|Year : 2014 | Volume
| Issue : 3 | Page : 428-433
Single-injection penile block versus caudal block in penile pediatric surgery
Enas M Ashrey1, Bosat E Bosat2
1 Department of Anesthesia and Intensive Care, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt
2 Department of General Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt
|Date of Submission||08-Jan-2014|
|Date of Acceptance||20-Aug-2014|
|Date of Web Publication||27-Aug-2014|
Enas M Ashrey
Department of Anesthesia and Intensive Care Unit, Al Azhar University Hospital, Abbasia, Cairo
Source of Support: None, Conflict of Interest: None
Penile block is recommended for analgesia during and after surface operation on the penis, for example circumcision, phimosis, meatal stenosis, and hypospadias repair.
To evaluate the effect of penile block versus caudal block using bupivacaine on the quality of analgesia, and the surgeon's and parents' satisfaction after penile pediatric surgery.
Patients and methods
This study was conducted on 80 healthy boys aged 1-7 years, of American Society of Anesthesiologists (ASA) I and II health classes, scheduled for hypospadias repair, circumcision and meatal stenosis under general anesthesia. The patients were randomly divided into two equal groups: group P (penile block, 0.25% bupivacaine, 0.5 mg/kg; n = 40) and group C (caudal block, 0.25% bupivacaine, 0.5 mg/kg; n = 40). The heart rate (HR), the mean arterial blood pressure (MAP) and oxygen saturation were measured perioperatively. Postoperative pain evaluated by the FLACC pain scale of five categories, (F) Face, (L) Leg, (A) Activity, (C) Cry, (C) Consolability, was assessed on admission to and on discharge from the PACU and 2, 4, 8, 12, 16 and 24 h postoperatively. Also, the time to first rescue analgesic request and doses of analgesic requirements were recorded. The surgeon's and parents' satisfaction were evaluated on the first day of the operation using a five-point verbal score.
In group P, there was no significant decrease in the HR and the MAP compared with the baseline, but in group C, there was a significant decrease in HR and MAP compared with the baseline. FLACC pain scores were significantly lower in group P compared with group C (P < 0.05). Also, the time to first need for analgesia was significantly (P < 0.05) lower in group P compared with group C. The total analgesic requirement was also significantly lower (P < 0.05) in group P compared with group C.
Single-injection penile block is superior to caudal epidural block for relief of postoperative pain in children undergoing penile surgery with more satisfaction to the surgeon and the parents, without significant increase in the rate of adverse events.
Keywords: bupivacaine, caudal block, penile block, penile surgery
|How to cite this article:|
Ashrey EM, Bosat BE. Single-injection penile block versus caudal block in penile pediatric surgery. Ain-Shams J Anaesthesiol 2014;7:428-33
|How to cite this URL:|
Ashrey EM, Bosat BE. Single-injection penile block versus caudal block in penile pediatric surgery. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2019 Jun 24];7:428-33. Available from: http://www.asja.eg.net/text.asp?2014/7/3/428/139588
| Introduction|| |
Pain relief after surgery continues to be a major medical challenge despite a significant improvement over the last decade in our understanding of acute pain mechanism .
Evidence suggests that inadequate relief of postoperative pain may result in harmful physiological and psychological consequences that may lead to significant morbidity, which may delay recovery and return to daily living  besides untoward behavioral changes in children . Specific early analgesic interventions may reduce the incidence of pain .
Regional anesthesia, in combination with general anesthesia, is frequently used for children undergoing surgical procedures. Advantages of this technique are a smoother intraoperative course and decreased requirements of general anesthetics, often leading to a faster, smoother wake up, decreased stress response and excellent pain relief in the immediate postoperative period.
Single-shot caudal block is one of the most useful and most often performed regional blocks in pediatric anesthesia. They are suitable for lower extremity, perineal, inguinal, and lower abdominal surgery. Properly performed, a single-shot caudal block is a rapid and safe technique that leads to better patient comfort and potentially better outcome, and it could also decrease the anesthesia time by speeding room turnover.
Penile blocks have became more commonly used in pediatric patients as adjunct to general anesthesia for procedures on the penis such as circumcision, hypospadias repair, urethral dilation and papilloma laser fulguration. It provides anesthesia to the distal 2/3 of the penis only .
An advantage of penile block over caudal anesthesia is the lack of sensory and motor block to the lower extremities, which might interfere with ambulation postoperatively in a day surgery patient .
