Dorsal Penile Nerve Block for Minor Penile Surgery: Does Timing Matter?
Christina P. Carpenter, MD, MS1, Derrick Johnston, MD2, Rhys Irvine, MD3, Ashley Dixon, MD4, Joseph M. Gleason, MD1, Gerald R. Jerkins, MD1, Dana W. Giel, MD1.
1Le Bonheur Children's Hospital, UTHSC, Memphis, TN, USA, 2Arizona Pediatric Surgery, Tucson, AZ, USA, 3University Pediatric Urology, Knoxville, TN, USA, 4UT Austin, Dell Medical School, Austin, TX, USA.
BACKGROUND: Dorsal penile nerve blocks (DPB) are utilized commonly to control pain after penile surgery. Timing of their administration, however, is not standardized. We hypothesized that efficacy of the nerve block in blunting the pain response is contingent upon when it is given.
METHODS: Following IRB approval, we performed a randomized, blinded, prospective trial comparing administration of a DPB (0.25% bupivacaine, 1cc/kg, 10cc maximum) at different time points. Boys aged 6 months through 7 years undergoing primary or revision circumcision were invited to participate. Enrollees were randomized to receive the DPB at different time points after anesthetic induction. These groups were designated as following: Before (prior to foreskin manipulation), After (after completion of surgery), and Both (equal aliquots before and after surgery). Postoperative pain was recorded using the validated Faces, Legs, Activity, Cry, and Consolability (FLACC) scale at specified intervals (24, 48, and 72 hours from surgery end time). FLACC scores were also recorded with administration of each standardized dose of oral narcotic pain medicine. Telephone interviews were conducted within two weeks of surgery to collect the data recorded by the caretaker.
RESULTS: Of the 218 boys enrolled, complete data was available for analysis in 107 patients. At 72 hours, there were no differences in pain among the three groups; however, at 24 hours, pain scores in the Both group were significantly better than those in the After group (p = 0.04), and those in the Before group trended better than those in the After group (p = 0.15) as well, though this did not reach statistical significance. No statistical difference in pain control was detectable between the Before and Both groups (p = 0.5). Interestingly, there was no difference in doses of pain medicine given among the groups, suggesting that administration of pain medication by caregivers is not correlated with objective pain measurement.
CONCLUSIONS: Administration of DPB in divided doses before and after minor penile surgery seemingly affords the best postoperative pain control, particularly when compared to post-operative administration alone. This approach should be considered when planning for optimal post-operative analgesia.
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