Abstract
This case presents the perioperative management of a 6-year-old male patient undergoing penoscrotal urethroplasty. General anesthesia was administered along with Fentanyl (1–2 mcg/kgBW) during induction Bilateral pudendal nerve blocks were performed using Bupivacaine 0.25 % with no additional opioids required during the surgery, and hemodynamic stability was maintained. Postoperative pain was effectively managed with paracetamol, and the patient was discharged on the second postoperative day without any complications. This case highlight the use of pudendal nerve block as a safe and effective analgesic thecnique for pediatric urethroplasty.
Highlights
- •
Pudendal nerve block provides effective analgesia in pediatric urethroplasty.
•Landmark-based technique used for pudendal nerve block in children.
•No additional intraoperative opioids were required during the procedure.
•Minimal postoperative pain managed with paracetamol.
•No complications observed, the patient discharged on the second postoperative day.
1
Introduction
The pudendal nerve arises from the sacral plexus. It exits through the greater sciatic foramina which is inferior to the piriformis muscle then it crosses the posterior aspect of the sacrospinous ligament at the level of the ischial spine. The pudendal nerve then reenters the pelvis through the lesser sciatic foramina and go inside the pudendal canal. Following this, it divides into the perineal nerve, inferior rectal nerve and dorsal nerve of the clitoris or penis. Hence, the pudendal nerve innervates the urethral muscles, clitoris, penis, perineum, pelvic floor sphincter, urethra and bladder triangle. , The pudendal nerve block may provide adequate perineal anesthesia during anorectal, urologic or obstetric procedures. This block is routinely done in women during labor through a transvaginal approach. However, it is possible to block the pudendal nerves through other approaches; such as transperineal and perirectal.
The efficacy of pudendal nerve block in widely known in adults. , However, only few studies were conducted in pediatric populations. In children, pudendal nerve block may serve as efficient alternative of caudal block with improved perioperative analgesia. We report a case of a pediatric patient who received a landmark based pudendal nerve block for intraoperative and postoperative analgesia following urethroplasty procedure.
2
Case reports
2.1
Patient preparation
The patient was a 6-year-old male scheduled to undergo penoscrotal urethroplasty. Written informed consent was obtained from his parents prior to the procedure. The patient underwent general anesthesia with laryngeal mask airway. The patient received Fentanyl 1–2 mcg/kgBW during induction.
2.2
Pudendal nerve block
Following the induction, the patient was placed in dorsal lithotomy position or “frog leg position”. The perineal area was prepared and draped in typical sterile fashion. The index finger was utilized to palpate the ischial spine along the perineum. Then by using a 3.8 cm, 27-gauge needle was advanced approximately 1 cm inferior and medial to the attachment of the sacrospinous ligament to the ischial spine ( Fig. 1 ). An aspiration test was performed before local anesthetic injection to avoid any intravascular injection. After negative aspiration test, 0.25 ml/kgBW of plain Bupivacaine 0.25 % was injected. The same procedure was then repeated contralaterally. Strict aseptic technique was followed throughout the procedure. The patient weighed 16.8 kg and measured 112 cm in heigh. A total volume of 10 ml of bupivacaine 0.25 % was administered. Intraoperatively, the patient received no additional opioid. Hemodynamic was stable throughout the surgery for the patient. The total length of surgery was between 2 and 3 hours.
2.3
Postoperative
Postoperatively, the patient received paracetamol at dose 20 mg/kgBW every 8 hours. No agitation was reported during recovery period. The patient had no signs of motor weakness in the lower extremities. The patient was discharged on the second postoperative day, and no other complications occurred following the pudendal nerve block in this case report.
3
Discussion
Majority of pediatric urologic surgeries are performed around the prepuce of phallus. Adequate perioperative pain management is essential to ensure a safe and convenient recovery. Insufficient postoperative pain control is associated with prolonged hospitalization, increased rate of hospital readmission, greater opioid consumption, increased postoperative nausea and vomiting, and eventually poor patient and parents’ satisfaction. Regional anesthesia, including caudal block, ring block, and penile nerve block, is relatively common addition to general anesthesia for this group of patients. Conventionally, caudal block provides adequate analgesia for any penile surgery. However, caudal block is contraindicated in children with anatomical abnormalities of the spine and may provide prolonged motor blockade and/or urinary retention. Ring block is also an option for this procedure. However, multiple injection site might cause discomfort compared to penile nerve block. Penile nerve block has also gained popularity among health practitioners because of its simplicity. Compared to caudal block, penile nerve block showed lower post-operative pain . However, penile nerve block is associated with hematoma formation, structure distortion, and inadequate analgesia of the ventral side of the penis.
The pudendal nerve comes from the sacral plexus with contributions from the ventral rami of the second through fourth sacral nerves. The nerve reenters the pelvic area through the lesser sciatic foramina then enters the Alcock’s canal. Later it will divide into the inferior rectal nerve, perineal nerve and the dorsal nerve of the clitoris or penis. , The pudendal nerve block is a local field block of the inferior rectal nerve, which covers the perianal skin, anoderm and the external anal sphincter, and the perineal nerve, which has a superficial branch that supplies the labia or scrotum and a deep branch that covers the external anal sphincter and urethral sphincter and mucosa ( Fig. 2 ). This block relies on the local anesthetic agents delivered around the tissues adjacent to the nerve, which may be accessed through landmark orientation or ultrasound guidance.
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