A Pictorial and Video Guide to Circumcision Without Pain

Nancy L. Kraft, RNC, MSN, NNP


Adv Neonatal Care. 2003;3(2) 

In This Article

The Safety and Effectiveness of Topical Anesthetics

In general, procedures with pain generated from superficial tissue planes respond well to topical anesthetics, whereas those that are more invasive and involve deeper tissue planes may have less effective or inadequate pain control from topical anesthesia. Several studies have evaluated the use of topical anesthesia for circumcision. The majority of research has been conducted with a lidocaine-prilocaine cream (Eutectic Mixture of Local Anesthetics [EMLA]; AstraZeneca Pharmaceuticals LP, Wilmington, DE). EMLA has been approved for one-time use in infants ≥37 weeks gestation.[50]

EMLA has been shown to be effective in diminishing the pain of circumcision,[54,55,56,57,58] but it is not as effective as a penile block with 1% lidocaine.[5,6,57,59] EMLA seems to effectively decrease pain during needle penetration of the skin when performing a penile block, but does not decrease the pain during infiltration of the lidocaine solution.[60] As expected, it also does not seem to relieve deeper tissue pain during the release of adhesions of the foreskin from the glans of the penis, or the pain from excision of the foreskin itself.[5]

Most studies evaluating EMLA report no side effects.[54,55,57,61,62] There have been reports of temporary blanching and redness of the skin. Redness and blanching may be normal skin blood flow effects caused by the vasodilation and vasoconstriction of skin blood vessels associated with the topical application.[50] Blistering also has been reported. There have also been rare reports of methemoglobinemia with the use of EMLA.[6,39,63,64]

A practical disadvantage of EMLA and other topical anesthetics is that they must be applied to the skin of the penis with an occlusive dressing for 60 to 90 minutes before a procedure.[5,6] The analgesic impact of EMLA is enhanced when used in conjunction with other interventions to reduce pain, such as the use of a pacifier dipped in sucrose.[55] However, EMLA is not recommended as the sole method of anesthesia for neonatal circumcision. If an effective penile block is used, the use of EMLA is probably not warranted. If a penile block is not performed, EMLA used in conjunction with sucrose and acetaminophen may modulate, but will not alleviate the pain associated with circumcision.


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