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Clinical Procedures > Anesthetic and Analgesic Techniques
Nerve Block, Dorsal Penile
Article Last Updated: May 22, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Editors: Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
nerve block, dorsal penile block, penile nerve block, penile anesthesia, penile block, local penile anesthesia, dorsal slit of the foreskin, phimosis reduction, paraphimosis reduction, repair of penile lacerations, release of penile skin entrapped in zippers, zipper injury
Local anesthesia1 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.
Transverse section through the base of the penis.
The use of parenteral analgesia with or without sedation is recommended before the application of local penile anesthesia.
For more information on pain management, see the Medscape Pharmacologic Management of Pain Resource Center.
Indications for anesthesia of the penis include the following:
Contraindications for anesthesia of the penis include the following:
- 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
- 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.
Patient preparation
- Obtain informed consent.
- 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.
Local infiltration – Penile lacerations
- 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.
Local infiltration – Dorsal slit of foreskin
- 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.
Local infiltration – Dorsal slit of the foreskin.
Local infiltration – Circumferential penile block
- 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.
Local infiltration – Circumferential penile block.
Penile block - 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.
Insertion sites at the 10- and 2-o'clock positions. - 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.
- 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.
Penile block - Paramidline technique.
- Only use anesthetic solutions without epinephrine when administering injectable anesthesia to the penis.7 Injected anesthetic solutions that contain epinephrine have been associated with penile ischemia and necrosis.
- 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.8
- 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.9 A prophylactic antibiotic is not recommended; rather, the patient should be given detailed return precautions.
Web Links
Update in Anaesthesia: The Anatomy and Technique of Penile Block New York School of Regional Anesthesia: Peripheral Nerve Blocks for Children American Academy of Family Physicians: Paraphimosis: Current Treatment Options
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
| Media file 1:
Transverse section through the base of the penis. |
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| Media file 2:
Local infiltration – Dorsal slit of the foreskin. |
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| Media file 3:
Local infiltration – Circumferential penile block. |
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| Media file 4:
Insertion sites at the 10- and 2-o'clock positions. |
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- 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. May 2003;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. Jun 2000;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. Feb 2006;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. Jul 2005;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. Feb 2003;96(2):396-9, table of contents. [Medline].
- Emsen IM. Catastrophic complication of the circumcision that carried out with local anesthesia contained adrenaline. J Trauma. May 2006;60(5):1150. [Medline].
- Kaplanian S, Chambers NA, Forsyth I. Caudal anaesthesia as a treatment for penile ischaemia following circumcision. Anaesthesia. Jul 2007;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. Oct 2006;16(10):1094-5. [Medline].
- Reichman E, Simon R. Anesthesia of the penis, testicle and epididymis. In: Emergency Medicine Procedures. New York, NY: McGraw Hill; 2004.
Nerve Block, Dorsal Penile excerpt Article Last Updated: May 22, 2008
Topic originally published: May 22, 2008
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