This study was aimed to evaluate the success rate and the effectiveness of penile block for penile urological surgeries in pediatric patients in comparison with caudal block.
| Patients and methods|| |
This study was performed in Al-Zhraa University Hospitals on 80 child patients, ASA I and II, aged 1-7 years, undergoing elective daycare penile surgeries (e.g. hypospadias repair, circumcision, meatal stenosis). After approval of the local ethics committee, an informed consent was obtained from parents after full explanation of the procedure, possible side effects and complications. Children with a history of pre-existing neurological or spinal disease, allergic reaction to local anesthetics, bleeding diathesis, aspirin intake in the preceding week and any sign of infection at the site of the proposed block or parents' refusal were excluded from the study.
According to the age of the child, a 24 or 22-G intravenous cannula was inserted into a small vein on the dorsum of the hand in the operating room without giving any premedication drug. Children were monitored with an ECG, noninvasive blood pressure and pulse oximetry by Penlon sPM 5 , and then general anesthesia with inhalational induction was performed with a face mask using 8% sevoflurane in O 2 without atropine or muscle relaxant. After induction, an oral endotracheal tube of the appropriate size was placed and sevoflurane was used for maintenance. Patients were randomized, using a computer-generated random numbers table, into two groups (40 each), during anesthetic maintenance. Group P penile block (n = 40) received dorsal penile nerve block by using the subpubic approach technique. All antiseptic precautions were taken, and then the penis was pulled downwards to put the scarpa's fascia under tension, and two symmetrical sites for the needle insertion were marked, 0.5-1 cm below the pubic symphysis, lateral to the midline. The short beveled needle of 25 G was directed 15° medially and caudally to the skin from each of the two insertion sites. As the needle penetrates scarpa's fascia, there will be a distinct 'pop'. If the needle is released at this point it will remain fixed in place and not tilt or recoil. This was followed by injection of 0.5 mg/kg of bupivacaine 0.25% on each side.
Group C caudal block (n = 40) received caudal epidural block using a 22- G needle in the lateral decubitus position. The needle was inserted into the caudal epidural space through the sacral hiatus, and with loss of resistance, bupivacaine 0.25% of 0.5 mg/kg was injected into the caudal epidural space.
Skin incision was performed 20 min after the block in each group. No analgesic drug was used during the surgery, and minimum alveolar concentration of sevoflurane was reduced 20 min after skin incision in each group with continuous standard monitoring.
If heart rate (HR) or BP increased by more than 20% of the baseline after skin incision, this means that the block is unsuccessful and the patient needs to receive analgesia in the form of 1 mg/kg fentanyl for pain relief intraoperatively, and this patient was excluded from the study.
After emergence from anesthesia, the patients were transferred to the recovery room where their HR, NIBP and SPO 2 were recorded at 0, 5, 15 and 30 min, and then every 2 h for the next 24 h. Also, postoperative pain was assessed and evaluated by the FLACC pain scale [this is a behavioral scale for scoring postoperative pain in young children, composed of five categories: (F) Face, (L) Leg, (A) Activity, (C) Cry, (C) Consolability - [Table 1], and the degree of pain was assessed. In the recovery room or the ward, if the FLACC pain score (0-10) was more than 3, ibuprofen was given postoperatively as a rescue analgesic and recorded at an oral dose of 10 mg/kg in repeated doses every six hours orally (with a maximum daily dose of 40 mg/kg); the time to first analgesia, the total analgesic requirement, any complications or side effects due to block or general anesthesia and parents' & surgeon's satisfaction were also observed and recorded.
Surgeons were asked to judge the adequacy of muscle relaxation.
The field of operation (quality of block) at the end of the surgery and satisfaction of the surgeon were rated as excellent, satisfactory or poor.
Also, parents' satisfaction was assessed on the first postoperative day about their feeling towards their children's recovery from anesthesia by the anesthetist. Their satisfaction was evaluated using a five-point verbal score with 0 = poor, 1 = accepted, 2 = good, 3 = very good, and 4 = excellent.
Data were collected, revised, coded and entered into the statistical package for social science version 17, whereas the sample size was calculated using Epi info program version 7 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were presented as numbers and percentages, whereas quantitative data were presented as means and SDs. The unpaired t-test, the c2-test and the Mann-Whitney U-test were used to compare the two groups. P value more than 0.05 was considered as non-significant, whereas P value 0.05 or less was considered significant and P value 0.01 or less was considered highly significant.
| Results|| |
There were no significant differences between the two groups with regard to age, weight, the ASA class, the duration of surgery or the duration of anesthesia ([Table 2] and [Table 3]).
The HR and the mean arterial blood pressure (MAP) showed no statistically significant differences between the two groups at the base value and after establishment of the block (P > 0.05) ([Figure 1] and [Figure 2]). However, 5 min after the block, HR and MAP gradually decreased in group C whereas they remained stable in group P (P < 0.05).
