Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys.

BACKGROUND: Circumcision is a commonly performed surgical procedure in boys and caudal analgesia is frequently used to minimize discomfort of penile surgery postoperatively. For humanitarian and physiological reasons pain should be anticipated and effectively controlled while ensuring patient safety. Several non-caudal analgesic techniques can be used including: penile block, systemic opioids and topical local anaesthetic cream,emulsion or gel. OBJECTIVES: To compare the relative efficacy and side effects of caudal epidural analgesia with other forms of postoperative analgesia following circumcision in boys. SEARCH STRATEGY: CENTRAL, MEDLINE (from 1966), and EMBASE are searched using MeSH headings: Circumcision, Anesthesia-Caudal, Pediatric or Child, and the text words circumcision and caudal. Bibliographies of published trials and conference proceedings are also reviewed. Date of last search: December 2002. SELECTION CRITERIA: Published randomized and quasi-randomized controlled trials in which postoperative analgesia by caudal epidural block is compared with a non-caudal method of analgesia, in boys whose mean age is between 28 days and 16 years, having elective surgery for circumcision. DATA COLLECTION AND ANALYSIS: Trials identified from searching are assessed for inclusion and data extracted independently by two reviewers. Review Manager software is used for calculation of the treatment effect, represented by relative risks (RR), using a fixed effects model with 95% Confidence Intervals (CI). MAIN RESULTS: Seven trials of average quality involving 374 patients are included in this review. Only two comparisons of caudal analgesia have been investigated; parenteral analgesics in six trials, and penile block in one trial. Although some trial heterogeneity is evident this does not reach statistical significance. The need for rescue analgesia is reduced when caudal analgesia is compared with parenteral medications,((RR 0.32(0.16,0.63)). The incidence of nausea and vomiting is decreased in caudal patients compared with those receiving parenteral analgesics (RR 0.57 (0.35-0.93)) but not with those receiving penile block. REVIEWER'S CONCLUSIONS: Few studies compare caudal analgesia with other commonly available methods of analgesia in boys having circumcision surgery. Although the need for rescue analgesia is reduced in the early postoperative period when caudal is compared with parenteral analgesia,evidence from trials may no longer reflect current practice and is limited by small numbers and poor methodology. There is a need for properly designed trials to study the relative efficacy of caudal epidural with other methods such as penile block, morphine, simple analgesics and topical local anaesthetic cream,emulsions or gel.