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Neonatal circumcision and penile dorsal nerve block—a painless procedure
998
June 1978 The Journal o f P E D I A T R I C S
Neonatal circumcision and penile dorsal nerve block-a painless procedure Circumcision is the only surgical procedure, excluding cord-clamping and cutting, which is routinely performed on normal, healthy newborn infants, usually during the first two or three days of life. Apparently no analgesic technique has been described nor suggested in association with neonatal circumcision. This is the first description of a technique of penile dorsal nerve block in neonatal circumcision. In 52 instances using 0.5 ml o f l% lidocaine (Xylocaine) and a 1.2 cm number 27 gauge needle PDNB was successfully and safely introduced with consistent elimination of pain, rendering NC a painless surgicalprocedure.
C h r i s t o p h e r Kirya, M.B., Ch.B., D.C.H.,* and M i l t o n W . W e r t h m a n n , Jr., M . D . , F.A.A.P., W a s h i n g t o n , D.C.
C I R C U M C I S I 0 N h a s b e e n practiced for centuries, being known in the era of the Pharaohs. 14 In different parts of the world it is performed for different reasons. 5-9 Whatever these may be, little if any attention has been paid to the pain endured by the infant, and consequently, elimination of this pain. Anyone who circumcises a neonate, using any of the available techniques, senses the pain and stress that the manipulative stages of this procedure generate?-11 During the procedure when the prepuce is clamped with the mosquito forceps, the infant cries vigorously, trembles, and tries to wriggle out of the restraint. He may eventually become plethoric, dusky, and mildly cyanotic because of prolonged crying. Occasionally, this results in respiratory pauses or regurgitation of feedings. A pacifier may be offered or in some other rituals, a little wine is given to the baby, in the probable expectation that the procedure might be tolerable. 6 The concept of regional nerve block is not new. It was the desire to extend this method of pain relief to the newborn infant, which prompted the development of this technique of PDNB for NC.
From Georgetown University Department of Pediatrics, Division of Neonatology, Columbia Hospital for Women, and Department of PerinatalNeonatal Pediatrics, Washington Hospital Center. *Reprint address: Georgetown University, Department of Pediatrics, Neonatology Division, Columbia Hospitalfor Women, 2425 L St. N.W., Washington, D.C. 20037.
0022-3476/78/0692-0998500.30/0 9 1978 The C. V. Mosby Co.
The equipment for the procedure is standard with the addition of a syringe, a 1.2 cm No. 27 gauge needle, and 1% lidocaine (Xylocaine) without epinephrine. ANATOMY
OF THE PENIS
A brief review of the anatomy of the penis is indicated before the technique is described. The penis has two main nerves. Despite being bilateral the nerves are designated dorsal nerves and the vessels as dorsal vein a n d dorsal artery as shown in Fig. 1. Abbreviations usdd NC: neonatal circumcision PDNB: penile dorsal nerve block At the penile root the nerves emerge between the dorsal and Cones fascia in almost one sheath on either side of the penis. The surface anatomy of these two dorsal nerves corresponds to 10 to 2 o'clock positions at the root of the penis. Ramifications of these nerves usually commence 1 cm distal to the penile root. The ideal site for PDNB is just proximal to these ramifications. TECHNIQUE Using the equipment previously described and using aseptic precautions, the 10 and 2 o'clock areas are identified and the depth of the penile root into the pubis is established. This identification is important because it will dictate the approximate point distal to the penile root (0.5
Vol. 92, No. 6, p p 998-1000
Volume 92 Number 6
Neonatal circumcision and penile dorsal nerve block
999
Fig 1. Cross section of the anatomy of the penile root. cm) into which the infiltration is to be made. It may be necessary in an occasional infant whose penile root is imbedded in pubic fat, to block the nerves at the junction of the pubic and penile skin. Stabilizing the organ with gentle traction of the skin of the penis, at an angle of about 20 to 25 degrees, the skin is pierced at one of the dorsolateral positions and the needle advanced posteromedially into the subcutaneous tissue (Fig. 2). The depth of the needle need not be more than 0.25 to 0.5 cm. There should be no further resistence felt after the skin is penetrated, the tip of the needle remaining freely movable. At this point infiltration of 0.2 to 0.4 ml of 1% lidocaine is made, taking great care to avoid accidental vascular injection. Under no circumstance should the infiltration be made as the needle is being advanced or withdrawn. The same procedure is repeated at the other dorsolateral position. Inevitably, since the penis is small, a circular lidocaine rmg is formed and the PDNB accomplished. The penis and prepuce should be insensitive to pain or pressure after two to three minutes. It is emphasized that the total volume of lidocaine should not exceed 0.8 ml, since a large volume could cause pressure to the organ with subsequent theoretical necrosis. The same concern obtains in regard to hematoma formation. RESULTS Fifty-two infants were circumcised after PDNB. One percent lidocaine volume ranged between 0.4 to 0.8 ml with an average of 0.5 ml. In all but two infants the
Fig. 2. Injection of the local anesthetic. response was excellent, demonstrated by complete absence of the usual clinical picture described previously. Infants were alert with no crying after the initial two small infiltration injections. Two infants did not respond completely. One failure was due to an inadequate volume of lidocaine; the syringe leaked during infiltration. The other failure was caused by too distal an injection on the left, since the child responded to painful stimuli with the application of forceps on that side only.
