Anaesthesia Used in
It is generally accepted that a General Anaesthetic (“GA”) is not necessary for male circumcision unless there are special circumstances. Usually a local anaesthetic is sufficient, but there are exceptions:
- Patients undergoing other pre-planned surgery that itself requires a GA.
Examples: Tonsillectomy, orchidopexy.
Circumcision should always be considered when an uncircumcised boy is to be hospitalised for other non-emergency paediatric surgery. Parents availing themselves of the opportunity should make sure that the surgeon is well versed in circumcision. Otherwise, the resulting style may disappoint.
- Patients insensitive to local anaesthetic drugs (of which more below).
- Patients who cannot be relied upon to remain still during the circumcision procedure.
Examples: Cerebral Palsy, Hyperactivity, Needle Phobia, or a generally nervous or uncooperative disposition.
There is a delicate balance to strike here between the statistical risks and costs of a GA on the one hand and the potentially abusive use of excessive restraint on the other.
© 2007 Professor Dr. Gamal Mousa
Can GA’s be given in local clinics?
In Europe, much of North America and certain other countries, GAs can only lawfully be given to children in settings where full resuscitation facilities are immediately available. Generally speaking, this means in a hospital. Modern anaesthetic gases are very much safer (and produce fewer side effects) than was the case even as recently as the mid-1990s, but every GA carries risk especially if it is the first one the patient has ever received. Hence the restriction; adverse reactions do occur albeit infrequently.
The photograph above shows anaesthetic gas being administered to a boy prior to his circumcision; the image comes from the opening sequence of Professor Dr. Gamal Mousa’s training video Circumcision - Dissection Method
. As regards anaesthesia the scene is reminiscent of paediatric dental practice in the UK in the 1950s and early 1960s.
Not all GAs involve gases. An alternative, especially suited to minor paediatric surgery, is intravenous injection of Ketamine. It is known that the late Dr Ossie Gibson, advocate and practitioner of circumcision and a consultant anaesthetist in the UK, used this technique for circumcising boys in the 1970s. Ketamine (more acurately "Ketamine Hydrochloride") is a widely available drug, being on WHO's List of Essential Medicines
for Children up to 12 Years of Age, March 2009 edition.
Multiple injections into the penis
The favoured technique nowadays is the Dorsal Penile Nerve Block. This involves an injection that penetrates the Buck’s Fascia (in contrast to a Subcutaneous Ring Block which does not). The difference is illustrated in the following diagram:
The injections are given close to the base of the penis, irrespective of whether shaft skin is to be removed (in order to produce a tight result) or not. Most patients find the first two injections somewhat painful but once the drug has started to take effect any subsequent injections and the circumcision itself should be pain free.
Beware that, very occasionally, a patient will be encountered whose pain response is not suppressed by such local anaesthesia. Always test the effectiveness of the anaesthesia rather than proceeding after a given time interval. Pinching of the condemned foreskin with forceps should not be felt at all once the drug has taken effect. Lidocaine insensitivity runs in families and is most likely to be found in patients with ADHD and/or Ehlers-Danlos Syndrome. Beware especially of the autistic boy who fails to communicate the continued feeling of pain when his response is tested.
Injection into the perineum
In 2011 a group of Lebanese doctors published a paper
commending the use of the pudendal nerve block technique. In a randomised controlled trial involving boys aged 3 to 5 years of age undergoing elective circumcision, the study returned significantly lower post-operative pain scores and lower demand for post-operative oral analgesics in the Pudendal Nerve Block group compared with the Dorsal Penile Nerve Block group. The technique involves transperineal injection into the pudendal nerve, the injection site being 15mm to 20mm from the centre of the anus. It is not entirely without risk, on account of the possibility of intravascular injection of local anesthetic, but when carried out with a full knowledge of the anatomy, physiology and associated pharmacology, it is a safe procedure with few complications. The published paper mentions "nerve stimulator-guided", the basics of which are explained here
Some patients have a greater fear of a local anaesthetic injection than they have of the circumcision itself, this on account of needle phobia. Successfully used in vasectomy clinics, one possible answer to the problem of needle phobia is needle-free injection. Typical equipment (a Dermojet) is illustrated here:
A Dermojet needle-free injector
Two products exist that can be applied topically to the penis, EMLA Cream and its more recently marketed competitor LMX4
. Dr. Terry Russell of Brisbane, Australia, describes on his website
a procedure whereby the parents apply EMLA Cream and wrap the penis in cling film two hours before bringing the boy to clinic. He reports success with this approach, infants requiring no further anaesthesia for a Plastibell circumcision. Lately, Dr. Russell has been substituting LMX4 for EMLA Cream. LMX4 is 4% Lidocaine w/w, whereas EMLA is typically Lidocaine 2.5% w/w plus Prilocaine 2.5% w/w.
