The Veterinary Journal xxx (2013) xxxxxx

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The Veterinary Journal

journal homepage: www.elsevier.com/locate/tvjl

Comparison of the effect of intratesticular lidocaine/bupivacaine vs. saline

placebo on pain scores and incision site reactions in dogs undergoing routine
castration
B.J. Stevens a,, L.P. Posner b, C.A. Jones c, B.D. Lascelles a,d
a
Department of Clinical Sciences, North Carolina State University, College of Veterinary Medicine, Raleigh, NC 27607, USA
b
Department of Molecular Biomedical Sciences, North Carolina State University, College of Veterinary Medicine, Raleigh, NC 27607, USA
c
Department of Anesthesia, Duke University Medical Center, Durham, NC 27710, USA
d
Comparative Pain Research Laboratory, Surgery Section, Center for Comparative Medicine and Translational Research, North Carolina State University,
College of Veterinary Medicine, Raleigh, NC 27607, USA

a r t i c l e i n f o a b s t r a c t

Article history: Post-operative pain scores and incision site reactions were compared in healthy dogs undergoing routine
Accepted 23 November 2012 castration at a county animal shelter and assigned to two treatment groups, namely: (1) lidocaine/bupiv-
Available online xxxx acaine (1 mg/kg lidocaine + 1 mg/kg bupivacaine mixture; n = 17), or (2) placebo (0.9% saline; n = 16),
administered via intratesticular injection. Dogs were injected with an equivalent volume of solution
Keywords: based on bodyweight. Premedication, induction and anesthetic maintenance protocols were identical
Anesthesia in all animals. Pain scores were assessed at 15 min, 60 min, 120 min and 24 h post-recovery from anes-
Bupivacaine
thesia. Surgical site evaluation based on swelling and bruising was evaluated at 24 h.
Canine
Castration
The addition of lidocaine/bupivacaine did not impact pain scores compared to the saline placebo
Lidocaine (P > 0.05). Incision site reactions were statistically similar between the two groups.
2013 Published by Elsevier Ltd.

Introduction
Canine castration is a common surgical procedure performed by
veterinarians, who aim to provide safe, effective and cost effective
analgesia and anesthesia. To achieve these goals, many veterinari-
ans employ a multi-modal approach, which, at least theoretically,
allows for increased efcacy with decreased side effects due to
the absence of reliance on a single agent. The addition of local
anesthetics to various protocols has been researched in human
and veterinary medicine (Brower and Johnson, 2003; Moinichem
et al., 2002; Skarda and Tranquilli, 2004) but these studies have
produced mixed results in terms of the benet of adding local
anesthetic during surgical procedures. Also, while studies investi-
gating the effects of local anesthetic use during castration are
available for humans, pigs and horses, there appears to be a paucity
of published research in dogs (Kamal, 2002; Aggarwal et al., 2009;
Portier et al., 2009).
A potential concern in using local anesthetic techniques is de-
layed healing or increased incision site reactions. Moreover, there
is evidence that the use of local anesthetics in wounds could in-
lows for administration of a local anesthetic away from the incision
site could be benecial.
The purpose of this placebo-controlled study was to evaluate
the effects of an intratesticular local anesthetic combination during
canine castration. It was hypothesized that the addition of lido-
caine and bupivacaine to a standard anesthetic protocol would
diminish pain scores and would not result in additional incision
site reactions. The Veterinary Anesthesia and Analgesia Support
Group,1 an online resource dedicated to promoting pain manage-
ment in the veterinary eld, describes and promotes intratesticular
lidocaine/bupivacaine injections for canine castrations. The tech-
nique described in the website was utilized for this study.
Materials and methods
The clinical study protocol was approved by the North Carolina State University
Institutional Animal Care and Use Committee (IACUC). The study was a blinded,
parallel group, placebo-controlled clinical study, with an intent-to-treat analysis.
Animals

crease the risk of incision site reactions (Hollman and Durieux,

2003; Brower and Johnson, 2003). Therefore, a technique that al-
Corresponding author. Tel.: +1 919 609 9600.
E-mail address: Brenda_Stevens@ncsu.edu (B.J. Stevens).
The aim was to recruit 40 dogs scheduled for routine elective castration at a lo-
cal animal shelter. Dogs of any breed, age or weight were entered into the study and
randomly assigned to one of two treatment groups. Group 1 (placebo group) re-
1
See: www.vasg.org.