10 0 0
Kirya and Werthmann
Bleeding at the injection site did not occur, except in one case in which the right superficial dorsal vein w a s penetrated. In all infants the lidocaine induced subcutaneous swelling at the penile root had disappeared in less than 24 hours after the procedure. Neither h e m a t o m a nor volume-induced pressure were observed. DISCUSSION To feel pain is,one of the functions of normality, and e v e r y normal neonate feels pain. The beliefs that infants "do not feel pain" or "won't r e m e m b e r it anyway" reflect concepts which cannot be substantiated. Nothing is known of the long-term effects of painful experiences sustained in the neonatal period on the subsequent shaping and realization of an infant's potential. Circumcision is painful and consequently stressful. Behavioral state in relation to stressful stimuli has been studied in the newborn infant and the endocrine response (adrenal) has been documented?. 1~ Using PDNB, the neonate can be spared the pain of circumcision and its consequent stress. The technique d e v e l o p e d and described herein virtually abolishes circumcision pain as s h o w n by a quiet child during the operation. No complications or untoward effects of lidocaine were encountered. The effect of lidocaine wore off completely within 30 minutes. The complications of circumcision described by others were not seen in this group. 1:'-" Caution must be exercised in introducing the 27 gauge needle, lest an occasional large superficial vein be accidently punctured. Also, too vertical an introduction of the needle can cause the tip to lodge in the erectile tissue. This would result in firm fixation of the needle tip and not the loose mobility characteristic of proper subcutaneous placement. H e m a t o m a s are avoided and volume-induced pressure is not evident since the quantity o f lidocaine is small.
The Journal of Pediatrics June 1978
Until now, circumcision was known to both parent and doctor to be quite painful; hence, rarely were parents allowed to witness the procedure. Since the introduction of PDNB, marked relief is evident in the parents who either attend the ceremony or are invited to witness the circumcision. The response o f the infants makes pain suppression desirable. REFERENCES
1. Gairdner D: The fate of the foreskin, Br Med J 2:14330, 1949. 2. Morgan WKC: The rape of the phallus, JAMA 193:223, 1965. 3. Prestin NE: Whither the foreskin, JAMA 213:1853, 1970. 4. Haines JR: The foreskin saga, JAMA 217:1241, 1971. 5. Hovsepian D: The pros and cons of routine circumcision, Calif Med 75:359, 1951. 6. Blonde RP: Ritualistic surgery-circumcision and tonsillectomy, N Engl J Med 280:593, 1969. 7. Burger R, and Guthrie TH: Why circumcision, Pediatrics 54:362, 1974. 8. Levin SS: Circumcision or uncircumcision, Aft Med J 24:913, 1976. 9. Talbert LM, Krerybill EN, and Potter HD: Adrenal cortical response to circumcision in the neonate, Obstet Gynecol 48:208:10, 1976. 10. Kitahara M: A cross-cultural test of the freudian theory of circumcision, Int J Psychoanal Psychother 5:535, 1976. 11. Gee WG, and Ansell JS: Neonatal circumcision, Pediatrics 58:824, 1976. 12. Anders TF, and Sachair EJ: Behavioral state and plasma cortisol in the human newborn, Pediatrics 46:532, 1970. 13. Speert H: Circumcision of the newborn, Obstet Gynecol 2:164, 1953. 14. Shulman J, Ben-Hur N, and Newman Z: Surgical complications of circumcision, Am J Dis Child 107:149, 1964. 15. Patel H: The problems of routine circumcision, Can Med Assoc J 95:576, 1966. 16. Rubenstein MD, and Bason WM: Complications of circumcision done With a plastibell clamp, Am J Dis Child 116:381, 1968. 17. McGovan AJ Jr: A complication, JAMA 207:2104, 1969.
