Regional anesthesia for ambulatory pediatric penoscrotal procedures



      Pediatric urology procedures are amongst the most commonly performed in children. The need for proactive treatment of pain is essential for optimal patient care. Current guidelines recommend the routine use of regional anesthesia in children as appropriate unless contraindicated. Given the commonality of urologic procedures in children, it is essential to understand the indications for and the utility of regional anesthesia.


      The current literature was searched using PubMed as the primary platform. Search words included ‘dorsal penile nerve block,’ ‘pudendal nerve block,’ ‘ring block,’ ‘spinal anesthesia,’ and ‘caudal,’ along with ‘pediatric’, ‘circumcision,’ ‘hypospadias,’ ‘urology’, and ‘urological surgery’ as part of the keywords of the search.


      The articles resulting from the literature search were reviewed for content, clarity and study design by two co-authors, and agreement determined the incorporation into the review. Additionally, a detailed description of study design, regional anesthetic technique, local anesthetic(s) used, and outcomes of each study referenced was incorporated into the supplemental table.


      Given the variance in block technique and local anesthetic choice amongst the current reported studies in the literature, it is difficult to truly compare and infer superiority of the regional anesthetic choices for ambulatory penoscrotal procedures. When choosing a regional anesthetic technique, careful consideration must be placed on block coverage, severity of expected pain and surgical duration of the procedure, type and dose of local anesthetic, as well as the patient’s past medical history and anatomy. Moreover, the regional block chosen should result from a thorough preoperative discussion between the surgeon and the anesthesiologist.


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        • American Society of Anesthesiologists Task Force on Acute Pain M
        Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management.
        Anesthesiology. Feb 2012; 116: 248-273
        • Chou R.
        • Gordon D.B.
        • de Leon-Casasola O.A.
        • Rosenberg J.M.
        • Bickler S.
        • Brennan T.
        • et al.
        Management of postoperative pain: a clinical practice guideline from the American pain society, the American society of regional anesthesia and pain medicine, and the American society of anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council.
        J Pain. Feb 2016; 17: 131-157
        • Taddio A.
        • Katz J.
        • Ilersich A.L.
        • Koren G.
        Effect of neonatal circumcision on pain response during subsequent routine vaccination.
        Lancet. Mar 1 1997; 349: 599-603
        • Labban M.
        • Menhem Z.
        • Bandali T.
        • Hneiny L.
        • Zaghal A.
        Pain control in neonatal male circumcision: a best evidence review.
        J Pediatr Urol. Feb 2021; 17: 3-8
        • Joshi G.
        • Gandhi K.
        • Shah N.
        • Gadsden J.
        • Corman S.L.
        Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities.
        J Clin Anesth. Dec 2016; 35: 524-529
        • Pedersen J.L.
        • Crawford M.E.
        • Dahl J.B.
        • Brennum J.
        • Kehlet H.
        Effect of preemptive nerve block on inflammation and hyperalgesia after human thermal injury.
        Anesthesiology. May 1996; 84: 1020-1026
        • Lee M.
        • Silverman S.M.
        • Hansen H.
        • Patel V.B.
        • Manchikanti L.
        A comprehensive review of opioid-induced hyperalgesia.
        Pain Physician. Mar-Apr 2011; 14: 145-161
        • Polaner D.M.
        • Taenzer A.H.
        • Walker B.J.
        • Bosenberg A.
        • Krane E.J.
        • Suresh S.
        • et al.
        Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia.
        Anesth Analg. Dec 2012; 115: 1353-1364
        • Ecoffey C.
        • Lacroix F.
        • Giaufre E.
        • Orliaguet G.
        • Courreges P.
        • Association des Anesthesistes Reanimateurs Pediatriques d'Expression F
        Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF).
        Paediatr Anaesth. Dec 2010; 20: 1061-1069
        • Alizadeh F.
        • Heydari S.M.
        • Nejadgashti R.
        Effectiveness of caudal epidural block on interaoperative blood loss during hypospadias repair: a randomized clinical trial.