On evaluation of the FLACC pain score at different time intervals (on discharge from the PACU and after 2, 4, 8, 12, 16 and 24 h) in the two groups, there were 12 of 40 patients (30%) in the penile block group and 21 of 40 patients (52.5%) in the caudal group who received analgesia in the first 24 h postoperatively, and the difference between two groups was significant (P < 0.05).
|Figure 1: Variations in the heart rate (HR) in the penile and the caudal groups with time; Data are expressed as mean±SD.|
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|Figure 2: Variations in the sytolic blood pressure (SBP) and the diastoli blood pressure c (DBP) blood pressure in both the study groups with time; Data are expressed as mean±SD.|
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|Figure 3: Comparison of postoperative FLACC pain scores at different time intervals between the two studied groups; Data are presented as median.|
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There was a significant increase in the pain score in group C starting from the fourth hour postoperatively and thereafter every hour, while the lowest pain scores were recorded in group P (P < 0.05) [Figure 3].
The rescue analgesic requirements were significantly higher in the caudal group than in the penile block group. The average time to first analgesia was significantly shorter in the caudal group (240 ± 105 min) than in the penile block group (720 ± 301 min) (P < 0.05), and the time for ambulation was significantly longer in the caudal group (6.95 ± 3.22) than in the penile block group (5.28 ± 1.99) (P < 0.01).
Parent's satisfaction was excellent in group P compared with group C: 28 of 40 patients scored an excellent in group P, whereas 19 of 40 patients scored an excellent in group C, which is considered significant.
The degree of surgeon satisfaction with the technique (judgment of the quality of blockade) was higher in group P compared with group C: it was excellent in 30 patients of 40 in group P versus 25 patients of 40 in group C, which is statistically significant. There were no cardiovascular, respiratory or neurological complications recorded in either group; also, no patient developed nausea, vomiting or urinary retention [Table 4], [Table 5], [Table 6].
| Discussion|| |
Children undergoing genitourinary surgery may face emotional difficulties. There may be increased anxiety and pain due to multiple procedures required for some of the surgical conditions .
For these reason, many of these patients may benefit from regional blocks performed under sedation or general anesthesia, as the association of the two techniques drastically cuts down the risk of both procedures .
Although single-shot caudal block in children is basically easy to perform, its success rate to cover postoperative pain adequately is questionable. About 60% of children undergoing groin surgery with this technique require further analgesia during the postoperative period .
Our study compared the efficacy of penile block and caudal block with bupivacaine for penile surgery including distal hypospadias repair, circumcision and meatal stenosis under general anesthesia, and demonstrated that penile block provides a low incidence of postoperative pain and high success rates.
In agreement with our results, Schuepfer and Jφhr  and Burke et al.  found that penile block is safe and easy to learn and provides pain relief for up to 24 h [11,12]. Also, it is simple and effective . Subpubic penile block is substantially free of complications . This technique is more preferred than the traditional dorsal penile nerve block that is performed by injecting a local anesthetic deep into the buck's fascia at the base of the penis because the major potential complication of this block is a hematoma caused by piercing the dorsal artery or vein or the corpus cavernosum, which could potentially lead to increased pressure under the buck's fascia with resultant ischemia of the penis, and so this complication is avoided by the subpubic approach .
In the current study, the patients' characteristics were comparable in the two groups (the mean age, the weight, the ASA class, the duration of surgery and the duration of anesthesia). Also, preoperative HR and MAP were not significantly different till 5 min after the block, when there was a decrease in the MAP and the HR in group C compared with group P due to the inhibitory effect of bupivacaine on the sympathetic nervous system. These results coincide with those found by Seyedhejaz et al. , who found that there was a statistically significant hemodynamic (blood pressure and HR) alteration during operation in each group and the hemodynamic parameters were stable during operation in successful blocks in both groups.
The present study showed that postoperative pain scores in group C were significantly higher from the fourth hour and thereafter when compared with group P. Also, analgesic requirements were significantly higher in group C than in group P, and the block was more effective and of longer duration in group P compared with group C with early ambulation in group P.
Our results are in agreement with Telgarsky et al.  and Cyna and Middleton , who found that penile block, when successful, can provide reasonable postoperative analgesia for up 12 h. It also allows faster recovery, earlier micturition and earlier discharge from the hospital. It is safe, easy and effective when used to reduce postoperative pain; at the same time, it reduces the adrenocortical stress response and behavioral distress.
Also, Kundra et al.  found that penile block provided better analgesia when compared with caudal epidural in children undergoing hypospadias repair, and postoperative urethral fistula formation was more likely in children who received caudal epidural.
Similarly, Chhibber et al.  concluded that two penile blocks performed at the beginning and the conclusion of hypospadias repair, respectively, provide better postoperative pain control than one penile block performed before or after the surgery (P < 0.05). These patients require less analgesia than those who receive a penile block only before or only after surgery.
