Nerve Block, Dorsal Penile, Neonatal

No Results

No Results

processing….

Circumcision is an age-old practice, described in stone-age cave sketches and depicted in Egyptian hieroglyphics. Today, it is commonly performed to fulfill religious commandments, mark transition into adulthood, change cosmetic appearance and, arguably, affect health outcomes. Traditionally, practitioners have believed that the neurological system of the neonate was not sufficiently developed to permit the neonate to feel pain during this surgical procedure. However, studies have shown that neonate undergo changes in the cardiovascular system, hormonal levels, and behavioral changes during the circumcision procedure. ^{[1, 2, 3]}

Circumcision in neonates was the most commonly performed surgical procedure in the United States prior to 1978; it was performed on more than 80% of neonatal males. The procedure was typically completed without pain-relieving anesthesia. The landmark 1978 Pediatrics article first describing dorsal penile nerve block (DPNB) initiated a slow but steady change in clinical practice regarding this neonatal surgical procedure. ^[4] Numerous studies have revealed not only biochemical changes related to cortisol levels but also the obvious psychological signs involving respirations and tissue oxygenation changes. ^[1] Facial changes, crying, and gross motor movements confirm the painfulness of the procedure. Despite the obvious signs of an neonate’s discomfort and pain during the procedure, tradition had held that the use of anesthetic was unnecessary and unwise.

Today, 9 out of 10 residency-trained physicians use anesthesia during this procedure. ^[5] Much of this change was first fueled by the American Academy of Pediatrics (AAP) in their 1999 recommendation that some method of pain relief should be used during circumcisions and that such pain relief is associated with very little risk. ^[6] This policy statement was updated and affirmed by the 2012 Pediatrics Task Force on Circumcision, which also states that non-pharmacological techniques such as positioning and sucrose pacifiers, although helpful, are inadequate alone for anesthesia and should be used only as analgesic adjuncts to improve infant comfort. ^[7]  Additional supports followed when several physician groups, including the AAP, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP), recommended universal use of local or topical anesthesia for pain relief during circumcision. The technical specifics of the dorsal penile block procedure can be readily taught and learned and have proven to be highly effective. ^[8]

Dorsal penile nerve block is one of several methods of providing pain relief during neonatal circumcision, thereby reducing the associated risks of psychological stress, aspiration, and psychological trauma that may result from the procedure.

Dorsal penile block offers an effective way of relieving the signs and symptoms of patient distress that occur during circumcision. ^[9] This indication is in compliance with the published guidelines and policies of the both the AAP and the AAFP.

Contraindications to the dorsal penile block are similar to those of the neonatal circumcision procedure.

Instability or illness of neonate

Prematurity of neonate

Fewer than 12 hours passed since birth

Anatomical abnormalities, such as hypospadias (For information on the diagnosis and treatment of hypospadias, please see Medscape Reference Pediatrics article Hypospadias.)

This article describes the dorsal penile nerve block performed with lidocaine 1% (without epinephrine).

For more information, see the Technique section.

The equipment needed includes the following:

Parental consent (Consent for the dorsal penile nerve block should be obtained separately from the consent obtained for the circumcision procedure.)

Restraining device (such as papoose board or a Strang circumcision chair)

Sterile gloves

Alcohol preparation pad

Syringe, 27 gauge (ga), 1.22 mL, with a 0.75-inch needle

Lidocaine 1% (without epinephrine)

Place the neonate in a warm environment on papoose board or similar restraint device (see image below).

Expose the genitalia for the procedure.

Use of a pacifier may help quiet the neonate for the injection.

The nerves to the penis are derived from the pudendal and cavernous nerves. The pudendal nerves supply somatic motor and sensory innervation to the penis. The cavernous nerves are a combination of parasympathetic and visceral afferent fibers and provide the nerve supply to the erectile tissue. The cavernous nerves run in the crus and corpora of the penis, primarily dorsomedial to the deep penile arteries. For more information about the relevant anatomy, see Penis Anatomy.

The penis contains 2 dorsal penile nerves that provide sensation to the foreskin glands and shaft of the penis. The nerves are located between the Buck fascia and the corpora cavernosa. See anatomy images below.

At the 10-o’clock and 2-o’clock positions on the penile shaft, these nerves lay approximately 3-5 mm beneath the skin at the root of the penis and course distally toward the glands to a more superficial location of 1-3 mL beneath the skin.

The lidocaine is injected subcutaneously below the Buck fascia in the 10- and 2-o’clock positions found approximately 0.5-1 cm distal to the base of the penis (see image below).

See the list below:

Undress the neonate from the waist down and place him in a neonate restraint.

Prepare the base of the penis with alcohol or povidone-iodine solution (eg, Betadine).

If topical anesthetics such as lidocaine/prilocaine and EMLA are used, due to a higher incidence of skin irritation in low birth weight infants, dorsal penile nerve block should be used alone or instead. ^[7]

Palpate the penile root with gloved fingers.