        J Pediatr Urol. Oct 2018; 14: 420 e1-420 e5
        • Coté C.J.
        • Lerman J.
        • Anderson B.J.
        A practice of anesthesia for infants and children.
        6th ed. Elsevier, 2019
        • Johr M.
        • Berger T.M.
        Caudal blocks.
        Paediatr Anaesth. Jan 2012; 22: 44-50
        • Okoro C.
        • Huang H.
        • Cannon S.
        • Low D.
        • Liston D.E.
        • Richards M.J.
        • et al.
        The pudendal nerve block for ambulatory urology: what’s old is new again. A quality improvement project.
        J Pediatr Urol. Jul 24 2020;
        • Rehfuss A.
        • Bogaert G.
        • Kogan B.A.
        Spinal anesthesia in children: most pediatric urologists are not on board.
        J Pediatr Urol. May 2019; 15: 263 e1-263 e5
        • Tutuncu A.C.
        • Kendigelen P.
        • Ashyyeralyeva G.
        • Altintas F.
        • Emre S.
        • Ozcan R.
        • et al.
        Pudendal nerve block versus penile nerve block in children undergoing circumcision.
        Urol J. May 3 2018; 15: 109-115
        • Aksu C.
        • Akay M.A.
        • Sen M.C.
        • Gurkan Y.
        Ultrasound-guided dorsal penile nerve block vs neurostimulator-guided pudendal nerve block in children undergoing hypospadias surgery: a prospective, randomized, double-blinded trial.
        Paediatr Anaesth. Oct 2019; 29: 1046-1052
        • Blaise G.
        • Roy W.L.
        Postoperative pain relief after hypospadias repair in pediatric patients: regional analgesia versus systemic analgesics.
        Anesthesiology. Jul 1986; 65: 84-86
        • Chan K.H.
        • Shah A.
        • Moser E.A.
        • Szymanski K.
        • Whittam B.M.
        • Misseri R.
        • et al.
        Comparison of intraoperative and early postoperative outcomes of caudal vs dorsal penile nerve blocks for outpatient penile surgeries.
        Urology. Aug 2018; 118: 164-171
        • Cyna A.M.
        • Middleton P.
        Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys.
        Cochrane Database Syst Rev. Oct 8 2008; : CD003005
        • Faraoni D.
        • Gilbeau A.
        • Lingier P.
        • Barvais L.
        • Engelman E.
        • Hennart D.
        Does ultrasound guidance improve the efficacy of dorsal penile nerve block in children?.
        Paediatr Anaesth. Oct 2010; 20: 931-936
        • Gaudet-Ferrand I.
        • De La Arena P.
        • Bringuier S.
        • Raux O.
        • Hertz L.
        • Kalfa N.
        • et al.
        Ultrasound-guided pudendal nerve block in children: a new technique of ultrasound-guided transperineal approach.
        Paediatr Anaesth. Jan 2018; 28: 53-58
        • Hecht S.
        • Pineda J.
        • Bayne A.
        Ultrasound-guided pudendal block is a viable alternative to caudal block for hypospadias surgery: a single-surgeon pilot study.
        Urology. Mar 2018; 113: 192-196
        • Kendigelen P.
        • Tutuncu A.C.
        • Emre S.
        • Altindas F.
        • Kaya G.
        Pudendal versus caudal block in children undergoing hypospadias surgery: a randomized controlled trial.
        Reg Anesth Pain Med. Sep-Oct 2016; 41: 610-615
        • Kundra P.
        • Yuvaraj K.
        • Agrawal K.
        • Krishnappa S.
        • Kumar L.T.
        Surgical outcome in children undergoing hypospadias repair under caudal epidural vs penile block.
        Paediatr Anaesth. Jul 2012; 22: 707-712
        • Naja Z.
        • Al-Tannir M.A.
        • Faysal W.
        • Daoud N.
        • Ziade F.
        • El-Rajab M.
        A comparison of pudendal block vs dorsal penile nerve block for circumcision in children: a randomised controlled trial.
