159

ORIGINAL ARTICLE
Comparison of preventive analgesia techniques in circumcision cases: Dorsal
penile nerve block, caudal block, or subcutaneous morphine?
Ebru Canakci,1 Ozgur Yagan,2 Nilay Tas,3 Tugçe Mutlu,4 Abdullah Cirakoglu,5 Erdal Benli6

Abstract
Objective: To compare 3 different techniques of preventive analgesia before circumcision operations in male
children between 6-12 years of age. Our objective was to investigate the duration and quality of postoperative
analgesia in patients, who were subject to caudal block technique, dorsal penile nerve block or who were
administered subcutaneous morphine.
Methods: The prospective, randomised, single-blind study was conducted at Ordu University Training and Research
Hospital, Ordu, Turkey, from January 1 to June 30, 2015, and comprised boys aged 6-12 years, who were scheduled
to undergo circumcision operation. All patients were under general anaesthesia by means of laryngeal masks. The
patients were randomised into 3 equal groups. The patients in Group C received caudal block with bupivacaine
0.25% in a total volume of 0.50 ml/kg in lateral position. Those in Group M received injections of 100 mcg/kg of
subcutaneous morphine into the deltoid muscle. Patients in Group DP were subjected to dorsal penile nerve block
with 1 mg/kg of bupivacaine 0.25%. Intraoperative haemodynamic data, pain and sedation scores, according to
Children's Hospital of Eastern Ontorio Pain Scale and Ramsay Sedation Scale, were recorded at postoperative 1st, 6th
and 24th hours in all cases.
Results: The 60 subjects in the study were divided into 3 groups of 20(33.3%) each. The overall mean age was
7.75±8.12 years. At 1 hour after surgery; 8(40%) cases in Group M, 5(25%) cases in Group DP, and all the 20(100%)
cases in Group C had a pain score <6 (p<0.05). When the scores were analysed 12 hours post-operatively, 5(25%)
cases in Group M and 10(50%) cases in Group DP had a pain score >6, while the pain scores of all the 20(100%) cases
in Group C were <6 (p<0.01). Among the groups, there was no statistically significant difference regarding the
sedation scores (p>0.05).
Conclusion: Using the three methods, analgesia lasted until 12 hours postoperatively, being more evident in the
caudal block group, minimising postoperative stress in children and parents.
Keywords: Preventive analgesia, Caudal block, Dorsal penile nerve block, Morphine. (JPMA 67: 159; 2017)

Introduction Association (ASA) at anaesthesia clinics affiliated to

Circumcision is a procedure to uncover the tip of the penis hospitals as well as fully-equipped office-based surgery
by means of surgical incision of the prepuce, which is units.3
called the foreskin, covering the glans penis in a certain
The purpose of an ideal anaesthesia is to ensure loss of
form and length. It is not only a longstanding tradition
practised, but also the most frequently performed consciousness and reflex deep enough, and motor block
surgical procedure in the world.1,2 and analgesia throughout the surgery under conditions
that would cause minimum damage to the physiology
Children are ideal patients for same-day surgeries. Same- and metabolism of the organism as well as to ensure a
day surgical procedures provide great advantage to safe and high quality wake-up period, fast recovery and
paediatric patients as they are not taken away from their normalisation of activities in the post-recovery period,
families and their usual environment for a long time. and to minimise the side effects such as nausea, vomiting,
Many surgical procedures can be performed on a same- pain, and vertigo etc. that would delay the discharge of
day basis in paediatric patients of any age under the patient.4,5
categories I and II of the American Anaesthesiology
Circumcision in paediatric patients is done under
1-3Department of Anaesthesiology and Reanimation, 5,6Department of sedation-analgesia, local anaesthesia, general anaesthesia
Urological Surgery, Ordu University School of Medicine, Turkey, 4Ordu or regional anaesthesia.4 The options of anaesthesia
University Training and Research Hospital, Clinic of Anaesthesiology and methods for circumcision depend on the status of the
Reanimation, Turkey. patient, conditions available at the hospital, professional
Correspondence: Ebru Canakci. Email: [email protected] skills and attitude of the anaesthesiologist.5

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160 E. Canakci, O. Yagan, N. Tas, et al

