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Case Report
Ultrasound-guided dorsal penile nerve block for ED
paraphimosis reduction☆,☆☆,★
Abstract
Adequate anesthesia for emergency department management
of
painful penile conditions such as paraphimosis or priapism is
often
both technically challenging and inconsistent using
traditional
landmark-based techniques of the dorsal penile block (DPB). The
pu-dendalnerves branch to form thepaired dorsal nerves of the penis
pro-
viding sensory innervation to the skin of both the dorsal and
ventral
aspectsof thepenis. “Blind” DPB techniques tend to rely on
subtle tactile
feedback from the needle and visual landmark approximation to
identi-
fy the appropriate subpubic fascial compartment for injection.
The
landmark-based DPB is not standardized with options including
“10
o'clock and 2 o'clock” infrapubic injections with or
withoutventral inl-
tration or a ring block. Given the lack of standardization and
inherent
technical imprecision with the landmark-based DPB, large volumes
of
local anesthetic (up to 50 mL) are sometimes required to achieve
a clin-
ically adequate block. In addition, inadvertent injection into
the corpora
cavernosa may occur. More recently, an ultrasound-guided
approach
has been developed. Using ultrasound, the dorsal penile nerves
can be
precisely targeted in the fascial compartment just deep to Buck
fascia,
potentially increasing block success rate and reducing the need
for
large local anesthetic volumes. Herein, we report the rst
adult case of
an ultrasound-guided dorsal penile nerve block performed in the
emer-
gency department for the reduction of a paraphimosis and review
the
relevant penile anatomy and technical details of the
procedure.
Penile emergencies such as paraphimosis, phimosis, and
priapism
are not uncommon in the emergency department (ED). Pain
manage-
ment is both essential and often challenging. “Blind”
or landmark-
based dorsal penile nerve blocks are the most common techniques
for
penile anesthesia [1]. Blind techniques are not
standardized, unreliable,
and associated with complications including local anesthetic
toxicity,
urethral injury, vascular puncture, and failed
anesthesia [2]. Ultrasound
guidance (UG) has become increasingly recognized as the standard
of
care for many invasive procedures in the ED including nerve
blocks, joint aspirations, and vascular access [3–7]. Our case
demonstrates a po-
tential improvement to the management of penile pain in the ED
by
using UG to preform the dorsal penile nerve block.
A 32-year-old male presented to the ED with penile pain and
swell-
ing for 3 days. Exam revealed paraphimosis with an extremely
tender,
painful, and swollen glans penis. For pain reduction, and
procedural an-
algesia, an UG dorsal penile nerve block (UDPB) was
performed.
The patient was placed on continuous cardiac monitoring in
supine
position. A high-frequency linear transducer (13-6 MHz;
SonoSite;
M-Turbo, Bothell, WA) was positioned at the ventral aspect of
the
base of the penis in transverse orientation just below the
symphysis
pubis. Buck fascia was identied supercial to the corpora
cavernosa
(CC). The skin was prepped with chlorehexidine, and a skin wheal
of 1% lidocaine was made at the 2 o'clock position. Using a
25-g 1.5-inch
hypodermic needle, with an in-plane, lateral-to-medial
approach,
8 mL of 0.5% bupivacaine was injected underneath Buck fascia
just
above the tunica albuginea of the CC (Fig. 1). Aspiration and
real-time
visualizationof local anesthetic spread were used to conrm
lackof vas-
cular puncture. Local anesthetic ow was noted to displace
the CC
downward and spread circumferentially to the ventral aspect of
penis
(Fig. 2). Approximately 15 minutes after block placement, the
patient
reported complete reduction of pain. The paraphimosis was
reduced
without complication or discomfort.
The UDPB was recently described for pediatric penile anesthesia
in-
cluding circumcision, dorsal slit of the foreskin, penile
lacerations, and
reduction of paraphimosis [1,8,9]. Herein we present the
rst of an
UDPB in the ED with an adult. The UDPB reported was easy to
preform
and quite successful in producing a dense anesthesia of the
penis. The
UDPB may be a useful adjunct to oral or parenteral analgesics
for painful
ED procedures involving the penis, most commonly, priapism,
and
paraphimosis reductions [8]. The UG technique holds
promise to in-
crease success rates and decrease complications associated with
tradi-
tional blind methods for penile nerve blocks.
The primary innervation of the penis derives from the
pudendal
nerves (S2-S4) that branch to create the paired dorsal nerves of
the
penis that pass under the pubis symphysistravelingjust below
Buck fas-
ciato supply sensory innervation to theskin of the dorsaland
ventralas-
pects of penis. Additional minor sensory innervation is supplied
by
branches of the ilioinguinal, genitofemoral, and posterior
scrotal nerves
(Fig. 3). Our technique takes advantage of the continuity of the
circum-
ferential fascial compartment beneath Buck fascia that allows a
single
injection to spread 360° to include the dorsal and ventral
aspects of
the penis.
