A Non-Narcotic Pathway for Pediatric Urology Pain Control

It is now well known that opioid abuse is a nationwide public health crisis. Prescription opioid use has been associated with long term opioid misuse in adult patients, and studies examining pediatric populations have shown similar findings. One longitudinal study found a 33% increased risk of future opioid misuse in patients who were prescribed narcotics before the 12th grade. 1 It is, thus critical for surgeons to be aware of the role of opioid prescribers in this context. Prior studies evaluating pediatric postoperative narcotic prescribing practices found no significant difference in pain scores despite wide variation of prescribing patterns.2 In pediatric urology, successful implementation of narcotic free prescribing practices has been well documented.3,4

At UCSF Pediatric Urology, we have established a narcotic free pathway for in patient and day surgery postoperative pain control that limits the exposure of our pediatric patients to opioid medications and provides excellent pain control and recovery for the surgeries performed by our providers. Pain control at the time of surgery is gained with local nerve blocks. In the two immediate postoperative days, scheduled acetaminophen and ibuprofen is used to stay ahead of any pain and discomfort. From three days on after surgery, acetaminophen and ibuprofen can be used on an as needed basis.

For local anesthesia at the time of surgery, our pediatric anesthesia team is often able to offer a caudal block which numbs sensation below the level of the belly button. This regional nerve block works similarly in concept to an epidural, such as a mother would have during labor and delivery. It is a single shot injection of numbing medication just outside of the spinal space, which can last from 6 to 12 hours after injection. The block is performed after the patient has gone to sleep and has had a remarkably safety record with exceedingly low complication rates.5 One limitation to the use of this block is that it can cause the patient to have some difficulty with walking while the numbing is in effect. Therefore, it is typically offered to patients who are small enough to be carried. In older patients and patients who have other contraindications to this block, the surgeons will perform a more targeted local block, either a penile block, spermatic cord block, or incisional block depending on the location and type of surgery.

Postoperatively, all of our patients receive a prescription for acetaminophen and ibuprofen with specific dosing instructions to help guide parents. We prescribe a dose of acetaminophen at 15mg/kg body weight to be given every 6 hours, and ibuprofen at 10mg/kg body weight to be given every six hours. We recommend that for the first two days after surgery to give these medications alternating and on a scheduled basis to stay ahead of the discomfort during this period. Following the first two days, these medications can be given as needed if the patients is reporting ongoing discomfort, which should be improving rapidly by that time. Our clinic and on-call physicians are also always available to answer any additional questions regarding postoperative pain control, whether it is to provide reassurance or to assess for any other concerns.

We look forward to taking care of your child and are proud to offer safe and effective pain control for our surgical patients.

1. Miech R, Johnston L, O’Malley PM, et al: Prescription opioids in adolescence and future opioid misuse. Pediatrics 2015; 136: e1169–e1177.

2. Horton JD, Munawar S, Corrigan C, et al: Inconsistent and excessive opioid prescribing after common pediatric surgical operations. J. Pediatr. Surg. 2019; 54: 1427–1431.

3. O’Kelly F, Pokarowski M, … KD-J of P, et al: Structured opioid-free protocol following outpatient hypospadias repair-A prospective SQUIRE 2.0-compliant quality improvement initiative. Elsevier. Available at: https://www.sciencedirect.com/science/article/pii/S1477513120303880, accessed December 22, 2021.

4. Donnelly L, Feustel PJ, Cangero T, et al: Postoperative pediatric urology opioid prescriptions at a tertiary academic medical center. J. Pediatr. Urol. 2021; 17: 633.e1-633.e6.

5. Jöhr M and Berger TM: Caudal blocks. Pediatr. Anesth. 2012; 22: 44–50. Available at: https://onlinelibrary-wiley-com.laneproxy.stanford.edu/doi/full/10.1111/j.1460-9592.2011.03669.x, accessed December 22, 2021.