June 1978 The Journal o f P E D I A T R I C S
Neonatal circumcision and penile dorsal nerve block-a painless procedure Circumcision is the only surgical procedure, excluding cord-clamping and cutting, which is routinely performed on normal, healthy newborn infants, usually during the first two or three days of life. Apparently no analgesic technique has been described nor suggested in association with neonatal circumcision. This is the first description of a technique of penile dorsal nerve block in neonatal circumcision. In 52 instances using 0.5 ml o f l% lidocaine (Xylocaine) and a 1.2 cm number 27 gauge needle PDNB was successfully and safely introduced with consistent elimination of pain, rendering NC a painless surgicalprocedure.
C h r i s t o p h e r Kirya, M.B., Ch.B., D.C.H.,* and M i l t o n W . W e r t h m a n n , Jr., M . D . , F.A.A.P., W a s h i n g t o n , D.C.
C I R C U M C I S I 0 N h a s b e e n practiced for centuries, being known in the era of the Pharaohs. 14 In different parts of the world it is performed for different reasons. 5-9 Whatever these may be, little if any attention has been paid to the pain endured by the infant, and consequently, elimination of this pain. Anyone who circumcises a neonate, using any of the available techniques, senses the pain and stress that the manipulative stages of this procedure generate?-11 During the procedure when the prepuce is clamped with the mosquito forceps, the infant cries vigorously, trembles, and tries to wriggle out of the restraint. He may eventually become plethoric, dusky, and mildly cyanotic because of prolonged crying. Occasionally, this results in respiratory pauses or regurgitation of feedings. A pacifier may be offered or in some other rituals, a little wine is given to the baby, in the probable expectation that the procedure might be tolerable. 6 The concept of regional nerve block is not new. It was the desire to extend this method of pain relief to the newborn infant, which prompted the development of this technique of PDNB for NC.
From Georgetown University Department of Pediatrics, Division of Neonatology, Columbia Hospital for Women, and Department of PerinatalNeonatal Pediatrics, Washington Hospital Center. *Reprint address: Georgetown University, Department of Pediatrics, Neonatology Division, Columbia Hospitalfor Women, 2425 L St. N.W., Washington, D.C. 20037.
0022-3476/78/0692-0998500.30/0 9 1978 The C. V. Mosby Co.
The equipment for the procedure is standard with the addition of a syringe, a 1.2 cm No. 27 gauge needle, and 1% lidocaine (Xylocaine) without epinephrine. ANATOMY
OF THE PENIS
A brief review of the anatomy of the penis is indicated before the technique is described. The penis has two main nerves. Despite being bilateral the nerves are designated dorsal nerves and the vessels as dorsal vein a n d dorsal artery as shown in Fig. 1. Abbreviations usdd NC: neonatal circumcision PDNB: penile dorsal nerve block At the penile root the nerves emerge between the dorsal and Cones fascia in almost one sheath on either side of the penis. The surface anatomy of these two dorsal nerves corresponds to 10 to 2 o'clock positions at the root of the penis. Ramifications of these nerves usually commence 1 cm distal to the penile root. The ideal site for PDNB is just proximal to these ramifications. TECHNIQUE Using the equipment previously described and using aseptic precautions, the 10 and 2 o'clock areas are identified and the depth of the penile root into the pubis is established. This identification is important because it will dictate the approximate point distal to the penile root (0.5
Vol. 92, No. 6, p p 998-1000
Volume 92 Number 6
Neonatal circumcision and penile dorsal nerve block
999
Fig 1. Cross section of the anatomy of the penile root. cm) into which the infiltration is to be made. It may be necessary in an occasional infant whose penile root is imbedded in pubic fat, to block the nerves at the junction of the pubic and penile skin. Stabilizing the organ with gentle traction of the skin of the penis, at an angle of about 20 to 25 degrees, the skin is pierced at one of the dorsolateral positions and the needle advanced posteromedially into the subcutaneous tissue (Fig. 2). The depth of the needle need not be more than 0.25 to 0.5 cm. There should be no further resistence felt after the skin is penetrated, the tip of the needle remaining freely movable. At this point infiltration of 0.2 to 0.4 ml of 1% lidocaine is made, taking great care to avoid accidental vascular injection. Under no circumstance should the infiltration be made as the needle is being advanced or withdrawn. The same procedure is repeated at the other dorsolateral position. Inevitably, since the penis is small, a circular lidocaine rmg is formed and the PDNB accomplished. The penis and prepuce should be insensitive to pain or pressure after two to three minutes. It is emphasized that the total volume of lidocaine should not exceed 0.8 ml, since a large volume could cause pressure to the organ with subsequent theoretical necrosis. The same concern obtains in regard to hematoma formation. RESULTS Fifty-two infants were circumcised after PDNB. One percent lidocaine volume ranged between 0.4 to 0.8 ml with an average of 0.5 ml. In all but two infants the
Fig. 2. Injection of the local anesthetic. response was excellent, demonstrated by complete absence of the usual clinical picture described previously. Infants were alert with no crying after the initial two small infiltration injections. Two infants did not respond completely. One failure was due to an inadequate volume of lidocaine; the syringe leaked during infiltration. The other failure was caused by too distal an injection on the left, since the child responded to painful stimuli with the application of forceps on that side only.