Also, Metzelder et al.  reported that penile block is the first-choice perioperative analgesia in distal hypospadias repair when spontaneous postoperative micturition must be guaranteed.
There were no complications recorded, such as nausea or vomiting, and also no retention of urine.
| Conclusion|| |
Single-injection penile block in children undergoing penile surgery provides effective and a longer duration of postoperative analgesia and decreased postoperative analgesic requirements with more hemodynamic stability both intraoperatively and postoperatively, besides excellent parent and surgeon satisfaction, because it is safer and easier to perform, with higher success rates than caudal epidural block, which is invasive and shows some difficulty in practice.
| Acknowledgements|| |
| References|| |
|1.||Australian and New Zealand College of Anaesthetists (ANZCA). Acute pain management: scientific evidence. Available at: http//www. Anzca. Edu/su/publications/acute pain. Htm. [Accessed 24 July 2005] |
|2.||Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North America 2005; 23:21-36. |
|3.||Kotiniemi LH, Ryhänen PT, Moilanen IK. Behavioral changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia 1997; 52:970-976. |
|4.||Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 1995; 83:757-765. |
|5.||Manuel Pradlo, James M. Sonner. Pocket clinician, Manual of Anethesia Practice, Cambridge University Press; 2012. |
|6.||Wider RT, Goldschneider KP. In: GAWALCO. Pain in children: a practical guide for primary care. Pain relief after out patient surgery. Humana press. Ch 11; pp 101-109. |
|7.||Frattali CM. National Institutes of Health, Warren Grant Magnuson Clinical Center. ASHA 1999; 41:46-49. |
|8.||Gandhi M, Vashisht R. Anaesthesia for paediatric urology in continuing education in anaesthesia, Critical Care & Pain by Oxford University, Oxford journal 2010; 10:152-157. |
|9.||Krane EJ, Dalens BJ, Murat I, Murrell D. The safety of epidurals placed during general anaesthesia. Reg Anesth Pain Med 1998;23:433-438. |
|10.||Wolf AR, Hughes D, Wade A, Mather SJ, Prys-Roberts C. Postoperative analgesia after paediatric orchidopexy: evaluation of a bupivacaine-morphine mixture. Br J Anaesth 1990; 64:430-435. |
|11.||Schuepfer G, Jöhr M. Generating a learning curve for penile block in neonates, infants and children: an empirical evaluation of technical skills in novice and experienced anaesthetists. Paediatr Anaesth 2004; 14:574-578. |
|12.||Burke D, Joypaul V, Thomson MF. Circumcision supplemented by dorsal penile nerve block with 0.75% ropivacaine: a complication. . Reg Anesth Pain Med 2000; 25:424-427. |
|13.||Dalens B, Vanneuville G, Dechelotte P. Penile block via the subpubic space in 100 children. Anesth Analg 1989; 69:41-45. |
|14.||Soh CR, Ng SB, Lim SL. Dorsal penile nerve block. Paediatr Anaesth 2003; 13:329-333. |
|15.||Dalens B. Regional aneathesia in infants, children and adolescent. London: Williams and Waverly Europe; 1995. |
|16.||Seyedhejazi M, Azerfarin R, Kazemi F, Amiri M. Comparing caudal and penile nerve blockade using bupivacaine in hypospadias repair surgeries in children. Afr J Paediatr Surg 2011; 8:294-297. |
|17.||Telgarsky B, Karovic D, Wassermann O, Ogibovicova E, Csomor D, Koppl J. Penile block in children, our first experience. Bratisl Lek Listy 2006; 107:320-322. |
|18.||Cyna AM, Middleton P. Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys. Cochrane Database Syst Rev 2008; 8:CD003005. |
|19.||Kundra P, Yuvaraj K, Agrawal K, Krishnappa S, Kumar LT. Surgical outcome in children undergoing hypospadias repair under caudal epidural vs penile block. Paediatric Anaesth 2012; 22:707-712. |
|20.||Chhibber AK, Perkins FM, Rabinowitz R, et al. Penile block timing for postoperative analgesia of hypospadias repair in children. J Urol 1997; 158:1156-1159. |
|21.||Metzelder ML, Kuebler JF, Glueer S, Suempelmann R, Ure BM, Petersen C. Penile block is associated with less urinary retention than caudal anesthesia in distal hypospadia repair in children. World J Urol 2010; 28:87-91. |
|22.||Metzelder ML, Kuebler JF, Glueer S, Suempelmann R, Ure BM, Petersen C. Penile block is associated with less urinary retention than caudal anesthesia in distal hypospadia repair in children. World J Urol 2010; 28:87-91. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]