Apply gentle traction to the penis to secure and straighten the shaft.

Pierce the skin with the 27-ga needle at the 10-o’clock position, slightly distal to where the penile and pubic skin meet (see image below).

Advance the needle tip is in a posterior medial angle of 25 degrees to an area 0.5 cm distal to the penile root.

After confirming that the needle tip is freely movable, attempt aspiration to avoid intravascular injection. Then, slowly inject 0.4 mL of plain 1% lidocaine.

Apply immediate light pressure to any bleeding or swelling.

Repeat the procedure on the opposite side of the penis, at the 2-o’clock position (see image below).

After 5 minutes, circumcision is performed.

Always provide clear informed consent to parents regarding indications and potential adverse effects of the nerve block. This consent should be separate from consent to the circumcision procedure itself.

Keep the neonate warm and calm as long as possible.

A sucrose pacifier may provide additional comfort to the neonate. ^[10]

Make sure the tip of the needle is freely movable and not in the body of the penis.

Apply immediate light pressure to any bleeding or swelling.

Be sure to allow at least 5 minutes to pass between the time of the injection and the beginning of the circumcision procedure.

In general, the dorsal penile nerve block is a very safe and effective procedure. Some minor complications have been encountered.

The most common complication is penetration of the superficial dorsal vein, which causes some bruising and bleeding. ^[11] If this occurs, immediate pressure should be placed on the area. The subcutaneous swelling and discoloration should resolve in about 24 hours.

If the needle is inserted too deeply in a vertical direction, the anesthetic is injected into the actual body of the penis or erectile tissue.

Another common complication is that of partial block, where only partial anesthesia of the foreskin is obtained. The occurrence of this complication seems to lessen with time and experience of the operator.

Complications can also be caused by the anesthetic itself. Patients may be allergic to lidocaine. Skin necrosis has been reported when certain long-acting anesthetics are used (eg, bupivacaine), suggesting that these anesthetics should be avoided. ^{[12, 13]} Systemic toxicity has been reported with bupivacaine causing lethargy, altered consciousness, and hypotonia. ^[14] Care should be taken with the choice of anesthetic agent and the age and weight of the infant, with appropriate adjustments of the concentration and volume used.

For more information, see Infiltrative Administration of Local Anesthetic Agents.

Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics. 1983 Jan. 71(1):36-40. [Medline].

Stang HJ, Gunnar MR, Snellman L, et al. Local anesthesia for neonatal circumcision. Effects on distress and cortisol response. JAMA. 1988 Mar 11. 259(10):1507-11. [Medline].

Kennedy RM, Luhmann J, Zempsky WT. Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics. 2008 Nov. 122 Suppl 3:S130-3. [Medline].

Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve block–a painless procedure. J Pediatr. 1978 Jun. 92(6):998-1000. [Medline].

Yawman D, Howard CR, Auinger P, et al. Pain relief for neonatal circumcision: a follow-up of residency training practices. Ambul Pediatr. 2006 Jul-Aug. 6(4):210-4. [Medline].

Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics. 1999 Mar. 103(3):686-93. [Medline].

American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012 Sep. 130 (3):585-6. [Medline].

Garry DJ, Swoboda E, Elimian A, Figueroa R. A video study of pain relief during newborn male circumcision. J Perinatol. 2006 Feb. 26(2):106-10. [Medline].

Brady-Fryer B, Wiebe N, Lander JA. Pain relief for neonatal circumcision. Cochrane Database Syst Rev. 2004 Oct 18. CD004217. [Medline].

Leef KH. Evidence-based review of oral sucrose administration to decrease the pain response in newborn infants. Neonatal Netw. 2006 Jul-Aug. 25(4):275-84. [Medline].

Fontaine P, Toffler WL. Dorsal penile nerve block for newborn circumcision. Am Fam Physician. 1991 Apr. 43(4):1327-33. [Medline].

Sara CA, Lowry CJ. A complication of circumcision and dorsal nerve block of the penis. Anaesth Intensive Care. 1985 Feb. 13(1):79-82. [Medline].

Kaplanian S, Chambers NA, Forsyth I. Caudal anaesthesia as a treatment for penile ischaemia following circumcision. Anaesthesia. 2007 Jul. 62(7):741-3. [Medline].

French LK, Cedar A, Hendrickson RG. Case report: bupivacaine toxicity with dorsal penile block for circumcision. Am Fam Physician. 2012 Aug 1. 86(3):222. [Medline].

M David Stockton, MD, MPH Professor, Department of Family Medicine, University of Tennessee Health Science Center College of Medicine

Disclosure: Nothing to disclose.

Joan B Patterson, MD Staff Physician, Department of Family Medicine, University of Tennessee

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center

Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Nerve Block, Dorsal Penile, Neonatal

Research & References of Nerve Block, Dorsal Penile, Neonatal|A&C Accounting And Tax Services
Source

Share on Facebook

Tweet

Follow us