seven times a day, which reduces the length of time that urine sits in the bladder and bacteria can grow, Dr. Khoury says

“Kids should go to the bathroom when they wake up; before going to school or at morning recess; at lunchtime; at afternoon recess or when they get home from school; before dinner; between dinner and bedtime; and before they go to bed,” he says.

Children also should be encouraged to use the toilet at school and not “hold it” until they get home, as some kids might do because they don’t want to give up playtime at recess.

To help encourage children to urinate regularly, parents can buy their kids a watch with multiple alarms or set a schedule, Dr. Khoury recommends.

“I tell kids, ‘I want you to be your bladder’s boss. You tell your bladder it’s time to go,’” he says.

Eat a healthy diet

Preventing and correcting constipation is an important factor in ensuring proper urinary tract health, children should eat plenty of fruits, veggies and foods rich in fiber, Dr. Khoury says.

Fiber-rich foods include cereals, whole wheat bread and Fiber One bars.

“I prefer water, but if parents have to give the kids juice, use cranberry juice or prune juice,” Dr. Khoury says.

Practice good hygiene

Cleanliness, good toilet habits and proper hygiene in the genital area helps prevent the introduction of bacteria into the urinary tract, Dr. Khoury says.

When using the toilet, girls should be taught to wipe from front to back to prevent the spread of bacteria, he recommends.

Uncircumcised boys should be taught to regularly clean their penis and foreskin in the bath or shower, Dr. Khoury advises.

More articles about urinary tract infections in kids:

  • Circumcision and Urinary Tract Infections
    Some evidence shows that circumcised boys have a lower chance of developing urinary tract infections (UTIs) in their first years of life, but the added protection  may be miniscule, say ...
  • Urinary Tract Infections
    “UTIs are very common in children. Kids can get them at any age as they grow,” says Dr. Khoury, medical director of pediatric urology at CHOC. “What’s important for parents ...
  • Urinary Tract Infections: Fact or Fiction?
    Urinary tract infections (UTIs) are common ailments for children and adults alike, but many myths about the condition persist. Today, a nurse practitioner at CHOC Urology Center helps discern between fact ...

Urinary Tract Infections: Fact or Fiction?

Urinary tract infections (UTIs) are common ailments for children and adults alike, but many myths about the condition persist.

Today, a nurse practitioner at CHOC Urology Center helps discern between fact and fiction when it comes to UTIs.

Fiction: Wearing wet bathing suits or too tight clothes causes UTIs

The list of supposed causes of UTIs goes on and on, but Blake Selby, DNP, says there is only one source: Bacteria.

“The biggest thing I can emphasize is that the only thing that causes UTIs is bacteria getting into the bladder,” she says.

Though bacteria are present in bodies all the time, people can do things that increase the chance that bacteria will migrate into the bladder and cause an infection, Selby says.

Practicing good hygiene is a primary way to help kids stave off UTIs, Selby says. After using the restroom, girls should wipe from front to back, ensuring that bacteria from the rectum does not come closer to the urethra. Boys who are uncircumcised should pull their foreskin back and wash carefully.

Also, though it cannot cause an infection, wearing wet bathing suits or clothes that are too tight can increase the spread of bacteria.

“They may give you a higher propensity for a UTI,” Selby says. “A wet bathing suit creates a warm and moist environment, which can increase skin irritation and breakdown. Although no current research confirms this, you may have a higher chance for a UTI, especially if the child has held her urine for a while or is constipated.”

Fact: Delaying urination can cause a UTI.

Simply put, urination flushes bacteria out of the bladder, Selby says.

The bladder is lined in a glycosaminoglycan – or GAG – layer, which keeps bacteria from latching to the bladder’s walls. However, if the bladder holds urine too long, the bacteria continues to multiply reaching a critical mass that overcomes the bladder defense mechanism, Selby explains.

Selby compares the scenario to washing dishes. If someone continues to pile dirty plates and bowls into the sink but doesn’t change the water, a mess of food scraps remains. The water must be continually flushed out – just as the bladder – to keep messes, or bacteria, at bay.

Fact: More girls than boys get UTIs.

