Pain Management in Circumcision

Male circumcision is the surgical removal of all or some of the foreskin of the penis. For Jews and Muslims, circumcision is a part of their religious custom. Studies have shown that in many countries, more than 40% of neonates are circumcised for nonreligious reasons.

The infectious bacterial colonization beneath the prepuce or foreskin of penis is remarkably reduced by this procedure. This results in minimal chance for urinary tract infections (UTI) mainly in the first year of life, and STDs like gonorrhea and syphilis. Studies have suggested decreased HIV infection for circumcised individuals. Circumcision could also reduce the chances of penile cancer. However, in 1999, the American Association of Pediatrics declared no evident medical benefits for circumcision.

The surgical procedure of circumcision can cause pain; hence the patient should receive an anesthetic during the procedure and a painkiller following the procedure. Topical application of anesthetic agents like 2.5% lidocaine or prilocaine, applied either alone or in combination for 60 to 90 minutes prior to the surgery with or without occlusive dressing, have proved to reduce pain. A more effective mode of pain management but invasive technique is nerve infiltration. Dorsal Penile Nerve Block is given using 1% lidocaine at two sites on the penile skin 3-5 minutes before the surgery. Epinephrine should not be used in the injection. Alternatively, 0.8% lidocaine can be administered as ‘ring’ around the penis 8 minutes prior to the surgery to anesthetize the area. Acetaminophen in a dose of 15mg/kg is given orally once every 4 to 6 hours for 24 hours postoperatively to reduce pain. Pacifiers dipped in a concentrated solution of sucrose have soothing and pain relief properties.

Circumcision is contraindicated in premature neonates, those with bleeding disorders or having a family history of the same. Bleeding and infection are the common complications for this surgery for which direct pressure and oral antibiotics with local wound care can be the respective remedies. Phimosis or inability to retract the remaining foreskin is a complication that needs topical steroids or repeat surgery for its cure. 

The final decision for surgical removal of the prepuce of male neonates should be taken by the parents as its medical benefits in the long run remain blurred.  

Reference: Drug Therapy Considerations in Circumcision; Rebecca Regen et al; US Pharmacist 2012

Source-Medindia