Peripheral Nerve Blocks: A Color Atlas, 3rd Edition

51. Penile Block

Giorgio Ivani

Valeria Mossetti

Patient Position: The patient lies on his back.

Indications: Analgesia during and after surface operations on the penis: circumcision, phimosis; also suitable for pain management following hypospadia repair, while it is not sufficient for the surgery itself, caudal anesthesia is preferable.

Needle Size: A short beveled needle (e.g., a caudal needle).

Volume: 0.1 mL/kg of ropivacaine 0.2% for children up to 7 years, levobupivacaine 0.5% for older children for each side without epinephrine (absolutely contraindicated because of the risk of ischemia of the dorsal arteries of penis) up to a maximum of 5 mL per side.

Anatomic Landmarks: Pubic symphysis (Figs. 51-1, 51-2, 51-3).

Approach and Technique: The penis is pulled downward and two symmetrical sites for needle insertion are marked, 0.5 to 1 cm both below the pubic symphysis, lateral to the midline. The short beveled needle is then inserted vertically pointing slightly caudally until there is a loss of resistance due to the piercing of Scarpa's fascia. The two-injection technique is recommended because the pubic space is frequently divided into two separate compartments by a medial division.

Another very useful technique is the subcutaneous ring approach. It is a very simple and successful technique using a subcutaneous ring of local anesthetic placed around the base of the penis. In this case no attempt is made to inject local anesthetic within Buck's fascia, thus avoiding the risk of compression of the vascular structures when an excessive volume of local anesthetic is injected within Buck's fascia. The points of injection are 2 to 3 cm from the base, at 10 and 2 o'clock level, in the subcutaneous space pointing to the base with the needle raised superficially injecting a half dose each side, thereby making a ring of local anesthetic. To complete the ring 1 mL of local anesthetic should be injected at the base of the penis, in the ventral part.

 

Figure 51-1. Penile block: subpubic approach.

Figure 51-2. Penile block: subcutaneous ring approach.

Figure 51-3. Penile block: subcutaneous ring approach.

Tips

1.   The penis is supplied by the two dorsal nerves which cross the subpubic space.

2.   The penis is supplied by terminal arteries, therefore epinephrine is contraindicated.

3.   The analgesia obtained by this block lasts for a period of at least 24 hours.

Suggested Readings

Broadman LM, Hannallah RS, Belman AB, et al. Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penis. Anesthesiology 1987;67:399–402.

Dalens B, Vanneuville G, Dechelott P. Penile block via the subpubic space in 100 children. Anesth Analg 1989;69:41–45.

Holder KJ, Peutrell JM, Weir PM. Regional anaesthesia for circumcision. Subcutaneous ring block of the penis and subpubic penile block compared. Eur J Anaesthesiol 1997;14:495–498.