        Anaesthesia. Sep 2011; 66: 802-807
        • Naja Z.M.
        • Ziade F.M.
        • Kamel R.
        • El-Kayali S.
        • Daoud N.
        • El-Rajab M.A.
        The effectiveness of pudendal nerve block versus caudal block anesthesia for hypospadias in children.
        Anesth Analg. Dec 2013; 117: 1401-1407
        • Ozen V.
        • Yigit D.
        Caudal epidural block versus ultrasound-guided dorsal penile nerve block for pediatric distal hypospadias surgery: a prospective, observational study.
        J Pediatr Urol. May 20 2020;
        • Ozen V.
        • Yigit D.
        A comparison of the postoperative analgesic effectiveness of ultrasound-guided dorsal penile nerve block and ultrasound-guided pudendal nerve block in circumcision.
        Urol Int. Aug 13 2020; : 1-7
        • Soliman M.G.
        • Tremblay N.A.
        Nerve block of the penis for postoperative pain relief in children.
        Anesth Analg. Jul-Aug 1978; 57: 495-498
        • Wiegele M.
        • Marhofer P.
        • Lonnqvist P.A.
        Caudal epidural blocks in paediatric patients: a review and practical considerations.
        Br J Anaesth. Apr 2019; 122: 509-517
        • Adler A.C.
        • Belon C.A.
        • Guffey D.M.
        • Minard C.G.
        • Patel N.V.
        • Chandrakantan A.
        Real-time ultrasound improves accuracy of caudal block in children.
        Anesth Analg. Apr 2020; 130: 1002-1007
        • Gupta A.
        • Saha U.
        Spinal anesthesia in children: a review.
        J Anaesthesiol Clin Pharmacol. Jan 2014; 30: 10-18
        • Trifa M.
        • Tumin D.
        • Whitaker E.E.
        • Bhalla T.
        • Jayanthi V.R.
        • Tobias J.D.
        Spinal anesthesia for surgery longer than 60 min in infants: experience from the first 2 years of a spinal anesthesia program.
        J Anesth. Aug 2018; 32: 637-640
        • Whitaker E.E.
        • Wiemann B.Z.
        • DaJusta D.G.
        • Alpert S.A.
        • Ching C.B.
        • McLeod D.J.
        • et al.
        Spinal anesthesia for pediatric urological surgery: reducing the theoretic neurotoxic effects of general anesthesia.
        J Pediatr Urol. Aug 2017; 13: 396-400
        • Patel A.P.
        Anatomy and physiology of chronic scrotal pain.
        Transl Androl Urol. May 2017; 6: S51-S56
        • Teunkens A.
        • Van de Velde M.
        • Vermeulen K.
        • Van Loon P.
        • Bogaert G.
        • Fieuws S.
        • et al.
        Dorsal penile nerve block for circumcision in pediatric patients: a prospective, observer-blinded, randomized controlled clinical trial for the comparison of ultrasound-guided vs landmark technique.
        Paediatr Anaesth. Aug 2018; 28: 703-709
        • Gitman M.
        • Barrington M.J.
        Local anesthetic systemic toxicity: a review of recent case reports and registries.
        Reg Anesth Pain Med. Feb 2018; 43: 124-130
        • Naja Z.A.
        • Ziade F.M.
        • Al-Tannir M.A.
        • Abi Mansour R.M.
        • El-Rajab M.A.
        Addition of clonidine and fentanyl: comparison between three different regional anesthetic techniques in circumcision.
        Paediatr Anaesth. Nov 2005; 15: 964-970
        • Irwin M.G.
        • Cheng W.
        Comparison of subcutaneous ring block of the penis with caudal epidural block for post-circumcision analgesia in children.
        Anaesth Intensive Care. Jun 1996; 24: 365-367
        • Sharara-Chami R.
        • Lakissian Z.
        • Charafeddine L.
        • Milad N.
        • El-Hout Y.
        Combination analgesia for neonatal circumcision: a randomized controlled trial.
        Pediatrics. Dec 2017; 140
        • Lander J.