The concept of preventive analgesia is a pharmacological local anaesthetics or opioids or those with a tendency to
strategy based on the administration of analgesic have allergies. Also excluded were children in ASA II/III
treatment before the surgical stimulus is induced in order physical status suffering from additional disorders such as
to prevent postoperative pain.6,7 Recent studies have childhood asthma, diabetes, epilepsy, liver disease,
shown that it is more effective to start postoperative pain congenital heart disease etc.; children who had bleeding,
treatment before surgery.6 An effective analgesia to be coagulation disorders or haematological problems such
ensured in the postoperative period will not only reduce as anaemia; morbidly obese children with body weight
complications but also bring along a fast recovery.6 above the 90th percentile according to the percentile
curves; children diagnosed with growth development
Today, it is known that children feel pain as much as adults retardation under the 3rd percentile according to the
do, that they develop stress response to surgery, and it is percentile curves; children diagnosed with some
necessary to address pain without affecting the additional endocrinological problems; children who were
respiratory centre. For that reason, regional anaesthesia followed by a paediatric psychiatrist and taking
techniques added to anaesthesia for the purpose of medication for any mental health problem like attention
postoperative analgesia are commonly used as they allow deficit hyperactivity syndrome, depression etc.; children
children to have a pain and problem-free postoperative with neurological, neuromuscular disorders; and children
period.8-10 outside the 6-12 age bracket.
In ambulatory cases, a child who has consistent pain in
and sample size test made at α=0.05 and 80% power, the
Considering an earlier study as the basis, power analysis
the postoperative period will be deprived of his chance to
recover and be discharged in a short period of time. Apart sample size was determined.
from conventional methods, caudal block technique,
which has recently gained importance in postoperative The selected sample was randomised into 3 equal groups:
analgesia, is preferred as it is easily implemented and has DP, C and M. All the patients were premedicated with 0.5
a high chance of success. Furthermore, the trauma of mg/kg of oral midazolam as they entered the operating
separation from family in children is also avoided in room, and when they were put on the operating table
addition to the benefit of analgesia.11-14 following routine monitoring procedures, each patient
went through the same standard general anaesthesia
The current study was planned to investigate the side method using laryngeal mask. First of all, an intravenous
effects and effects of caudal epidural bupivacaine, (IV) line was started with 22-gauge intracath, and then
subcutaneous morphine and dorsal penile nerve block induction was done with 2.5 mg/kg of propofol. For the
performed with bupivacaine on postoperative analgesia maintenance of anaesthesia, sevoflurane with 2%
in paediatric cases. concentration and 50% nitrous oxide (N2O) - 50% oxygen
Subjects and Methods (O2) was used. In the penile block Group DP, following the
The prospective, randomised, single-blind study was necessary sterilisation and covering procedures in supine
conducted at Ordu University Training and Research position, dorsal penile nerve block was performed on the
Hospital, Ordu, Turkey, from January 1 to June 30, 2015, dorsal penile root by the urologist with a 27-gauge dental
and comprised boys aged 6-12 years, who were needle by means of injecting bupivacaine 0.25% in 1
scheduled to undergo circumcision operation. After mg/kg dose (maximum upper limit is 50mg). In the caudal
approval was obtained from the ethics committee of block Group C, on the other hand, after anaesthetising the
Samsun Ondokuz Mayis University, Turkey, the subjects patient by the standard general anaesthesia method, the
were selected who were in ASA I physical status without patient was put in lateral decubitus position, and
any additional disorders. Informed consent was collected following the necessary sterilisation and covering
both from the subjects and their parents. procedures, in line with the absolute asepsis and
antisepsis conditions in surgery, sacral cornua was
Children or parents who did not accept our analgesia palpated, sacral hiatus was located, and bupivacaine
techniques when explained to them were excluded. 0.25% of 0.5 ml/kg volume in 1 mg/kg dose (maximum
Likewise, those who also had some additional urological 50mg, 20cc volume) was administered by the
problems such as paraphimosis reduction, hypospadias anaesthesiologist into the sacral hiatus by means of a 22-
repair, epispadias repair, undescended testicles surgery; gauge caudal needle (B Braun®, Melsungen, Germany).
and who were planned to be operated for those reasons Once the caudal needle was inserted, as we were in the
and to be circumcised at the same time were also sacral epidural space and assured that there was no blood
excluded. And so were patients who had allergy against or Cerebrospinal Fluid (CSF) coming through, the local