Anatomy plays a significant role, Selby says. Because girls’ urethras and rectums are closer in proximity than in boys, the likelihood that bacteria can move into the urethra increases.

Another factor, Selby says, is that girls anecdotally tend to delay urination longer than boys. Again, frequent urination helps flush bacteria out of the bladder.

Fact: Cranberry juice can help prevent a UTI – but water is the best option.

Cranberry juice contains a simple sugar called D-Mannose, which some studies have shown binds to the bacterium E.coli, Selby says.

By doing so, D-Mannose can keep E.coli from sticking to the bladder’s wall, multiplying and causing a UTI.  However, scientific evidence is inconclusive that the amount of D-Mannose obtained by oral consumption is sufficient to make a difference in preventing a UTI.

If parents opt to try cranberry juice, Selby cautions to should look for real cranberry juice with no sugar added – not juices labeled as “cranberry cocktail.” These beverages are diluted and packed with sugar.

Also, water works well to prevent UTIs, along with encouraging frequent voiding. To ensure a child is properly hydrated, a good rule of thumb is to drink 8 ounces of water for every year of age, Selby says. So, a 4-year-old should drink 32 ounces of water daily.

All people 8 years old and older should drink eight cups of water daily.

An uncircumcised baby has a higher UTI risk: Fact, but just barely.

A baby who is not circumcised increases his risk of developing a UTI tenfold, but only in his first year of life, Selby says.

Learn more about CHOC’s Urology Center.

Protect Your Kids’ Kidneys and Bladder This Summer With Lots of H20

If May’s unseasonable heat wave was any indication of the hot temperatures Orange County could face this summer, you’d better get your water bottle ready.

Children are especially vulnerable to dehydration during the summer. Kids who are active outdoors – whether they play sports or hit the beaches – need to remember that drinking plenty of water is critical to maintaining good health during the hot months.

The CHOC Children’s Urology Center treats many kids during summertime who suffer from urologic conditions related to poor water drinking, said Dr. Antoine Khoury, a pediatric urologist and the center’s medical director.

“It is remarkable how frequently children and their families forget to drink water. The fluid they take in is juice, soda and milk, and not water,” Dr. Khoury said.

A good way to tell if a child is hasn’t been drinking enough is to check the color of his urine. If it’s dark yellow, the urine is concentrated and the child needs to drink more. The urine should be pale in color or better still clear, this provides the child with immediate feedback to drink more water any time the urine is not clear. And, “Any time the child is thirsty he is already dehydrated,” Dr. Khoury said.

Drinking liquids other than water is not as effective in keeping the body hydrated, Dr. Khoury explained. Our bodies require “free water,” or water that is available to the kidneys so they can do their job filtering blood and extracting waste through urine. Giving the kidneys extra water helps them do their job.

Dehydrated children can face several serious urological problems. They include:

1) Kidney stones. Due to a lack of water intake, the urine becomes concentrated and overly rich in salts and crystals. Crystals can be a nidus for kidney stones formation. This can be a very painful condition.

2) Bladder infections. If a child’s body doesn’t make enough urine, the urine becomes concentrated. Children who don’t produce enough urine will not get the urge to urinate and tend to hold it in. Holding in urine for several hours accelerates bacteria growth and may cause a bladder infection.

3) Constipation and incontinence. The more water the colon absorbs from the food due to lack of water in the body, the harder and smaller the stool is. Children who don’t drink enough water can become constipated. The dysfunctional emptying of the bladder associated with constipation promotes incontinence and infections.

4) Urgent and frequent urination. A child’s urine can become so concentrated and loaded with crystals and salts that the bladder becomes irritated. This may lead to urgent and frequent urination.

Drinking Water Guidelines

Dr. Antoine Khoury, Medical Director of the CHOC Children’s Urology Center, recommends that children drink an 8-ounce cup of water daily for every year of age, up to the age of 8. (So a four-year-old should drink at least four cups of water daily). Kids over 8 and adults should drink 8 cups of water daily. This recommended water intake is in addition to any other fluids consumed. Finally, sports drinks are not a substitute for water!

If your child experiences a urological problem, call the CHOC Children’s Urology Center at 714-512-3919.

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