1090-0233/$ - see front matter 2013 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.tvjl.2012.11.019

Please cite this article in press as: Stevens, B.J., et al. Comparison of the effect of intratesticular lidocaine/bupivacaine vs. saline placebo on pain scores and
incision site reactions in dogs undergoing routine castration. The Veterinary Journal (2013), http://dx.doi.org/10.1016/j.tvjl.2012.11.019
2 B.J. Stevens et al. / The Veterinary Journal xxx (2013) xxxxxx

ceived an intratesticular injection of 0.9% saline. Group 2 (treatment group) re- Table 1
ceived an intratesticular injection of a 1 mg/kg lidocaine and 1 mg/kg bupivacaine Dog characteristics and length of procedure in the two treatment groups.
mixture. Group size was based on power calculations following review of data from
pilot cases. This indicated that 50% of the dogs undergoing castration surgery had Group 1 Group 2 P
pain scores P2 during the rst 24 h after surgery. We made the assumption that placebo treatment
if the addition of a local anesthetic block to the surgical procedure was to be con- (n = 16) (n = 17)
sidered clinically relevant, it would drop the pain score to <2 in 90% of cases. Using Age (years) mean SD 2.43 0.39 2.29 0.38 0.490
these criteria, we estimated we would need 20 cases per group to achieve a statis- Weight (kg) mean SD 17.7 2.0 20.6 2.0 0.400
tical power of 0.8, with alpha set at 0.05. Time from testicular injection to 23.8 1.8 22.2 1.8 0.660
start of surgery (min) mean SD
Inclusion criteria kg, kilograms; SD, standard deviation.