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Comparison of preventive analgesia techniques in circumcision cases: Dorsal penile nerve block... 161
anaesthetic solution prepared for the case (bupivacaine Table-2: Intraoperative mean arterial pressure (MAP).
0.25%) was administered into the caudal space. Finally, in
the subcutaneous morphine Group M), following Group M Group DP Gr0up C p
standard general anaesthesia, 100 mcg/kg of
MAP(mmHg) Mean±SD Mean±SD Mean±SD
subcutaneous morphine was injected into the deltoid 5th min 93.36±16.61 88.16±17.09 90.36±15.60 0.387
muscle by means of a 26-gauge insulin needle. For 10th min 91.15±13.86 87.05±12.78 89.16±13.45 0.354
dosage, recommended guidelines of the World Health 15th min 88.56±12.79 85.25±11.45 86.05±11.40 0.354
Organisation (WHO) were taken as the basis, without 20th min 91.15±16.03 82.35±12.58 86.91±13.82 0.141
exceeding a total dose of 2.5 mg.15 One-way analysis of variance (ANOVA) test.

Non-invasive arterial pressure measurements and heart

rates (HR) at the post-induction intraoperative 5th, 10th,
Table-3: Intragroup Analysis of Mean Arterial Pressure (MAP) Values.
15th and 20th minutes were recorded; pain and sedation
scores at 1, 6, 12 and 24 postoperative hours were MAP(mmHg) Group M Group DP Group C
recorded separately for each case. Children's Hospital of
Eastern Ontario Pain Scale (CHEOPS)16 (Figure-1) for 5th min 0.06 0.048* 0.06
children aged 6 months to 12 years was used for the 10th min 0.08 0.039* 0.01**
assessment of pain in children. For sedation, the Ramsay 15th min 0.04* 0.036* 0.01**
Sedation Scoring System (RSS)17 (Figure-2) was used. 20th min 0.04* 0.025* 0.01**
Paired Samples t test *p<0.05 **p<0.01.
When analysing the data, in addition to descriptive
statistical methods of mean and standard deviation (SD),
one-way analysis of variance (ANOVA) test and Tukey Table-4: Heart Rates (HR).
honest significant difference (HSD) test were also used for
the comparison of quantitative data for the intergroup Group M Group DP Group C p
comparison of the parameters with normal distribution.
HR(Beat/min) Mean±SD Mean±SD Mean±SD
For intergroup comparison of parameters without normal 5th min 120.50±19.30 114.50±13.23 103.90±12.76 0.337
distribution, on the other hand, Kruskal Wallis test was 10th min 116.05±19.59 109.25±16.42 105.20±14.16 0.256
used. As regards the intragroup analysis of parameters 15th min 103.30±11.02 102.20±10.45 97.16±15.19 0.04*
with normal distribution, repeated measure ANOVA with 20th min 111.62±15.13 108.06±9.13 101.80±16.57 0.399
paired samples -t test was used. The level of significance Oneway ANOVA test *p<0.05.
was p<0.05.

Results In Group C, according to the MAP levels before caudal

The 60 subjects in the study were divided into 3 groups of block, significantly low values were observed at the 10th,
20(33.3%) each. The overall mean age was 7.75±8.12 15th and 20th minutes following the caudal block (p<0.01)
years. There was no statistically significant difference In Group DP, statistically significant MAP values were
among the demographic data of the groups (p>0.05) recorded at 5th, 10th, 15th and 20th minutes
(Table-1). intraoperatively (p<0.05). In Group M, however, statistically
significant MAP changes were observed only at 15th and
Intraoperative mean arterial pressure (MAP) values were 20th minutes intraoperatively (p<0.05) (Table-3).
noted (Table-2). There was no statistically significant
difference among the groups in terms of MAP values While there was no statistically significant difference in
measured at the 1st, 5th, 10th, 15th and 20th the HRs recorded at the 5th, 10th and 20th minutes
intraoperative minutes (p>0.05). among the groups (p>0.05), significant differences were
observed in the HRs recorded at the 15th minute after the
caudal block in Group C (p<0.05). It was determined that
Table-1: Demographic characteristics and duration of surgery. the heart rates of Group M were significantly higher than
Group C (p=0.012) (Table-4).
Group M Group DP Group C P
Highly significantly low values were observed in the HR at
Age (years) 6.05±13.1 9.62±11.6 8.82±7.6 0.578 all intraoperative measurement times in all the groups
Weight (kg) 18.2±2.1 19.4±3.4 20.5±3.7 0.621 (Table-5).
Height (cm) 80.9±10.3 90.8±9.5 91.5±8.5 0.543
Duration of surgery (min) 20.7±3,5 19.5±2.5 19.8±3.1 0.539 Statistically significant differences were observed among

Vol. 67, No. 2, February 2017

162 E. Canakci, O. Yagan, N. Tas, et al

Table-5: Intragroup Analysis of Heart Rates (HR).