There are several disadvantages to the blind, landmark
procedure.
Blind nerve blocks run the risk of suboptimal injection away
from cor-
rect fascial compartment or directly into theCC potentially
causinginju-
ry. Large volumes of local anesthetic are often required raising
concerns
for toxicity. Albeit rare, penile ischemia can occur as
well [10]. The UG
approach allows for proper visualization of the target fascial
compart-
ment just deep to Buck fascia supercial to tunica albuginea of
the CC.
Among infants, Faraoni et al [11] reported that the
UDPB for infant cir-
cumcisions improved its ef cacy, in terms of postoperative
pain in the
rst hour and time required to rst postoperative analgesia,
whereas
American Journal of Emergency Medicine 33 (2015)
863.e3–863.e5
☆ Prior presentations: None.☆☆ Conicts of interest:
The authors report no conicts of interest.★ Source of
support: None.
0735-6757/Published by Elsevier Inc.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
j o u r n a l h o m e p a g e : w w w . e l s e v i
e r . c o m / l o c a t e / a j e m
http://dx.doi.org/10.1016/j.ajem.2014.12.041http://dx.doi.org/10.1016/j.ajem.2014.12.041http://dx.doi.org/10.1016/j.ajem.2014.12.041http://www.sciencedirect.com/science/journal/http://www.sciencedirect.com/science/journal/http://dx.doi.org/10.1016/j.ajem.2014.12.041http://crossmark.crossref.org/dialog/?doi=10.1016/j.ajem.2014.12.041&domain=pdf
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O'Sullivan et al [8] reported no difference between UG
and landmark-
based techniques. Use of the UDPB has not been previously
reported
in adults. The larger girthof the typical adult penis may make
theproce-
dure technically easier than that in children.
Complications of the UDPB are similar to the landmark-based
dorsal
penile nerve block; however, we anticipate a reduced incidence
with
UG [1]. We recommend not using epinephrine which risks inducing
pe-
nile ischemia [12].
Our case suggests that UDPB is a potentially effective nerve
block for
ED management of acute penile pain and penile procedures such
as
paraphimosis and priapism reductions. Advantages include
real-time
visualization of local anesthetic spread underneath Buck fascia,
de-
creased risks of penile injury or inadvertent neurovascular
injection,and decreased volume of local anesthetic. Perhaps, most
importantly,
our experience with UDPB suggests that increased success rates
may
be possible with an UG approach vs a landmark-based technique.
Pro-
spective study of the UDPB is warranted to better determine the
use
of this technique for ED for management of acute penile pain and
penile
procedures.
Stefan Flores MD
Department of Emergency Medicine, Highland
Hospital– Alameda Health
System, Oakland, CA
Corresponding author. Department of Emergency Medicine
Highland Hospital–Alameda Heath System, 1411 East 31st St,
Oakland
CA 94602-1018. Tel.: +1 510 437 8497; fax: +1 510 437 8322
E-mail address: Stefanos.
[email protected]
Andrew A. Herring MD
Department of Emergency Medicine, Highland
Hospital– Alameda Health
System, Oakland, CA
Department of Emergency Medicine, University of California, San
Francisco
San Francisco, CA
http://dx.doi.org/10.1016/j.ajem.2014.12.041
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Fig. 1. Toppanel: cross-sectional anatomy at thebase of
thepenisshowing theinjectionsite foran UDPB.The UDBP involvesa
single injectionbeneathBuck fascia (dotted line). Once Buck
fascia is penetrated, local anesthetic
readilyspreadscircumferentially to reach both dorsaland
ventralaspects of thepenis.Bottom panel:sonogramshowing needle tip
placementunder-
neath Buck fascia with hypoechoic (black) local anesthetic
displacing the CC downward.
863.e4 S. Flores, et al. / American Journal of Emergency
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Fig. 2. Top panel: ultrasound image of the penis in
longitudinal axis (sagittal imaging
plane) after local anesthetic for penile block. Buck fascia,
symphisis pubis, and CC are la-
beled for identication. The asterisk indicates the spread of
local anesthetic injectate un-
derneath the Buck fascia, above the tunica albuginea of the CC.
Bottom panel:
ultrasound image of the penis in cross section (coronal imaging
plane) after local anes-
theticfor penile block showing thesupercialdorsal veinaboveBuck
fascia with thecom-
ponents of the dorsal neurovascular complex—
dorsal nerves, arteries, and deepveins—beneath Buck fascia
surrounded by local anesthetic.
Fig. 3. Sagittal plane anatomy of the penis showing the
pudendal nerve and its dorsal pe-
nile branches. Illustration based on the 20th US edition
of Gray's Anatomy of the Human
Body, originally published in 1918.
863.e5S. Flores, et al. / American Journal of Emergency Medicine
33 (2015) 863.e3–863.e5
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