Abstract
Purpose: Circumcision is one of the most common surgeries performed in the pediatric population. Multiple regional analgesic techniques, including caudal (CB) and penile block (PB), have championed as offering optimal analgesia for circumcision in the post-neonatal pediatric population without clear consensus. This meta-analysis sought to investigate CB and PB’s analgesic efficacy and the impact on postoperative analgesic requirements in pediatric circumcisions. Methods: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Library (1966-2016) was completed to identify all published randomized control trials (RCTs). Keywords searched included “circumcision”, “caudal block”, “penile block”, and “analgesia”. Inclusion criteria were limited to the comparison of PB versus CB in children less than 18 years of age and its efficacy towards circumcision. The efficacy, time to first additive analgesia, time to first micturition, duration of prolonged motor blockade, incidence of vomiting, and length of stay were analyzed. Results: 9 RCTs involving 574 children (N = 287 in CB and PB) were included. No differences in analgesic efficacy (relative risk (RR) = 0.983, 95% confidence interval (CI) = 0.95 to 1.02; p = 0.328) or time to first additive analgesia were observed (standardized difference in mean (SDM) = 0.438, 95% CI = -0.04 to 0.92; p = 0.073). Time to first micturition (SDM = 0.680, 95% CI = 0.40 to 0.96; p p = 0.007) were significantly prolonged in patients receiving CB. No differences were observed between groups in regards to the incidence of vomiting (RR = 1.56, 95% CI = 0.91 to 2.67; p = 0.107) and length of stay (SDM = 0.741, 95% CI = -0.05 to 1.53; p = 0.066). Conclusion: CB and PB offer similar analgesic success rates for pediatric patients (age 18 months to 16 years) undergoing circumcision. CB is associated with a trend towards longer duration of analgesia, but is associated with prolonged urinary retention and delayed ambulation. CB use is recommended in non-ambulatory children, whereas PB is recommended in ambulatory children.
Highlights
Male circumcision is the most common pediatric surgical procedure performed globally [1] [2]
The children were divided with 287 patients in each group receiving either caudal block (CB) or penile block (PB) for circumcision
A randomized control trials (RCTs) of 104 patients by Haliloglu et al (2013) reported a higherpain score in children postoperatively following PB at 30 minutes but not at 60 minutes (30 minutes: p < 0.001 and at 60 minutes: p = 0.189) [1]. These results suggest any difference in analgesia after PB and CB wanes quickly after the first half hour of administration
Summary
Male circumcision is the most common pediatric surgical procedure performed globally [1] [2]. A 2010 report by the Centers for Disease and Prevention (CDC) reported 80% of males between the ages of 14 - 59 years were circumcised in the United States (US) [4] [5]. Reports of medical benefits have contributed to the high prevalence rates of circumcision in the US. Morris et al (2014) reported that over the course of a circumcised male’s lifetime, the benefits of circumcision exceed the risks by a ratio of 100:1 [5]. The only risks associated with circumcision were surgical complications such as wound infections, whereas the benefits included reduction in urinary tract infections, pyelonephritis, candidiasis, and sexually transmitted infections [5]. A recent systematic review by Morris and Krieger (2013) involving 19,542 uncircumcised and 20,931 circumcised men demonstratedno adverse effects of circumcision on sexual function, sensitivity, or sexual satisfaction [8]-[10]
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