10 0 0
Kirya and Werthmann
Bleeding at the injection site did not occur, except in one case in which the right superficial dorsal vein w a s penetrated. In all infants the lidocaine induced subcutaneous swelling at the penile root had disappeared in less than 24 hours after the procedure. Neither h e m a t o m a nor volume-induced pressure were observed. DISCUSSION To feel pain is,one of the functions of normality, and e v e r y normal neonate feels pain. The beliefs that infants "do not feel pain" or "won't r e m e m b e r it anyway" reflect concepts which cannot be substantiated. Nothing is known of the long-term effects of painful experiences sustained in the neonatal period on the subsequent shaping and realization of an infant's potential. Circumcision is painful and consequently stressful. Behavioral state in relation to stressful stimuli has been studied in the newborn infant and the endocrine response (adrenal) has been documented?. 1~ Using PDNB, the neonate can be spared the pain of circumcision and its consequent stress. The technique d e v e l o p e d and described herein virtually abolishes circumcision pain as s h o w n by a quiet child during the operation. No complications or untoward effects of lidocaine were encountered. The effect of lidocaine wore off completely within 30 minutes. The complications of circumcision described by others were not seen in this group. 1:'-" Caution must be exercised in introducing the 27 gauge needle, lest an occasional large superficial vein be accidently punctured. Also, too vertical an introduction of the needle can cause the tip to lodge in the erectile tissue. This would result in firm fixation of the needle tip and not the loose mobility characteristic of proper subcutaneous placement. H e m a t o m a s are avoided and volume-induced pressure is not evident since the quantity o f lidocaine is small.
The Journal of Pediatrics June 1978
Until now, circumcision was known to both parent and doctor to be quite painful; hence, rarely were parents allowed to witness the procedure. Since the introduction of PDNB, marked relief is evident in the parents who either attend the ceremony or are invited to witness the circumcision. The response o f the infants makes pain suppression desirable. REFERENCES
1. Gairdner D: The fate of the foreskin, Br Med J 2:14330, 1949. 2. Morgan WKC: The rape of the phallus, JAMA 193:223, 1965. 3. Prestin NE: Whither the foreskin, JAMA 213:1853, 1970. 4. Haines JR: The foreskin saga, JAMA 217:1241, 1971. 5. Hovsepian D: The pros and cons of routine circumcision, Calif Med 75:359, 1951. 6. Blonde RP: Ritualistic surgery-circumcision and tonsillectomy, N Engl J Med 280:593, 1969. 7. Burger R, and Guthrie TH: Why circumcision, Pediatrics 54:362, 1974. 8. Levin SS: Circumcision or uncircumcision, Aft Med J 24:913, 1976. 9. Talbert LM, Krerybill EN, and Potter HD: Adrenal cortical response to circumcision in the neonate, Obstet Gynecol 48:208:10, 1976. 10. Kitahara M: A cross-cultural test of the freudian theory of circumcision, Int J Psychoanal Psychother 5:535, 1976. 11. Gee WG, and Ansell JS: Neonatal circumcision, Pediatrics 58:824, 1976. 12. Anders TF, and Sachair EJ: Behavioral state and plasma cortisol in the human newborn, Pediatrics 46:532, 1970. 13. Speert H: Circumcision of the newborn, Obstet Gynecol 2:164, 1953. 14. Shulman J, Ben-Hur N, and Newman Z: Surgical complications of circumcision, Am J Dis Child 107:149, 1964. 15. Patel H: The problems of routine circumcision, Can Med Assoc J 95:576, 1966. 16. Rubenstein MD, and Bason WM: Complications of circumcision done With a plastibell clamp, Am J Dis Child 116:381, 1968. 17. McGovan AJ Jr: A complication, JAMA 207:2104, 1969.