Dorsal Penile Nerve Block
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Local anesthesia [1] of the penis is used as preparation to perform various procedures, including release of paraphimosis, dorsal slit of the foreskin, circumcision, [2, 3, 4] and repair of penile lacerations. The penis is innervated by the pudendal nerve (S2-S4). This nerve eventually divides into the right and left dorsal nerves of the penis that pass under the pubis symphysis to travel just below the Buck fascia to supply the sensory innervation to the penis. See relevant anatomy in the image below.
The penile shaft is composed of 3 erectile columns, the 2 corpora cavernosa and the corpus spongiosum, as well as the columns’ enveloping fascial layers, nerves, lymphatics, and blood vessels, all covered by skin. The 2 suspensory ligaments, composed of primarily elastic fibers, support the penis at its base. For more information about the relevant anatomy, see Penis Anatomy.
The use of parenteral analgesia with or without sedation is recommended before the application of local penile anesthesia.
Indications for anesthesia of the penis include the following:
Repair of penile lacerations
Release of penile skin entrapped in zippers
Contraindications for anesthesia of the penis include the following:
Suspected testicular torsion
Skin infection at the site of injection
The use of topical anesthetic cream is recommended for all penile procedures. [5]
Eutectic mixture of local anesthetics (EMLA) cream is commonly used. [6]
The cream should be left on the skin area for at least 45 minutes before the planned procedure.
For more information, see Anesthesia, Topical.
Patients who do not achieve adequate anesthesia with the topical application of an anesthetic cream should receive either a local anesthetic infiltration or a penile block. [3]
The following equipment is needed:
Povidone iodine solution (eg, Betadine)
4 x 4 gauze
Local anesthetic solution without epinephrine
Syringe, 5 mL
Needles, 16 and 27 gauge (ga)
The patient should be in the supine position with his genitalia exposed.
After obtaining informed consent from the patient, the healthcare professional should follow these steps:
Have the patient lay supine on a gurney with his genitalia exposed.
Clean gross debris.
Apply a generous amount of povidone iodine solution to the penis and scrotum.
Soak a 4 x 4 gauze pad in povidone iodine solution.
Clean the glans and shaft in a circular motion.
Repeat this step at least 2 more times.
Create a sterile field by placing drapes between the scrotum and the shaft, above the shaft, and on either side.
Administer parenteral analgesia with or without sedation.
See the list below:
Use a 27-ga needle to raise a skin wheal.
Insert the needle subcutaneously through the skin wheal to infiltrate the local anesthetic on both sides of the skin laceration.
See the list below:
Use a 27-ga needle to raise a skin wheal at the base of the foreskin in the dorsal 12-o’clock position.
Insert the needle subcutaneously through the skin wheal and advance it distally while infiltrating local anesthetic all the way to the tip of the foreskin (see image below).
See the list below:
This technique can be used for anesthesia of complex penile skin lacerations or before attempting to manually reduce paraphimosis.
Use a 27-ga needle to circumferentially infiltrate local anesthetic around the penis (see image below).
See the list below:
The right and left dorsal penile nerves should be blocked as proximally to the base of the penis as possible.
Use a 27-ga needle to raise skin wheals at the 2- and 10-o’clock positions (see image below).
Slowly insert the needle through the center of each skin wheal.
The needle should be directed toward the center of the shaft, to a depth of about 0.5 cm or until loss of resistance is felt to suggest that the tip of the needle is within the Buck fascia.
Aspirate to ensure that the needle is not in a blood vessel, and slowly inject about 2 mL of local anesthetic on each side. In neonates and children (< 10 kg), inject 0.2-0.4 mL of lidocaine 1% on each side (10 and 2 o’clock) using a 30-g needle. No more than 4.5 mg/kg should be injected. [7]
An alternative method is to inject 2 mL of local anesthetic on either side of the midline, avoiding injecting into the superficial dorsal penile vein (see image below).
Only use anesthetic solutions without epinephrine when administering injectable anesthesia to the penis. [8] Injected anesthetic solutions that contain epinephrine have been associated with penile ischemia and necrosis.
Complications may include the following:
Bleeding and hematomas: Most penile bleeding can be easily controlled with direct pressure.
Failure to achieve adequate anesthesia: A different block should be attempted as long as the toxic dosage of the anesthetic was not exceeded. [9]
Skin sloughing: This complication is more common with distal shaft/glans injections and when anesthetic that contains epinephrine is used.
Infection: The injection site can become infected, but this is rare. [10] A prophylactic antibiotic is not recommended; rather, the patient should be given detailed return precautions.
Overview
What is the anatomy of the penis relevant to dorsal penile nerve block?
What are indications for dorsal penile nerve block?
What are contraindications for dorsal penile nerve block?
What is the role of topical anesthesia in the administration of dorsal penile nerve block?
What equipment is needed to perform dorsal penile nerve block?
How is the patient positioned for a dorsal penile nerve block?
How is the patient prepped for a dorsal penile nerve block?
What is the dorsal penile nerve block approach for penile lacerations?
What is the dorsal penile nerve block approach for dorsal slit of the foreskin?
What is the dorsal penile nerve block approach for complex penile lacerations?
How is a dorsal penile nerve block administered?
What is the role of epinephrine in the administration of dorsal penile nerve block?
What are the possible complications of dorsal penile nerve block?
Telgarsky B, Karovic D, Wassermann O, Ogibovicova E, Csomor D, Koppl J, et al. Penile block in children, our first experience. Bratisl Lek Listy. 2006. 107(8):320-2. [Medline].
Soh CR, Ng SB, Lim SL. Dorsal penile nerve block. Paediatr Anaesth. 2003 May. 13(4):329-33. [Medline].
Taddio A, Pollock N, Gilbert-MacLeod C, Ohlsson K, Koren G. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med. 2000 Jun. 154(6):620-3. [Medline].
Garry DJ, Swoboda E, Elimian A, Figueroa R. A video study of pain relief during newborn male circumcision. J Perinatol. 2006 Feb. 26(2):106-10. [Medline].
Lehr VT, Cepeda E, Frattarelli DA, Thomas R, LaMothe J, Aranda JV. Lidocaine 4% cream compared with lidocaine 2.5% and prilocaine 2.5% or dorsal penile block for circumcision. Am J Perinatol. 2005 Jul. 22(5):231-7. [Medline].
Choi WY, Irwin MG, Hui TW, Lim HH, Chan KL. EMLA cream versus dorsal penile nerve block for postcircumcision analgesia in children. Anesth Analg. 2003 Feb. 96(2):396-9, table of contents. [Medline].
Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb. 31(1):237-60. [Medline].
Emsen IM. Catastrophic complication of the circumcision that carried out with local anesthesia contained adrenaline. J Trauma. 2006 May. 60(5):1150. [Medline].
Kaplanian S, Chambers NA, Forsyth I. Caudal anaesthesia as a treatment for penile ischaemia following circumcision. Anaesthesia. 2007 Jul. 62(7):741-3. [Medline].
Abaci A, Makay B, Unsal E, Mustafa O, Aktug T. An unusual complication of dorsal penile nerve block for circumcision. Paediatr Anaesth. 2006 Oct. 16(10):1094-5. [Medline].
Reichman E, Simon R. Anesthesia of the penis, testicle and epididymis. Emergency Medicine Procedures. New York, NY: McGraw Hill; 2004.
Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC
Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center
Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, American Association of Physicians of Indian Origin
Disclosure: Nothing to disclose.
Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
Dorsal Penile Nerve Block
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