HR (Beat/min) Group M Group DP Group C

5th min 0.01** 0.01** 0.01**

10th min 0.01** 0.01** 0.01**
15th min 0.01** 0.01** 0.01**
20th min 0.01** 0.01** 0.01**
Paired Samples t test **p<0.01.

Table-6: CHEOPS Postoperative Pain Scale Analysis.

Group M Group DP Group C p

CHEOPS Scale Mean±SD (Median) Mean±SD (Median) Mean±SD (Median)

1st hour 4.88±1.22 (4) 4.76±0.82 (5) 3.30±0.36 (3) 0.018*
6th hour 4.19±0.76 (4) 4.19±0.27 (4) 3.13±0.24 (3) 0.059
12th hour 5.64±2.36(5) 4.68±1.11 (4) 3.12±0.10 (3) 0.017*
24th hour 5.37±1.11(5.5) 5.47±2.06 (4) 3.38±0.79 (3) 0.037*
CHEOPS: Children's Hospital of Eastern Ontorio Pain Scale.
Kruskal Wallis test *p<0.05.

Table-7: Postoperative Ramsay Sedation Scale (RSS) Analysis of the Groups.

Ramsay Group M Group DP Group C P

Sedation Scale Mean±SD Mean±SD Mean±SD
(Median) (Median) (Median)

1st hour 3.09±1,22(3) 3.05±1.17(3) 3.09±1,24 (3) 0.295

6th hour 2.91±1.02(3) 2.96±1.09(3) 2.66±0.87(2,5) 0.324
12th hour 2.05±0,2 (2) 2.13±0,39(2) 1.99±0,18 (2) 0.339
24th hour 2.16±0.48(2) 2.19±0.70(2) 1.98±0.19 (2) 0.759
Kruskal Wallis test.
Figure-1: CHEOPS pain scale.

Table-8: Side Effect Analysis of the Groups.

Possible side Group M Group DP Group C P

effects n (%) n (%) n (%)

Nausea 4 (%20) 2 (%10) 1 (%5) 0.369

Vomiting 2 (%10) 1 (%5) 0 (%0) 0.105
Pruritus 2 (%10) 0 (%0) 0(%0) 0.387
Respiratory Depression 0(%0) 0(%0) 0(%0) 0
Other 0 (%0) 0 (%0) 1 (%5) 0.387
Kruskal Wallis test *p<0.05.

Figure-2: Ramsay sedation scale.

the groups in terms of the postoperative 1st, 12th, 24th

hour CHEOPS pain scores (p<0.05), whereas there was no
postoperative 1st, 6th, 12th and 24th hour sedation scores
significant difference among the groups regarding the
of the groups (p>0.05) (Table-7). When the total of 24
postoperative 6th hour CHEOPS pain scores (p>0.05)
hours was analysed, the mean sedation score of Group M
(Table-6).
was 2.5±0.45; 2.61±0.62 for Group DP; and 2.41±0.22 for
There was no statistically significant difference among the Group C.

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Comparison of preventive analgesia techniques in circumcision cases: Dorsal penile nerve block... 163
Incidences of nausea, vomiting, pruritus, respiratory compared to the period before preventive analgesia in all
depression and other side effects did not indicate any groups. Thereafter, at 15th and 20th minutes the decrease
statistically significant difference among the groups did not continue and the monitored parameters started
(p>0.05) (Table-8). One (5%) patient developed urinary to stabilise. We believe that these results stemmed from
retention 4 hours after the caudal block in Group C and the reduction in the need for anaesthetics and in
bladder catheterisation was required. Urination was cardiovascular stress reaction. Therefore, we interpreted
achieved in a short period of time. that this situation was in favour of the patients.

