VUR and Circumcision in Baby Boys: Does It Reduce Infection Risk?

In the first year of life, urinary tract infection (UTI) is significantly more common in uncircumcised boys than in circumcised ones. The inner surface of the foreskin creates a warm, moist environment; bacteria of intestinal origin (chiefly E. coli) colonize this area and multiply close to the opening of the urinary tract. Because the foreskin usually cannot be retracted in infants, cleaning this area is also limited.

The EAU/ESPU 2024 pediatric urology guideline and the AUA VUR guideline both state that circumcision reduces UTI risk in boys with VUR and recommend that this option be explained to families in early infancy. The recommendation is a medical assessment independent of cultural or religious reasons; the decision belongs to the family.

The benefit is greatest in the infants at highest risk. The groups that stand out in guidelines and observational studies are listed below; for these babies, the question of circumcision is discussed at the first visit, alongside the decision on antibiotic prophylaxis.

• Baby boy under one year of age (especially the first 6 months)
• High-grade (III–V) or bilateral reflux
• Baby who has had a febrile UTI, especially recurrent
• Baby found through high-grade antenatal hydronephrosis
• Baby who develops infection while on antibiotic prophylaxis or has difficulty with medication adherence

• In a boy with low-grade reflux, no prior UTI, and past one year of age, the reflux-specific added benefit of circumcision is small; in that case, the decision is left to the family's other reasons. In our practice, when VUR is diagnosed in a baby boy, the option of circumcision is discussed in the same visit as the antibiotic prophylaxis and surveillance plan; if the procedure is needed, it is performed by the same team.

This is the most important warning on this page: if the urinary opening is not at the tip of the penis but on the underside (hypospadias), if the penis curves forward, or if the foreskin is missing on the underside and hood-shaped on top, circumcision should not be performed. In hypospadias repair, the foreskin is the main tissue used to reconstruct and cover the new urinary channel; if this tissue is lost through circumcision, repair becomes more difficult.

• The urinary opening not being at the tip of the penis, or urine spraying downward
• The penis curving forward during erection or at rest
• The foreskin being absent on the underside and hood-shaped on top
• Testicles not palpable in the scrotum, or the scrotum appearing split down the middle
• If any of these findings is present, a pediatric urology exam is needed before circumcision

• For this reason, every baby boy should be examined by a pediatric urologist or pediatric surgeon before circumcision. In cases of hypospadias, buried penis, or notable penile curvature, circumcision is planned together with, or after, the repair as needed. If hypospadias accompanies reflux in a baby, infection protection is achieved through means other than circumcision (antibiotic prophylaxis, close surveillance).

If infection protection is the goal, circumcision gives the greatest benefit when done in the first months of life. In the newborn period it is done with local anesthesia; in an older baby, under general anesthesia. If an endoscopic injection or another procedure is planned for the reflux, performing the circumcision under the same anesthesia is a commonly preferred arrangement.

• Circumcision itself is a low-risk procedure; bleeding, infection, and rarely narrowing of the urinary opening (meatal stenosis) are the reported complications. Performing it in experienced hands and under sterile conditions is essential. Circumcision does not eliminate the reflux; surveillance rules such as antibiotic prophylaxis, urine culture with fever, and annual ultrasound continue afterward as well.