Two effective techniques
Steven R. Mattson, MD
VOL 106 / NO 1 / JULY 1999 / POSTGRADUATE MEDICINE
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Preview: Circumcision of male newborns is one of the most common procedures performed in the United States. Use of local anesthesia reduces the pain and distress associated with neonatal circumcision. Dr Mattson describes two techniques that provide effective anesthesia with minimal risks for newborns undergoing circumcision.
Mattson SR. Routine anesthesia for circumcision: two effective techniques. Postgrad Med 1999;106(1):107-9
Pain is an immediate and disturbing sequella of circumcision in newborns. Although opinions regarding the use of anesthesia to control such pain have varied, a recent study by Lander and associates (1) showed that without question, routine anesthesia provides significant benefits in neonatal circumcision.
Some physicians still maintain that circumcision causes minimal pain, that newborns do not remember pain, and that performing a quick, efficient circumcision causes less pain than providing local anesthesia (2). To the contrary and without exception, however, newborns who do not receive anesthetic suffer greatly from the distress of circumcision during and following the procedure. In addition, they are exposed to many unnecessary risks, including choking and apnea. Of course, in some circumstances circumcision should not be performed (table 1).
| Table 1. Contraindications to neonatal circumcision |
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Hypospadias
Unusual-appearing genitalia Inability to determine phenotype of child (ambiguous genitalia) Age <12 hr (physiologic adaptation requires 12-24 hr) Severe illness Prematurity (wait until child is ready to be discharged from hospital)
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The two common anesthesia techniques described here--dorsal penile nerve block and subcutaneous ring block--are effective for circumcision in newborns and have also been used with good success in adults (3). Both methods appear to be more effective than use of a topical eutectic mixture of local anesthetics for neonatal circumcision (4).
Ideally, both dorsal penile nerve block and ring block should be performed in the newborn nursery before the infant is placed in restraints for circumcision. This allows adequate time (5 to 10 minutes) for the anesthetic to take effect while preparations are being completed for the circumcision.
This is the procedure that has been most often recommended for neonatal anesthesia before circumcision (1). First, the skin at the base of the penis is cleansed with povidone-iodine or alcohol (table 2) and allowed to dry. Next, the lateral side of the penis is palpated with the index finger to determine the position of the root of the penis. With a tuberculin syringe and needle, the anesthetic is injected parallel to the root of the penis, as follows:
| Table 2. Equipment needed for anesthesia procedures |
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Povidone-iodine solution or alcohol pads
1-cc syringe with 27-gauge needle (tuberculin) 1% lidocaine without epinephrine
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While the penis is stabilized by gentle downward or ventral traction, the needle is inserted at the 2-o'clock position at the base of the penis in a posteromedial direction. The needle is inserted to a depth of 0.3 to 0.5 cm beneath the skin surface. The tip of the needle should be freely movable, indicating that it is imbedded in loose connective tissue. This positioning prevents injection into Buck's fascia, which surrounds the corpora cavernosum. If the needle is not easily advanced, it should be slightly withdrawn and a more cephalad direction should be undertaken. Once the needle is properly placed, 0.4 mL of 1% lidocaine without epinephrine is injected. The needle is then withdrawn. In rare cases in which the root of the penis is not palpable because it is surrounded by pubic fat, the needle is inserted 0.3 to 0.5 cm proximal to the penile-suprapubic junction (figure 1: not shown).
The injection should be repeated at the 10-o'clock position. The total dose of lidocaine should be 0.8 mL.
This procedure is a newer technique that takes advantage of the superficial nerves in the shaft of the penis. The skin around the base of the penis is cleansed with povidone-iodine or alcohol and allowed to dry. A tuberculin syringe is filled with 1 mL of 1% lidocaine without epinephrine, and the needle is inserted into the lateral side of the penis at the base (figure 2: not shown). A subcutaneous bleb of lidocaine is placed. The needle is then advanced circumferentially around the base of the penis, completing a 180° half circle. Intravascular injection can be avoided by frequently aspirating the needle prior to enlarging the subcutaneous ring.
The same procedure is followed on the opposite side of the penis, so that a 360° circumferential ring of anesthesia is completed around the penis. A maximum of 1 mL of lidocaine should be used.
There are good data to support the use of either dorsal penile nerve block or subcutaneous ring block for neonatal circumcision. Physicians should choose the method with which they are most comfortable. No major complications have been reported with either method. Minor complications have included edema of the foreskin and transient ischemia of the skin of the glans penis (5).
Third in a series of articles on office procedures coordinated by David A. Driggers, MD, faculty member of the Alaska Family Practice Residency Program, Anchorage, and Roger A. Schauer, MD, director of predoctoral medical education in family medicine and associate professor of family medicine, University of North Dakota School of Medicine, Grand Forks.