        • Brady-Fryer B.
        • Metcalfe J.B.
        • Nazarali S.
        • Muttitt S.
        Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial.
        J Am Med Assoc. Dec 24-31 1997; 278: 2157-2162
        • Ozen V.
        • Yigit D.
        A comparison of the postoperative analgesic effectiveness of low dose caudal epidural block and US-guided dorsal penile nerve block with in-plane technique in circumcision.
        J Pediatr Urol. Feb 2020; 16: 99-106
        • Gelfand H.J.
        • Ouanes J.P.
        • Lesley M.R.
        • Ko P.S.
        • Murphy J.D.
        • Sumida S.M.
        • et al.
        Analgesic efficacy of ultrasound-guided regional anesthesia: a meta-analysis.
        J Clin Anesth. Mar 2011; 23: 90-96
        • Wright T.E.
        • Orr R.J.
        • Haberkern C.M.
        • Walbergh E.J.
        Complications during spinal anesthesia in infants: high spinal blockade.
        Anesthesiology. Dec 1990; 73: 1290-1292
        • Cardona-Grau D.
        • Bayne C.E.
        • Hsieh M.H.
        Featuring: spinal anesthesia for pediatric urological surgery: reducing the theoretic neurotoxic effects of general anesthesia.
        J Pediatr Urol. Oct 2017; 13: 428-429
        • Williams R.K.
        • Adams D.C.
        • Aladjem E.V.
        • Kreutz J.M.
        • Sartorelli K.H.
        • Vane D.W.
        • et al.
        The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry.
        Anesth Analg. Jan 2006; 102: 67-71
        • Braga L.H.
        • Jegatheeswaran K.
        • McGrath M.
        • Easterbrook B.
        • Rickard M.
        • DeMaria J.
        • et al.
        Cause and effect versus confounding-is there a true association between caudal blocks and tubularized incised plate repair complications?.
        J Urol. Mar 2017; 197: 845-851
        • Tanseco P.P.
        • Randhawa H.
        • Chua M.E.
        • Blankstein U.
        • Kim J.K.
        • McGrath M.
        • et al.
        Postoperative complications of hypospadias repair in patients receiving caudal block vs. non-caudal anesthesia: a meta-analysis.
        Can Urol Assoc J. Dec 3 2018; : E249-E257
        • Zhu C.
        • Wei R.
        • Tong Y.
        • Liu J.
        • Song Z.
        • Zhang S.
        Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis.
        Reg Anesth Pain Med. Feb 2019; 44: 259-267
        • Kao S.C.
        • Lin C.S.
        Caudal epidural block: an updated review of anatomy and techniques.
        BioMed Res Int. 2017; 2017: 9217145
        • Giaufre E.
        • Dalens B.
        • Gombert A.
        Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists.
        Anesth Analg. Nov 1996; 83: 904-912
        • Suresh S.
        • Long J.
        • Birmingham P.K.
        • De Oliveira Jr., G.S.
        Are caudal blocks for pain control safe in children? an analysis of 18,650 caudal blocks from the Pediatric Regional Anesthesia Network (PRAN) database.
        Anesth Analg. Jan 2015; 120: 151-156
        • Taicher B.M.
        • Routh J.C.
        • Eck J.B.
        • Ross S.S.
        • Wiener J.S.
        • Ross A.K.
        The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair.
        Paediatr Anaesth. Jul 2017; 27: 688-694
        • Boretsky K.R.
        • Camelo C.
        • Waisel D.B.
        • Falciola V.
        • Sullivan C.
        • Brusseau E.
        • et al.
        Confirmation of success rate of landmark-based caudal blockade in children using ultrasound: a prospective analysis.
        Paediatr Anaesth. Jun 2020; 30: 671-675
        • Ngoo A.
        • Borzi P.
        • McBride C.A.
        • Patel B.
        Penile nerve block predicts higher revision surgery rate following distal hypospadias repair when compared with caudal epidural block: a consecutive cohort study.
        J Pediatr Urol. Aug 2020; 16: 439 e1-439 e6