All dogs were at least 4 months of age (as determined by dentition if date of
birth was not known), in general good health, did not require any additional surgery
and did not have any evidence of scrotal or testicular disease. All dogs received a Table 2
pre-surgical examination several hours prior to surgery by senior veterinary stu- Occurrence of cremastor twitch during the surgical procedure.
dents and a veterinary clinician. Breed, age, bodyweight, rectal temperature, heart
rate and respiratory rate were recorded. No twitch Twitch P
Group 1 (n = 16) 1 15
Group assignment Group 2 (n = 17) 8 9
0.009
Dogs were assigned sequential study numbers on qualifying for admission to
the study. A dedicated third party then randomly assigned them to either group 1
(placebo) or group 2 (treatment). Each dog was premedicated with a mixture of ace-
promazine (0.025 mg/kg; Fort Dodge) and morphine (0.5 mg/kg; Baxter) adminis- Table 3
tered IM 2045 min prior to induction. Anesthetic induction was accomplished Pain score results at various time points post-procedure.
with tiletamine and zolazepam (Telazol, Pzer) administered at 0.22 mL/kg IV. Fol-
lowing induction, dogs were intubated with an endotracheal tube using a laryngo- 15 min 60 min 120 min 24 h
scope for visual guidance. The endotracheal tube was secured in place and general a a
Fail Success Fail Success Fail Success Fail Success
anesthesia was maintained with isourane (Isourane, Abbott) in O2.
Routine physiological measurements were performed by a certied veterinary Group 1 14 2 15 1 15 1 16 0
technician to monitor heart rate, respiratory rate and mucous membrane color. Tis- Group 2 13 4 13 4 16 1 17 0
sue oxygenation was assessed using pulse oximetry. Isourane concentration and P 0.410 0.160 0.960 1.000
O2 ow rate were also recorded throughout the procedure. Recordings were docu- a
Pain scores of 01 constitute success and pain scores of 2, 3, or 4 constitute
mented at 5 min intervals.
fail.
Once an appropriate anesthetic plane was achieved, group 1 dogs received an
injection of 0.9% normal saline into each testicle. The volume was equivalent to
the volume of the lidocaine/bupivacaine mixture based on the dogs bodyweight.
Group 2 animals received a mixture of 2% lidocaine (1.0 mg/kg; Phoenix Pharma- Table 4
ceuticals) and 0.5% bupivacaine (1.0 mg/kg; Marcaine, Hospira) intratesticularly. Results of evaluation of the wound for bruising and edema at 24 h post-procedure.
Each drug was drawn up into an individual syringe and mixed into a single syringe
just prior to injection. The saline injections were also presented to the administrator Score Swelling Bruising
in two separate syringes and were combined into a single syringe for injection. 0 1 2 3 0 1 2 3
Injections were performed with a 22 g 1 in. (25 mm) or 1.5 in. (38 mm) needle start-
ing at the caudal pole of the testis and directing the needle towards the spermatic Group 1 12 5 0 0 11 5 0 0
cord. The syringe was aspirated before injection. Injection was performed while Group 2 11 4 1 0 11 6 0 0
slowly withdrawing the needle. It was expected that one-third to a half of the total P 0.569 0.805
volume would be injected into each testicle, leaving the organ turgid. The total vol-
ume injected into each testicle and the times of intratesticular injection and surgery
were recorded. success. Animals with a pain score of 24 were given a value of 1 and considered
The clinician administering the injection, the students and the clinician assess- a fail. A Pearson chi-squared analysis was utilized during each time frame analysis
ing pain and performing the incision site scoring were blinded to the content of the for pain. Incisional site reactions were also evaluated utilizing the Pearson chi-
syringes. For consistency, one individual performed all the intratesticular injections squared analysis contingency table. A P value of <0.05 was considered signicant
and one clinician also performed all the surgical site and pain score evaluations. and data were presented as mean SD. Statistical analysis was performed using sta-
After injection the animals underwent standard open castration surgery (Hedl- tistical software (JMP, SAS).
und, 2007). The surgical and closing techniques and the suture materials used were
consistent among the students. The vascular bundle and tunics were ligated using
20 or 30 Vicryl (Novartis) and 30 Vicryl was used for subcutaneous and subcu-
Results
ticular closure. Students were asked to note whether the dog exhibited a cremastor
muscle twitch during the procedure. Thirty-eight dogs initially met study admission criteria but data
At the completion of the surgical procedure isourane was discontinued and the from ve dogs were excluded as they were unavailable for the 24 h
dogs were extubated when swallowing. Each dog received carprofen at recovery
assessment. Thirty-three dogs met the inclusion criteria and were
(4.4 mg/kg SC; Rimadyl, Pzer) and for the following 4 days (4.4 mg/kg PO every
24 h). used in the study; 16 were in the placebo group (group 1) and 17 in
Dogs were evaluated for pain at 15 min, 1, 2 and 24 h post-surgery using a pain the treatment group (group 2). There was no signicant difference
score evaluation modied from that described by Sammarco et al. (1996; Table A1). between groups regarding age, weight or length of time from injec-
In accordance with our IACUC protocol, any dog with a pain score of P6 received tion to start of surgery (Table 1).
rescue analgesia of either morphine (0.5 mg/kg IM; Baxter) or tramadol (12 mg/
All but three dogs received the total volume of agent supplied in
kg PO; Janssen). At 24 h post-surgery, incision sites were evaluated for swelling
and bruising using a scale that was in routine use at the facility (Table A2). the syringe. The three dogs that did not receive the total calculated
volume received 90%, 90% and 75% of the calculated volume,
Statistical analysis respectively, and they were included in study analysis (see
Table 2).
Following testing of the data for normality, one way ANOVA was used to eval- Dogs in group 1 (placebo) were more likely to produce a crema-
uate randomization based on age, weight and length of time from injection to the stor muscle twitch during ligation than those in group 2 (treat-
commencement of surgery. Presence or absence of a cremastor twitch was evalu-
ated using a Pearson chi-squared and reported in a contingency table. For pain score
ment; P = 0.009) and 15/16 dogs in group 1 demonstrated a
analysis, the composite pain scores were regrouped into success/fail categories. twitch. In group 2, eight dogs did not twitch during the procedure
Dogs with a composite pain score of 01 were given the value 0 and considered a and nine dogs produced a cremastor twitch.

