Ultrasound-guided pudendal nerve block as good as penile nerve block for analgesia during pediatric circumcision

The surgeon satisfaction, however, was shown to be higher in the pudendal group. The findings appeared in the BMJ journal Regional Anesthesia & Pain Medicine.

Circumcision is a ceremonial tradition or a religious rite in many cultures and is most common in Islamic and Jewish faiths. Circumcision is a surgery performed to remove the skin covering the penis' end, called a foreskin. The procedure is performed only on healthy babies. As the process is painful, the AAP (American Academy of Pediatrics) recommends using local anesthesia for newborn circumcision.

There is still debate on the optimal analgesia choice for circumcision. The dorsal penile nerve block is superior to topical and caudal analgesia. The ultrasound-guided pudendal nerve block has recently been popularized. To clarify which is a better choice, Frédérique Boisvert-Moreau from Canada and colleagues conducted a randomized, blinded clinical trial to compare an ultrasound-guided dorsal penile nerve block (group penile) with an ultrasound-guided pudendal nerve block (group pudendal) under general anaesthesia for pediatric circumcision.

The trial included prepubertal males aged 1–12 years undergoing elective circumcision. They were randomized to either group pudendal or group penile. The authors examined postoperative FLACC scores (face, legs, activity, cry, consolability) (primary outcome). The secondary outcomes comprised analgesic consumption during the first 24 hours, the parent's postoperative pain measure, time to perform the block, the surgeon's and parent's satisfaction, postanesthesia care unit and until discharge, and hemodynamic changes intraoperatively.

A total of 155 patients, 78 in group penile and 77 in group pudendal, were included for analysis. The mean age was 7.3 years old.

The authors reported the following findings:

• FLACC scores were not statistically different between groups.
• Surgeon satisfaction was higher with group pudendal (90.8% vs 56.6% optimal).
• Intraoperative hemodynamic changes (>20% rise of heart rate or blood pressure) were higher in group pudendal (33.8% vs 9.0%), as was intraoperative fentanyl use (1.3 vs 1.0 μg/kg). Other secondary outcomes were not statistically different.

"The findings showed that both ultrasound-guided blocks, conducted under general anesthesia, provided similar analgesia for pediatric circumcision, as evidenced by low opioid consumption and pain scores," the authors wrote. "In the pudendal group, surgeon satisfaction was higher."

Reference:

Boisvert-Moreau F, Turcotte B, Albert N, et alRandomized controlled trial (RCT) comparing ultrasound-guided pudendal nerve block with ultrasound-guided penile nerve block for analgesia during pediatric circumcisionRegional Anesthesia & Pain Medicine Published Online First: 17 November 2022. doi: 10.1136/rapm-2022-103785