Discussion Locatelli et al.23 compared levobupivacaine 0.25%,

Caudal epidural block is a safe technique, which has ropivacaine 0.25% and bupivacaine 0.25% in caudal block
recently been widely used in paediatric surgery, cases in a study in which they administered local
particularly in the operation of subumbilical and anaesthetics of 0.5ml/kg to 99 children under age 10 for
genitourinary regions, and it is routinely practised in circumcision and a single dose of local anaesthetics of
many centres.18-20 1ml/kg for inguinal hernia repair and orchiopexy operations,
and they could not identify any difference between the
Caudal block performed before surgical incision relieves groups in terms of intraoperative efficacy of caudal block.
intraoperative pain, reduces the need for general They reported that the induction time of analgesia was
anaesthetics and muscle relaxants, facilitates faster similar among the groups, and they observed distinct
restoration of airway reflexes and gastrointestinal motility, residual motor blockade in bupivacaine at the end of
and contributes to a more comfortable recovery. As the anaesthesia when compared with levobupivacaine and
duration of analgesia provided by the caudal block ropivacaine. We did not observe motor block in any of our
performed before surgery is much longer than the caudal block cases. In our study as well, the group with
duration of the operation, the need for additional opioid caudal block had the lowest scores (median value 3) on the
and non-opioid analgesics in the postoperative period is CHEOPS scale according to the measurements recorded at
reduced.21,22 In our study as well, the group with pre- 1st, 6th, 12th and 24th hours. In terms of clinical
emptive analgesia through caudal block had the lowest observations, similarly, the most comfortable postoperative
scores (median value 3) on the CHEOPS scale according to period was observed in the same group.
the measurements recorded at 1st, 6th, 12th and 24th
hours. In terms of clinical observations, similarly, the most Breschan et al. concluded that the time period until the
comfortable postoperative period was in the same group. first analgesia requirement was longer in levobupivacaine
in their study, in which they compared 1 ml/kg of
We investigated the haemodynamic data of all our patients
levobupivacaine 0.20%, ropivacaine 0.20%, and
through intraoperative monitoring. As for the patients
bupivacaine 0.20% in caudal block cases. They used the
analysed for their MAP values, there was no difference in
Children and Infants Postoperative Pain Scale (CHIPPS) for
their results before the pre-emptive analgesia technique was
the evaluation of postoperative analgesia time and they
performed. We observed that the MAP significantly went
reported that the time period until the first analgesics
down at the 5th, 10th, 15th and 20th minutes in all groups.
requirement was 11.4 hours in levobupivacaine, while it
When the HR were analysed, no difference among the was 10 hours in bupivacaine and ropivacaine. Our study
groups was observed before the pre-emptive analgesia never needed additional analgesics in the caudal block
technique was performed. We identified significant patients.24
decrease in the HRs at 5th, 10th, 15th and 20th minutes in
In a study conducted by Kazak et al., just like in our study,
all groups. We did not observe any differences among the
caudal block was done by an anaesthesiologist and dorsal
groups in the decrease of HRs at 10th, 15th and 20th
penile nerve block was done by a urologist. In the study of
minutes. However, there was a difference among the
Kazak et al.,25 according to the comparison of caudal
groups regarding the HRs recorded at the 5th minute; the
block and penile block for the management of
statistical analysis indicated that the low HR recorded at
postoperative pain, it was reported that caudal block
the 5th minute in the caudal block group (Group C) was
provided longer postoperative analgesia, but there was a
significant when compared with the subcutaneous
higher risk for motor block compared to the penile block
morphine Group M.
because of the delay in time to first walking. It is also
In general, when we analysed the MAP and HR, reported that many anaesthesiologists prefer dorsal
statistically significant but clinically insignificant low penile nerve block due to this complication risk. We did
levels were observed until the 10th and 15th minutes not observe motor block in any of our caudal block cases.