Please cite this article in press as: Stevens, B.J., et al. Comparison of the effect of intratesticular lidocaine/bupivacaine vs. saline placebo on pain scores and
incision site reactions in dogs undergoing routine castration. The Veterinary Journal (2013), http://dx.doi.org/10.1016/j.tvjl.2012.11.019
 B.J. Stevens et al. / The Veterinary Journal xxx (2013) xxxxxx
No dog received a pain score >4 at any assessment time point
during the study and so no animal required rescue analgesia. No
anesthetic complications were reported. Success/failure analysis
indicated no statistical difference between groups 1 and 2 with re-
gard to pain scores at any time point (Table 3). No signicant dif-
ferences were found between the two groups with regards to
incisional reactions (Table 4).
Discussion
In this study, it was demonstrated that an intratesticular injec-
tion of a lidocaine/bupivacaine mixture prior to castration pro-
vided no additional measurable analgesic benet compared to a
saline placebo. There did not appear to be any increased risk of
complications associated with the injection when incisions were
evaluated at 24 h for bruising or swelling.
Interestingly, there is limited information available regarding
the efcacy of intratesticular local anesthesia during the canine
castration. A PubMed search utilizing the search terms canine cas-
tration local anesthesia returned three publications, but none spe-
cically referred to a canine castration procedure. However, a
similar search of the Veterinary Information Network,2 an online
veterinary community tool which accesses published information
and online discussion groups, returned 187 responses. The authors
assume that this is because there is great interest in providing addi-
tional analgesia for canine castrations, but limited published infor-
mation in the scientic literature.
The concept of multimodal anesthesia/analgesia is to apply dif-
ferent classes of analgesics to provide superior pain relief with re-
duced risk of drug-related side effects (Joshi, 2005). Local
anesthetics have long been employed as part of multimodal proto-
cols to enhance pain relief, as they interrupt the ascending pain
pathway by blocking sodium channels in nerves, they are relatively
inexpensive, easy to use and can be given before or after a surgical
procedure. However, the use of local anesthetics can carry some
risk and concerns have arisen regarding systemic absorption and
potential cardiac side effects. In this study, lidocaine, which has a
wide safety margin, was mixed with bupivacaine, which has a nar-
rower safety margin. The fast onset of action and dilution of bupiv-
acaine decreased absorption concentration, but there was a shorter
duration of action than if bupivacaine had been used alone (Cuvil-
lon and Nouvellon, 2009).
Importantly, the addition of local anesthetics to multi-modal
pain strategies has produced contradictory ndings with regards
to their benets (Carpenter et al., 2004; Bubalo et al., 2008; Zilber-
stein et al., 2008; Fitzpatrick et al., 2010; Myrna et al., 2010). In one
study, the inltration of bupivacaine at the incision site in dogs
undergoing ovariohysterectomy provided no additional analgesic
benet when used with a multimodal analgesic protocol (Fitzpa-
trick et al., 2010). Other studies have reported the benets of add-
ing local anesthesia to anesthetic protocols for dogs undergoing
enucleation and cats and dogs undergoing ovariohysterectomy
(Zilberstein et al., 2008; Myrna et al., 2010; Kim et al., 2011). It
has also been reported that intrafunicular and intratesticular injec-
tions of lidocaine aided analgesia in piglets during castration (Haga
and Ranheim, 2005).
The question arises as to why in some studies there is a demon-
strable benet with the addition of local anesthetics whereas in
others, such as the current study, no benet is apparent. There
are several potential reasons for this nding. First, the analgesic
and anesthetic protocol used might have been sufcient to manage
the pain from castration without additional local analgesia (Shih,
2008). Morphine is a potent mu opioid agonist commonly used
2
See: www.vin.com.
Please cite this article in press as: Stevens, B.J., et al. Comparison of the effect of intratesticular lidocaine/bupivacaine vs. saline placebo on pain scores and
incision site reactions in dogs undergoing routine castration. The Veterinary Journal (2013), http://dx.doi.org/10.1016/j.tvjl.2012.11.019
3
in dogs and might have provided sufcient pre- and peri-operative
analgesia used alone. Morphine would be expected to last 24 h
after administration and was likely still effective during recovery
and the early assessment time points. Acepromazine is a phenothi-
azine sedative that does not have analgesic properties but has been
shown to potentiate analgesia of opioids (neuroleptic analgesia;
Cornick and Hartseld, 1992; Dyson and Atilola, 1992). Dogs also
received tiletamine (Telazol, Pzer) during induction. Tiletamine,
similar to ketamine, is a dissociative general anesthetic that also
inhibits NMDA-receptors and might have an additive analgesic ef-
fect, as has been demonstrated in canine ovariohysterectomy with
a single bolus of ketamine (Slingsby and Waterman-Pearson,
2000).
Following surgery, all dogs received the non-steroidal anti-
inammatory drug (NSAID) carprofen (Rimadyl, Pzer) initially
by SC injection and then PO for the next 4 days. NSAIDs are quite
effective agents that attenuate post-surgical pain over a period of
2024 h. Several studies have demonstrated the excellent analge-
sic qualities of NSAID medications during castration and ovario-
hysterectomy (Lascelles et al., 1994; Balmer et al., 1998;
Camargo et al., 2011). Thus, it is possible that after the analgesic
effects of morphine had worn off, the effects of carprofen was en-
ough to manage the dogs pain. In the one study that has evalu-
ated intratesticular local anesthetic for castration (Haga and
Ranheim, 2005), no other analgesic was administered, which
could be the reason for the positive ndings in that study. We
therefore conclude that the combination of morphine and an
NSAID provided sufcient analgesia following canine castration
in our study.
It is also possible that the pain assessment tool we used was not
sensitive enough to detect subtle differences, as it relied on subjec-
tive assessments. We selected the modied Sammarco composite
pain scoring tool as it was routinely used by the assessor in the
shelter environment and we were not as familiar with the Glasgow
Short Form scale, which is better validated (Reid et al., 2007). A
point to note is that while pain scores were only obtained at
15 min, 1 h, 2 h and 24 h, animals were monitored for discomfort
between 2 h and 24 h by shelter personnel. No dog required rescue
analgesia during the study period. We elected to not include these
data as multiple personnel performed the evaluations and the po-
tential lack of consistency was considered a signicant variable.
Future studies could include a longer time frame to more com-
pletely evaluate the pain prole following castration. However, if
local anesthetic injection was truly benecial, the effect should
have been maximal within the rst 2 h post-surgery. As we did
not include a group that received no intratesticular injection, we
cannot make conclusions about the pain associated with intrates-
ticular injection per se.
In hindsight, a pressure palpation device (PPD; Slingsby et al.,
2001) could have been useful to further assess wound sensitivity
and add semi-objective data to the subjective pain score data.
Thermal threshold nociceptive testing has been used in veterinary
medicine to assess nociceptive thresholds and their modulation by
analgesics. Although devices have been developed to measure
thermal nociceptive thresholds (Dixon et al., 2002; Taylor and Rob-
ertson, 2007), these have not been used at the site of surgery in
clinical cases. Indeed, it would likely be difcult to use the cur-
rently available devices on the prescrotal area of untrained dogs.
The use of a long acting sedative (acepromazine) could also have
masked some behaviors that might have differentiated the two
groups. However, other blinded studies investigating post-opera-
tive pain in dogs have used acepromazine in similar shelter popu-
lations of dogs and found differences in pain measurements
between treatment groups (Lascelles et al., 1994, 1997, 1998).
Despite power analysis based on pilot observations, it is possi-
ble that the number of dogs in our study was not sufcient to ob-
4 B.J. Stevens et al. / The Veterinary Journal xxx (2013) xxxxxx

