5 Feb 2020

Anesthesia for Neonatal Circumcision

Circumcision, a fairly common procedure for newborn males in certain parts of the world, is the surgical removal of the skin covering the genitals.1 In 2016, the estimated global prevalence of circumcision among males aged 15 to 64 years was 38.7 percent.2 Circumcision can be performed as a religious or cultural ritual or because of family tradition.1 Though the American Academy of Pediatrics states that the health benefits of newborn male circumcision outweigh the risks, its policy maintains that the final decision should still be left up to the parents.3 The various health benefits of circumcision include easier hygiene; decreased risk of urinary tract infections, sexually transmitted infections and penile cancer; and prevention of penile problems such as inflammation.1 Given that circumcision is a surgery, anesthesia providers play an important role in the procedure.4 Given the high rates of circumcision around the world, anesthesiology practitioners should consider best practices before, during and after surgery.5

The anesthesia provider should begin with a preoperative medical history and physical examination.5 Unless a positive bleeding history indicates further testing, blood testing is unlikely to predict surgical complications and is thus considered unnecessary.6,7 To avoid unwarranted laboratory expenses and labor costs, anesthesia providers should deliberate about performing extra blood tests on a male child before circumcision.5 Additionally, the age of the patient may vary widely depending on cultural norms. While a study by Nguyen et al. in New York included infants from one to six months of age,4 Aydur et al.’s study on Turkish circumcision practices showed that the majority of men were circumcised between six and 12 years of age.8 The patient’s age and verbal stage may affect the anesthesia provider’s preoperative counseling methods, preparation for surgery, equipment selection and choice of anesthesia.5 As with other surgical procedures, preoperative preparation is crucial for relieving patients’ and relatives’ anxieties, identifying surgical contraindications and choosing anesthetic practices.

Intraoperative practice for circumcision is unique from other types of surgery, and there remains no consensus on the most effective types of anesthesia.9 Methods include topical analgesia, caudal block, dorsal penile nerve block (DPNB), nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids.5 For example, the American Society of Pain Management Nurses (ASPMN) recommends using a subcutaneous ring block, which prevents increased heart rate, or a dorsal penile nerve block.10 ASPMN also suggests intraoperative comforting for a neonate undergoing circumcision, such as positioning the child in a semirecumbent position on a padded surface and providing a sucrose pacifier.10 Sharara-Chami et al. found that the most effective analgesia for neonatal circumcision was ring block combined with lidocaine cream and oral sucrose.9 Meanwhile, Karasu et al. compared a ketamine/midazolam combination with a propofol/sevoflurane combination for circumcision and found that intraoperative bleeding was significantly higher in the ketamine/midazolam group.11 Some anesthesia providers also use ultrasound to locate sites of anesthesia administration. A study by Faraoni et al. found that though ultrasound guidance increased the length of the circumcision procedure, it improved the efficacy of penile nerve block in pain management as compared to the classic landmark-based technique.12 Age can also influence the use of different anesthesia modalities. For infants younger than six months of age whose parents want to avoid general anesthesia, Nguyen et al. recommend a modified circumcision technique under local anesthesia.4 A paper by Gonzalez et al. suggests that simultaneous circumcision and myringotomy (an eardrum procedure) may reduce costs and minimize the neurocognitive risks of general anesthesia at a young age.13 Evidently, the best types of anesthesia vary based on the patient’s age, parental preference and provider’s practices.

As with all surgeries, the anesthesia provider is responsible for postoperative care of a patient undergoing circumcision. This includes monitoring for signs of postoperative complications and overseeing postoperative pain management. Possible postoperative complications include re-operation for control of hemorrhage, wound infection, circumcision revision and urethral meatotomy (widening of the opening).4 For postoperative analgesia, anesthesia providers commonly use acetaminophen or related drugs.5 A study by Münevveroglu and Gunduz on analgesia methods for circumcision found that penile block, caudal epidural block, subcutaneous ring block, intravenous paracetamol and intravenous tramadol HCl were equally efficacious for reducing postoperative pain.14 It is up to the provider and the patient’s parents to determine the best postoperative management for the child.14

 Anesthesia providers must be knowledgeable about perioperative care for circumcision given that it is a fairly common procedure. Preoperative history collection, physical examination and preparation of the parents is vital to a successful surgery. The patient’s age and parents’ decisions, as well as the provider’s professional experience, may influence the type of anesthesia used intraoperatively. Postoperative management includes prevention of complications and pain reduction. Future research should explore the long-term effects of neonatal anesthesia exposure, as well as the most effective anesthetic methods for circumcision patients of various ages.

1.         Mayo Clinic. Circumcision (male). Tests & Procedures February 10, 2018; https://www.mayoclinic.org/tests-procedures/circumcision/about/pac-20393550.

2.         Morris BJ, Wamai RG, Henebeng EB, et al. Estimation of country-specific and global prevalence of male circumcision. Population Health Metrics. 2016;14:4.

3.         American Academy of Pediatrics. Newborn Male Circumcision. News Room August 27, 2012; https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/Newborn-Male-Circumcision.aspx.

4.         Nguyen TT, Kraft E, Nasrawi Z, Joshi M, Merianos D. Avoidance of general anesthesia for circumcision in infants under 6 months of age using a modified Plastibell technique. Pediatric Surgery International. 2019;35(5):619–623.

5.         Altaş C, Küçükosman G, Yurtlu BS, et al. Anesthesia methods used by anesthetic specialists for circumcision cases. National survey study for Turkey. Saudi Medical Journal. 2017;38(1):75–81.

6.         Bhasin N, Parker RI. Diagnostic outcome of preoperative coagulation testing in children. Pediatric Hematology and Oncology. 2014;31(5):458–466.

7.         Johnson RK, Mortimer AJ. Routine pre-operative blood testing: Is it necessary? Anaesthesia. 2002;57(9):914–917.

8.         Aydur E, Gungor S, Ceyhan ST, Taiimaz L, Baser I. Effects of childhood circumcision age on adult male sexual functions. International Journal of Impotence Research. 2007;19(4):424–431.

9.         Sharara-Chami R, Lakissian Z, Charafeddine L, Milad N, El-Hout Y. Combination Analgesia for Neonatal Circumcision: A Randomized Controlled Trial. Pediatrics. 2017;140(6):e20171935.

10.       McCaffery M. Circumcision: Is a local anesthetic appropriate? Nursing2020. 2002;32(4):24.

11.       Karasu D, Yilmaz C, Ozgunay SE, Karaduman I, Ozer D, Kaya M. Effects of Different Anesthetic Agents on Surgical Site Hemorrhage During Circumcision. Urology Journal. 2018;15(2):21–26.

12.       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? Paediatric Anaesthesia. 2010;20(10):931–936.

13.       Gonzalez DO, Cooper JN, Minneci PC, Deans KJ, McLeod D. Reducing the Number of Anesthetic Exposures in the Early Years of Life: Circumcision and Myringotomy as an Example. Clinical Pediatrics. 2017;57(3):335–340.

14.       Münevveroglu C, Gunduz M. Postoperative pain management for circumcision; Comparison of frequently used methods. Pakistan Journal of Medical Sciences. 2020;36(2).