Penile Block Indication
This block is usually performed for a circumcision, along with a ring block of the penis.
The penis is innervated by the left and the right dorsal nerves, both of which are derived from the pudental nerve. The right and the left dorsal nerves are separated by the suspensory ligament of the penis. Each dorsal nerve passes inferior to the inferior ramus of the pubis, after which it penetrates the superficial fascia to supply the skin. After penetrating the superficial fascia, each dorsal nerve gives off a branch to the corpus cavernosus of the penis.
EMLA cream can be applied to the prepuce and the mucosal surfaces of the penis for a period of 45 min to ease the performance of the penile block. With the patient in the supine position, a 27-gauge needle is inserted at the base of the penis over the middle of the pubic arch, until it touches the pubic symphysis. The needle is then withdrawn and redirected to pass below the symphysis and 3-5 mm deeper depending on the size of the patient. It is preferable to direct it slightly laterally into the pear-shaped space and then to reinsert it on the other side, depositing equal volumes on each side. After negative aspiration, a total of 5-7 cc of a mixture of 0.25% bupivacaine and 1% lidocaine is given on either side.
Avoiding the midline injection reduces the chance of penetrating the dorsal vessels of the penis and causing hematoma.
This block is performed along with the penile block to provide anesthesia for circumcision. The ring block is a subcutaneous injection at the base of the penile shaft usually performed with a 27-gauge needle. A total of 10 cc of a mixture of 0.25% bupivacaine and 1% lidocaine can be given via two injection sites - one dorsally and one ventrally.
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