serve subtle differences in pain scores and to achieve statistically
signicance. Unfortunately, the number of dogs we had hoped to
include was decreased by seven, although a post hoc analysis
showed that including another seven dogs would not have made
any difference to the results.
Finally, it is possible that the local anesthetic combination
administered via intratesticular injection simply did not consis-
tently have a local analgesic action at the required site. In pigs,
severing the spermatic cord was reported to be the most signicant
source of pain during the castration procedure (Taylor and Weary,
2000). Providing the local anesthetic distal to the site of transection
might seem counterintuitive, but in horses undergoing intratestic-
ular local anesthesia for castrations, local anesthetic was found
proximal to the injection site. Despite this nding, blood pressure
rises during the time of transection suggested the block might
not have been complete (Portier et al., 2009). In this same study,
relaxation of the cremastor muscle was noted in horses that re-
ceived the local anesthetic injection, but it did not correlate with
levels of local anesthetic in the cremastor muscle. It was concluded
that decreased visceral nociception was responsible for the lack of
cremastor muscle tension. Cremastor twitching in the present
study was statistically different between the control and study
groups, but was not eliminated in all the dogs in the local anes-
thetic group. This suggests that it is possible that the block could
have been incomplete in some dogs.
No differences in wound scores were seen between the two
groups, although the non-validated, subjective wound scoring sys-
tem might not have been sufciently sensitive to detect these.
Thermal imaging of wounds might be useful in future studies to
compare local inammation between treatment groups more
objectively.
Conclusions
The results of this study demonstrate that the addition of lido-
caine/bupivacaine via intratesticular injection did not reduce pain
scores in dogs undergoing castration when a multimodal analgesic/
anesthetic protocol was used. It also concludes that post-operative
complications were similar for dogs in placebo and treatment
groups.
Conict of interest statement
None of the authors of this paper has a nancial or personal
relationship with other people or organizations that could inappro-
priately inuence or bias the content of this paper.
Appendix A
See Tables A1 and A2.