Typically Lidocaine C14 H22 N2 O [2-(diethylamino)-N-(2,6-dimethylphenyl) acetamide] or one of its commercial derivatives will be used.
|The molecular structure of Lidocaine
Mixture of Lidocaine and Epinephrine
Some commercial derivatives add epinephrine, giving rise to the following exchange that appeared in the CIRCLIST Discussion Group several years ago:
Question: I have read that epinephrine added to the lidocaine is a bad idea for use in circumcision. Is this true?
Answer: The idea about being cautious in using epinephrine is right, but it’s use is rarely contraindicated in circumcision: some qualifying if’s and where’s may have gotten lost in what you recall.
Epinephrine or any drug that produces local vasoconstriction is definitely to be avoided in areas where it could compromise adequacy of haemoperfusion and predispose to slow healing or infection by anaerobes, potentially setting the stage for sloughing or even gangrene.
The textbook example is that one does NOT do a ring block of a toe or finger. Why then is a penis different from a finger? Because its blood supply is enormously greater (the incoming dorsal artery is of such caliber as not to have its blood flow significantly impeded by the vasoconstriction epinephrine would induce) and more distributed, with a Byzantine net of anastomoses amongst myriad smaller vessels. Structurally, the area of interest consists of highly vascularised connective tissue (external to Buck’s Fascia) surrounded by a LOOSE, distensible integument. This allows expansion when swelling occurs either as a result of the injection or later as a response to surgical trauma. The blood vessels traversing the region are NOT therefore unduly compressed.
The situation with a finger or toe is quite otherwise: the only blood supply is essentially through four small arteries, two located on either side dorsally and two on the palmar or plantar aspect of each. The skin covers each digit tightly and is essentially non-distensible without producing a lot of compression within the surrounding tissues. And at the center of everything there is a solid, unyielding core of bone. Circulatory insult had best be avoided in a body part with relatively restricted circulation in the first place - note that our fingers and toes often get cold, while our penis rarely does.
In the right circumstances, epinephrine can do all sorts of good things. As an adjunct in local anesthesia, it can both minimize bleeding and hold the anesthetic agent in place longer, so you need use less of it. Dentists inject epinephrine with the local anesthetic agent to get solid, long-lasting nerve blocks or to infiltrate around the operative site.
Nothing ever comes without a downside: the very vasoconstriction that allows you to kick a patient out of impending haemodynamic shock and circulatory collapse could precipitate a crisis in one with hypertension, a circumstance to be avoided! Systemically, it accelerates heart rate and can make people feel nervous, anxious and edgy for a while.
Epinephrine is an appropriate and valuable adjunct in achieving good local anesthesia and perhaps in bettering haemostasis during circumcision.
Mixture of Lignocaine and Bupivacaine
Experimentally, a mixture of lignocaine and bupivacaine has been trialled for use in adult circumcision. The purpose is to extend the duration of the pain control. A report of the trial is available on the PubMed
website. (NB Lignocaine is the old "British Approved Name" for Lidocaine. There is no significant difference between the two for the purposes of the reported trial.)
Circumcision without Anaesthetic
Until the 1980s it was commonplace for “RIC” (Routine Infant Circumcision) to be performed on neonates without anaesthetic. That is no longer the case, it now being realised that newborns do have a developed pain awareness.
There can be little doubt that some tribal circumcision ceremonies still take place without the benefit of modern medical techniques. Some may even regard the resulting pain as a valuable experience, a part of the transition from boyhood to manhood that characterises the “Coming of Age” aspects of the event. Circumcision without pain relief is, rather obviously, survivable - our ancestors did it for centuries before drugs were invented. But why suffer in the modern world, when pain control is readily available?
Uniquely (so far) amongst the Clip-&-Wear clamps, the PrePex™
device does not require anaesthesia. More detail can be found on our PrePex page
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