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164 E. Canakci, O. Yagan, N. Tas, et al

In many studies, caudal and penile block were compared in dose morphine blocks the pituitary-adrenal response to
terms of their efficacy with different local anaesthetics. surgical stress and inhibits the release of
Dorsal penile nerve block has been preferred more in post- adrenocorticotropic hormone (ACTH), making it an effective
circumcision pain management in children old enough to prototype agent in postoperative analgesia.35 In our study
walk due to temporary weakness in the legs.26 Vater and we used morphine subcutaneously and found it to be better
Demiraran concluded in their study that caudal block and short-term analgesia compared to the other two groups.
penile block with bupivacaine were effective in the
management of post-circumcision pain.27,28 Demiraran et al. Subcutaneous morphine induces analgesic effect within
showed in their study with bupivacaine (0.25%) (0,2 ml/kg) 10 minutes, plasma levels reach the peak within 15-30
that postoperative analgesia lasted 6-8 hours with a single minutes, and it can be repeated every 4 hours.34
epidural dose and 6 hours with dorsal penile nerve block.28 Aschenbrenner et al. reported that its effect lasted 4-7
Güçlü et al., on the other hand, used 1 ml/kg of ropivacaine hours.36 In their study conducted with mice, Gades et al.
0,25 % and found no difference between caudal block and stated that subcutaneous morphine reached its highest
penile block in terms of postoperative analgesia.29 Margetts analgesic effect within 2-3 hours and the dose interval was
et al. suggested that both methods were effective, but 2-3 hours.37 Semple et al. stated that the peak serum
analgesia lasted longer with the caudal.30 Our results are morphine levels were recorded within 16±7 minutes after
compatible with literature data. Beyaz et al. conducted a the subcutaneous injection.38 Subcutaneous
study on circumcision cases and used levobupivacaine administration of morphine ensures earlier postoperative
0,25% as local anaesthetic in caudal and dorsal penile pain control compared with the IM route because with the
blockade, and reported that analgesia duration and IM administration of morphine, peak plasma
complication rates were similar in both methods.31 Our concentration is reached within 17.5 to 27.8 minutes.39 In
results are comparable with the results of Margetts et al.'s addition to the same clinical effect and efficacy with IV and
study, but when it comes to the complication rates and side subcutaneous administration of morphine, Stuart-Harris et
effects, our results are in line with that of Beyaz et al. In our al. stated that morphine-6-glucuronide (M6G) and
study, as well, we experienced no serious complications in morphine-3-glucuronide (M3G), active metabolites of
either the dorsal penile nerve block group or the caudal morphine, were revealed in large amounts after IV
group. In the subcutaneous morphine Group M, on the administration of morphine. One of these active
other hand, we had side effects such as nausea, vomiting, metabolites, M3G, causes opioid hyperalgesia.40 This
pruritus in only a couple of cases. rebound effect also increases more the side effects such as
nausea and vomiting.40 For this reason, in our study, we
Opioids are guaranteed medications to ensure quality preferred to administer the morphine through the
analgesia; even morphine alone can provide postoperative subcutaneous route to the children for pre-emptive
analgesia.32 Krane et al. compared the duration, quality and analgesia purposes. When compared with the other two
side effects of analgesia with caudal morphine, caudal groups in terms of postoperative pain and sedation scores,
bupivacaine and IV morphine. They used 100 mcg/kg we achieved similar results in the subcutaneous morphine
caudal morphine administered through caudal route and it group, only with the exception of a slightly higher
provided satisfactory postoperative analgesia for 8-24 incidence of side effects and lower painless postoperative
hours. However, due to the high dose, nausea, vomiting and period vis-a-vis the other groups.
increase in urinary retention were reported. Drug
combinations are recommended in order to decrease the Conclusion
dose of the morphine.33 Kundra et al. indicated that All the three preventive analgesia techniques enabled early
preventive use of caudal bupivacaine and low-dose postoperative analgesia, but the caudal analgesia group
morphine (20 mcg/kg) was more advantageous in hernia had longer pain-free periods. Parent and child satisfaction
repair in paediatric patients than the postoperative group.34 was quite good in all the groups, but caudal analgesia
In our study as well, effective analgesia was achieved in the group was the most comfortable of the three groups. Pain
subcutaneous morphine group in the early postoperative and anxiety experienced by children to be circumcised
period. Ramsay Sedation Scores were not high in our should be taken seriously by all physicians and one of the
morphine group; all the groups had similar scores. We preventive analgesia techniques should be used.
believe that this favourable result stemmed from the fact
that we administered morphine through subcutaneous Disclaimer: None.
route instead of IV, intramuscular (IM) or caudal routes. As Conflict of Interest: None.
the subcutaneous morphine is slowly released to the
plasma, it does not cause an evident sedation.35 Even low- Funding Source: None.

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Comparison of preventive analgesia techniques in circumcision cases: Dorsal penile nerve block... 165
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Vol. 67, No. 2, February 2017