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      Epinephrine Injection Associated Scrotal Skin Necrosis

      case-report

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          Abstract

          Male circumcision is among the most frequent surgical interventions throughout history. Although considered as a minor intervention, it may have complications ranging from insignificant to catastrophic. These complications can be attributed to the surgical procedure and anesthesia. In this report we present two cases of scrotal skin necrosis after lidocaine with epinephrine injection using subcutaneous ring block technique prior to circumcision.

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          Complications of circumcision.

          Bonnie Kaplan (1983)
          In summary, there are multiple complications that can occur following circumcision, ranging from the insignificant to the tragic. Virtually all of these complications are preventable with only a modicum of care. Unfortunately, most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons. However, it usually will fall to the urologist to consult in the management of these complications and to repair such problems as they arise.
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            The increasing incidence of newborn circumcision: data from the nationwide inpatient sample.

            Caleb P Nelson, Rodney L Dunn, Julian Wan … (2005)
            Newborn circumcision is the most common surgical procedure in the United States, yet there are few contemporary data regarding circumcision rates or the factors that affect these rates. The goal of this study was to determine trends in the national rate of newborn circumcision between 1988 and 2000, and to evaluate patient and hospital factors associated with newborn circumcision. The Nationwide Inpatient Sample provides information on 5 million to 7 million inpatient stays per year. Newborn male hospitalizations were selected, and those newborns who underwent circumcision were identified using International Classification of Disease-9 procedure codes. Weighted national estimates of circumcision rates were calculated, and patient and hospital characteristics were examined to identify factors associated with newborn circumcision. We identified 4,657,402 newborn male hospitalizations during a 13-year period. Circumcision rates increased significantly with time-48.3% of newborn males underwent circumcision in 1988 to 1991 vs 61.1% in 1997 to 2000 (p <0.0001). In multivariate regression analysis the odds of circumcision increased by 6.8% per year during the study period (p <0.0001). Patient characteristics associated with increased odds of circumcision in the multivariate model included private insurance (p <0.0001), higher socioeconomic status (p <0.0001), fewer co-morbid diagnoses (p <0.0001) and black race (p <0.0001). Hospital factors associated with increased odds of circumcision included Northeast or Midwest geographic region and rural location. There was a significant increase in the rate of newborn circumcision between 1988 and 2000. The increase may be related to increased recognition of the potential medical benefits of circumcision. However, the increase may also result in a higher incidence of surgical complications of circumcision.
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              Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial.

              J Lander, B Brady-Fryer, J B Metcalfe … (2016)
              Beliefs about the safety and effectiveness of current anesthetics have resulted in many newborns being circumcised without the benefit of anesthesia. To compare ring block, dorsal penile nerve block, a topical eutectic mixture of local anesthetics (EMLA), and topical placebo when used for neonatal circumcision. The placebo represented current practice, with no anesthetic for neonatal circumcision. A randomized controlled trial. Antenatal units in 2 tertiary care hospitals in Edmonton, Alberta. A consecutive sample of 52 healthy, full-term, male newborns, aged 1 to 3 days. Physiological and behavioral monitoring occurred in a series of trials: baseline, drug application, preparation, circumcision, and postcircumcision. Surgical procedures defined the following 4 stages of the circumcision: cleansing, separation, clamp on, and clamp off. Methemoglobin level was assessed 6 hours after surgery. Heart rate, cry, and methemoglobin level. Newborns in the untreated placebo group exhibited homogeneous responses that consisted of sustained elevation of heart rate and high-pitched cry throughout the circumcision and following. Two newborns in the placebo group became ill following circumcision (choking and apnea). The 3 treatment groups all had significantly less crying and lower heart rates during and following circumcision compared with the untreated group. The ring block was equally effective through all stages of the circumcision, whereas the dorsal penile nerve block and EMLA were not effective during foreskin separation and incision. Methemoglobin levels were highest in the EMLA group, although no newborn required treatment. The most effective anesthetic is the ring block; EMLA is the least effective. It is our recommendation that an anesthetic should be administered to newborns prior to undergoing circumcision.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Case Rep Urol
                Journal ID (iso-abbrev): Case Rep Urol
                Journal ID (publisher-id): CRIU
                Title: Case Reports in Urology
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 2090-696X
                ISSN (Electronic): 2090-6978
                Publication date (Print): 2015
                Publication date (Electronic): 22 June 2015
                Volume: 2015
                Electronic Location Identifier: 187831
                Affiliations
                1Department of Urology, Van Training and Research Hospital, 65100 Van, Turkey
                2Department of Urology, Selcuk University School of Medicine, Turkey
                3Department of Pediatric Surgery, Selcuk University School of Medicine, Turkey
                Author notes

                Academic Editor: Ferdinando Fusco

                Article
                DOI: 10.1155/2015/187831
                PMC ID: 4491570
                PubMed ID: 26185706
                SO-VID: e491738a-7c55-4b17-ae78-19f73330ba1e
                Copyright © Copyright © 2015 Murat Gul et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 14 April 2015
                Date accepted : 14 June 2015
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Urology
                Data availability:
                ScienceOpen disciplines: Urology

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