Table A1
Pain score evaluation (modied from Sammarco et al. (1996)).

Criteria Score Description

Comfort 0 Dog asleep or calm
1 Mild-moderate agitation, awake, interested in surroundings
2 Extremely agitated
Movement 0 No movement
1 Frequent positional changes per min
2 Continuous positional changes per min
Appearance 0 Eye normal or partially closed, ears attened or normal in position
1 Moderate changes, eyes glazed, unthrifty appearance
2 Severe changes: eyes pale, pupils enlarged, guarding, legs in abnormal position or other abnormal facial expressions
Vocalization 0 No vocalization
1 Crying, responds to calm voice and stroking
2 Crying, does not respond to calm voice and stroking
Heart rate 0 <10% greater than preoperative value
1 1025% greater than preoperative value
2 25% or more greater than preoperative value
Respiratory rate 0 <10% greater than preoperative value
1 1025% greater than preoperative value
2 25% or more greater than preoperative value
Total (012)

Table A2
Surgery site evaluation at 24 h.

Swelling/bruising evaluation Score Bruising evaluation Score

No swelling 0 No bruising 0
Mild swelling 1 Mild bruising 1
Moderate swelling 2 Moderate bruising 2
Marked swelling 3 Marked bruising 3
Swelling score description
0 No visible evidence of swelling noted
1 Swelling minor, raised less than 23 mm and extending less than 23 mm
2 Swelling obvious but not signicantly irritated. Extending between 3 and 6 mm laterally or raised
3 Swelling clearly visible. Over 6 mm in width or height, obviously irritated
Bruising score description
0 No visible evidence bruising
1 Minor bruising, color minimally changed, bruise extends less than 3 mm
2 More signicant erythema or color change. Bruise obvious but between 3 and 6 mm in distance from incision
3 Bruise is obvious, over 6 mm in size darker in color, more pronounced erythema

Please cite this article in press as: Stevens, B.J., et al. Comparison of the effect of intratesticular lidocaine/bupivacaine vs. saline placebo on pain scores and
incision site reactions in dogs undergoing routine castration. The Veterinary Journal (2013), http://dx.doi.org/10.1016/j.tvjl.2012.11.019
 B.J. Stevens et al. / The Veterinary Journal xxx (2013) xxxxxx 5

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Please cite this article in press as: Stevens, B.J., et al. Comparison of the effect of intratesticular lidocaine/bupivacaine vs. saline placebo on pain scores and
incision site reactions in dogs undergoing routine castration. The Veterinary Journal (2013), http://dx.doi.org/10.1016/j.tvjl.2012.11.019