One of the concerns is that DPNB may cause hearing impairment; however, studies have shown normal brain-stem-evoked responses after circumcision performed with the use of DPNB with lidocaine.[2] Skin changes after circumcision in which DPNB was used for postoperative pain control were documented in two older children; however, in these children circumcision was performed under a general anesthetic, with the use of vascular ties and circumferential sutures.[3] It was unclear whether the complication was directly attributable to DPNB. Similar problems have not been reported in routine circumcision of newborns. In experience with large numbers of newborns circumcised with DPNB, the only complication has been minor bruising or hematoma at the site of injection.[4]
Newborns undergoing circumcision should have the benefit of anesthesia. Although there are always possible complications, the current literature shows that DPNB is safe, effective and easy to learn. It is currently the best method for providing pain control in newborns undergoing routine circumcision.
Jonathan Tolkin, MB, BCh, FRCPC
Medical program director
IODE Children's Centre
North York General Hospital
Willowdale, Ont.
The question of the risk of urinary tract infection (UTI) posed by circumcision is an important one. A 1-in-80 chance does not appear to justify circumcising 79 other boys. However, the authors do not mention the problem of making the proper diagnosis of UTI. Almost every baby has a fever during the first 2 years of life. Does the baby have a UTI?
A study at the National Children's Hospital in Dublin[2] found that Proteus mirabilis was cultured from 22.6% of the swabs taken from uncircumcised boys and from only 1.7% of those taken from circumcised boys. These patients had conditions unrelated to the urinary tract and no history of urinary tract disease. This suggests that many patients have a positive result of a culture simply because of the presence of bacteria on the prepuce, yet may end up being treated for a UTI.
Another issue is pain. Circumcision is very painful, and full consideration should be given to reducing this pain as much as possible. Many physicians are now being taught to anesthetize the penile nerves locally. The society is correct in stating that "the most effective and least risky type of anesthesia or analgesia remains to be determined."
I do not favour penile blocks. They can be as painful as the procedure itself, and they have complications. I believe that pain can be greatly reduced through the use of the Mogen circumcision instrument, which is used by all Jewish Mohels. As a Mohel, I also use a sweet Jewish wine to help with analgesia.
Circumcision performed with the Gomco clamp can take 5 minutes or more and involves a lot of tissue manipulation. With the Mogen circumcision instrument, circumcision takes 30 seconds. The Gomco clamp should be thrown in the garbage.
The society does not address the circumcision of infants beyond the neonatal age. Our centre serves as the main circumcision service for referrals for most hospitals in Montreal. We routinely circumcise patients up to 15 months of age with the use of only a eutectic mixture of local anesthetics (EMLA, consisting of lidocaine and prilocaine in an emulsion base) and sweet wine as analgesics. There is rarely any bleeding, but any that occurs is easily controlled with a special coagulation powder used by the Mohels, available commercially in a mixture called Kwik Stop. Sutures have never been required.
Larsen and Williams[3] have pointed out the disadvantages of circumcision conducted under a general anesthesic. The use of the Mogen circumcision instrument to circumcise patients up to 15 months of age, without a general anesthesic or sutures and with appropriate hemostasis, is a move in the right direction.
Murray S. Katz, MD, CM
Medical director
Tiny Tots Medical Centre
Dollard-des-Ormeaux, Que.
We agree with Dr. Tolkin's comment that newborns undergoing circumcision should have the benefit of anesthesia. Unfortunately, there are still physicians who do not feel that anesthesia is necessary. Most physicians who performed newborn circumcisions answering a recent survey used either no analgesics or analgesics of questionable efficacy.[1] Respondents stated that they were unfamiliar with the use of analgesics, and DPNB in particular, in newborns. Most of the respondents believed that newborns can feel pain. However, the physicians surveyed were reluctant to adopt new techniques because of safety concerns. The authors of that study emphasize the need for further research into analgesic alternatives for circumcision, including evaluations of efficacy, safety and generalizability of the techniques in community practice. Another report describes a marked increase in the use of local analgesics for neonatal circumcision after the introduction of awareness and educational programs on this topic.[2] These two reports emphasize the need for and potential success of continuing efforts to increase the use of safe and effective techniques of anesthesia and analgesia in circumcision.
Dr. Katz's comments are a good reminder of the problem of contamination of urine cultures taken from uncircumcised male infants. Although, because of space constraints, we do not discuss the difficulty of diagnosing UTI correctly in our statement, we do note that the diagnosis of UTI had been correctly made with cultures of urine samples obtained by bladder tap or catheter in all but one of the studies linking an increased incidence of UTI to the uncircumcised state. There is no evidence that contaminants accounted for a significant part of this reported association.
We are interested in Katz's comments concerning the Mogen circumcision instrument used by Mohels. We are aware of this experience but were unable to find any publications concerning the use of this device. A well-designed trial comparing circumcision performed with the Mogen instrument with that performed with the Gomco clamp would be important to confirm Katz's experience. We are also aware of the ritual use of wine to aid analgesia but, similarly, we could find no articles comparing the use of wine with other techniques.
Important medical advances occur when professional experiences or even intuitions are followed up with appropriate trials. Silverman[3] reminds us of some tragic mistakes that have been made when therapies or interventions have been practised, sometimes widely, without adequate evaluation. It is important that experiences such as those described by Katz receive a proper evaluation, so that physicians can offer parents appropriate information regarding the best way to carry out circumcision.
Eugene Outerbridge, MD, CM, FRCPC
Department of Pediatrics
Montreal Children's Hospital
Montreal, Que.
Douglas D. McMillan, MD, FRCPC
Chairman
Fetus and Newborn Committee
Canadian Paediatric Society
Department of Pediatrics
Foothills Hospital
Calgary, Alta.