What Are the Indications for a Circumcision?

Circumcision is the most common surgical procedure performed in males. This can be performed for medical reasons (e.g., phimosis, balanitis, chronic urinary tract infection), religious practice, societal norms, and/or aesthetic reasons. Commonly, circumcision is performed in the neonatal period; however, it can be delayed for a variety of reasons including prematurity, genitourinary anomalies (e.g., hypospadias) or religious practice.

Medical indications for circumcision include phimosis due to balanitis xerotica obliterans (with a reported incidence of 1.5%) and recurrent balanoposthitis, which is inflammation of the glans and foreskin (1.0% incidence). Other relative indications for circumcision are based on retrospective data that suggests the prevention of sexually transmitted diseases, and a reduced incidence of penile cancer and urinary tract infections, especially in patients with urologic abnormalities who are prone to infections.

Risks of circumcision are rare and include inadequate foreskin removal, inadequate cosmetic appearance, retained plastic ring when using the Plastibell device, infection, and glans or urethral injury.

What Is the Sensory Innervation of the Penis?

The sensory innervation of the penis is supplied by the dorsal nerve of the penis, a branch of the pudendal nerve. The pudendal nerve supplies the entire perineum and originates from the ventral rami of the sacral nerve roots S2, S3, and S4. The pudendal nerve appears in the pudendal canal where it travels anteriorly into the deep perineal pouch. It continues along the dorsum of the penis terminating in two dorsal nerves, located at 10- and 2-o’clock, which are targeted during a dorsal penile nerve block.

Describe the Anatomy of the Caudal Epidural Space and the Sacral Hiatus

The caudal epidural space is the most distal portion of the epidural space at the level of the sacrum. The sacrum is made up of five fused vertebrae (S1–S5) that join the lumbar vertebrae with the coccyx. All of the sacral laminae are fused in the midline with the exception of the S5 lamina, which form the sacral cornua. This defines the sacral hiatus, which is a midline opening in the sacral vertebrae S4 and S5. The sacral hiatus is covered by a membranous layer that extends downward to the coccyx (the sacrococcygeal ligament). It is through this ligament that the caudal space can be entered during a caudal block.

Is a Caudal Block a Good Adjunct to General Anesthesia for Postcircumcision Pain?

Circumcision can cause significant postoperative pain and discomfort. Therefore, it is important to provide postoperative analgesia, the most efficacious of which is a nerve block to provide total anesthesia. Caudal blocks are the most common regional anesthetic performed in infants and children. They consistently demonstrate effectiveness as an adjunct to general anesthesia for surgeries below the umbilicus in children, including circumcision, by lowering the perioperative narcotic requirement.

How Is a Caudal Block Performed?

A caudal block is placed during general anesthesia while the child is in a flexed lateral decubitus position. The sacral cornu can be palpated at the midline just above the gluteal cleft. Once the sacral hiatus is found, a needle (butterfly, straight, or angiocatheter) can be inserted into the hiatus. The needle will pierce skin, a subcutaneous fatty layer, and the sacrococcygeal ligament/membrane. Many experienced practitioners will describe feeling a loss of resistance into the epidural space and the needle should then be advanced several millimeters further into the space. Aspiration of the catheter should occur to decrease the risk of intravascular injection.

What Is a Test Dose in Relation to a Caudal Block?

A test dose is performed to assess if a block is intravascular prior to injection of the local anesthetic. Epinephrine (0.5 mcg/kg) may be used to identify intravascular injection. Most providers use lidocaine 1.5% with 1:200,000 epinephrine for this purpose.

A positive test dose is evidenced as shown in Table 43.1.

What Are Indications for a Caudal Block?

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  Lower abdominal surgery – e.g., inguinal hernia repair

  
  
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  Testicular procedures – e.g., hydrocele

  
  
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  Penile surgery – e.g., hypospadias/circumcisions

  
  
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  Hip – e.g., manipulations/pinning

  
  
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  Lower limb – various orthopedic procedures

What Are Contraindications to a Caudal Block?

Contraindications to caudal anesthesia are similar to that of epidurals and/or spinals and include:

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  Patient or legal guardian refusal

  
  
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  Sepsis or infection at the site of injection (diaper rash)

  
  
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  Coagulopathy

  
  
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  Congenital anomaly of the lower spine