Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia
Version 3.1 (Dec09)
they do not wriggle. It can also be used for boys who are old
enough to cooperate during the procedure. For children
between the ages of about 1 and 12 years, use of local
anaesthetic alone is more problematic, since the boy may not
remain still during the operation. Sedation may be required in
addition to local anaesthesia, but there are risks, particularly of
air-way obstruction and anoxia. If sedation is necessary to
perform the procedure safely the patient should be referred to
an appropriate facility.
EMLA cream
EMLA 5% cream (eutectic mixture of local anaesthetics,
containing 2.5% lidocaine and 2.5% prilocaine) has been
extensively used for Plastibell circumcision in children of all
ages. It is safe and provides effective anaesthesia when
correctly used. It must be applied with care in neonates,
because of the potential risk of methaemoglobinaemia from
prilocaine metabolites, which can oxidize haemoglobin and
dangerously reduce the oxygen-carrying capacity of the blood.
Care must be taken to ensure that the cream is not
accidentally rubbed onto a large area of the baby’s body, as a
result of the hands and feet wriggling during the procedure.
This can be done by covering the penis with a small piece of
polythene held in place with a sticking plaster. It has been
shown that, provided the cream is applied only to the penis,
EMLA is safe for both term and preterm infants. 1 Possible
minor adverse events include transient local skin reactions,
such as blanching and redness.
EMLA cream should be applied to the whole penis 1–2 hours
before the procedure. In older boys whose foreskin can be
retracted, the cream should be applied to the glans so that the
glans and the underside of the foreskin are covered.
Depending on local circumstances, it is often possible for the
parent to apply the cream at home before coming to the clinic.
If this is done, the clinic staff should ensure that the cream has
been applied properly.
The maximum recommended doses and durations of exposure
to EMLA cream are summarized in Table 6.1.
Infant and paediatric circumcision Chapter 6 - 4