Comparison among Ultrasound guided Pudendal Nerve Block Dorsal Penile Nerve Block and Caudal Block for perioperative analgesia on pediatric patients undergoing penile surgeries

Pediatric penile surgery done under general anesthesia requires adequate analgesia. Selecting an efficient regional anesthesia for penile surgery on pediatric patients is crucial for lowering postoperative discomfort, cutting down on systemic opioid use and promoting early recovery. We expect to find out the optimal regional anesthesia/nerve block method in the peri operative period for pediatric patients undergoing penile surgeries.

After premedication with midazolam 0.1mg/kg, the patients will be taken into the operating room for application of all ASA monitoring and anesthesia induction will be achieved with Fentanyl (2mcg/kg), Propofol (2mg/kg) & sevoflurane in titrated dose. Laryngeal Mask Airways or Endotracheal tube of the appropriate size to be inserted after muscle relaxant administration as Atracurium (0.5mg/kg).

In Dorsal Penile nerve block group (A- group/ DPNB), Dorsal penile nerve will be achieved in the supine position. After skin sterilization, by using linear probe putting on the symphysis pubis & perforating the Scarpa’s fascia with 25G needle under ultrasound guided technique, injecting 0.25% bupivacaine mixture of 0.3ml/kg volume on the midline into the dorsal base of penis, between the pubis and the penis under Scarpa’s fascia.

In Pudendal nerve block group (B- group/ PDNB), block will be performed in lithotomy position. After the appropriate skin sterilization 22-24G needle, 50-100 mm will be inserted under ultrasound guided technique from inferomedial aspect of ischial tuberosities. Inj. Bupivacaine will be administered as a 0.25% mixture of 0.3ml/kg. This procedure will be performed bilaterally. In Caudal block group (C-group/ CDB), caudal block will be performed under ultrasound guided technique in the lateral decubitus position, the sacral hiatus area will be sterilized with an antiseptic solution and a 24G needle will be used for puncture. Local anesthetics inj. Bupivacaine 0.25% will be given as 0.5ml/kg after confirming the absence of blood and cerebrospinal fluid by aspiration.

The FLACC pain scale will be used to gauge the patients’ level of discomfort. The FLACC postoperative scores at 0 minutes, 2 hour, 4 hours, 6 hours, 12 hours and 24 hours will be noted. Paracetamol 15 mg/kg will be given intravenously at an interval of 6 hours, the first dose to be given intraoperatively. A rescue analgesic to patients will be administered with a score of more than 4, in the form of Inj. Tramadol 1-1.5 mg/kg. In case the analgesia is still inadequate after 30 minutes, inj. Morphine 0.05 mg/kg will be given as and the three techniques will be compared based on FLACC pain scale and with regard to analgesic consumption.