Dorsal Penile Nerve Block - An Overview

Introduction

A critical component of medical operations, particularly in the field of urology, is the proper control of pain. The dorsal penile nerve block is one method that has gained popularity in this area. In this technique, the dorsal penile nerve is given local anesthetics to effectively numb the area and lessen pain during different urological operations, such as circumcision or penile surgery. This approach has various benefits, such as fewer side effects for patients, better operating room conditions, and maybe faster recovery periods.

What Is a Dorsal Penile Nerve Block?

The dorsal penile nerve block is a very efficient way to target regional anesthesia of the penis while requiring little local anesthetic. This technique holds paramount importance for all urologists, being an indispensable skill to possess. Additionally, it is an advantageous skill for healthcare professionals in emergency departments, particularly when encountering urgent cases like paraphimosis (males who have not undergone circumcision are susceptible to paraphimosis. It appears when the foreskin is no longer able to be drawn forward over the penis).

What Are the Indications for Dorsal Penile Nerve Block?

• Circumcision

  • Used for performing the circumcision process under local anesthesia.

  • Used to relieve postoperative discomfort following a procedure done under general anesthesia.

• Dorsal Slit Procedure - Dorsal penile nerve block is used to make the dorsal slit treatment easier to perform. The dorsal slit procedure is a surgical technique frequently used to address ailments, including phimosis (a condition where the foreskin is too tight to be drawn back over the penis).

• Paraphimosis Reduction - Dorsal penile nerve block is used for reducing paraphimosis, a disease when the foreskin gets stuck behind the glans and restricts blood.

• Repair of Penile Laceration - A dorsal penile nerve block is used to treat discomfort while repairing a tear or laceration in the penile tissue.

• Release of Trapped Penile Skin (Zipper Injuries) - The dorsal penile nerve block is administered to control discomfort and enable medical treatments in situations with trapped penile skin, such as zipper injuries.

What Are the Contraindications for Dorsal Penile Nerve Block?

• Allergic Reactions - A dorsal penile nerve block should be avoided if the patient is known to have a severe adverse response to the local anesthetic or any of its components.

• Active or Existing Infection - Administering a dorsal penile nerve block might potentially make the infection worse or spread it further if there is an existing infection at the injection site or in the vicinity.

• Bleeding Disorders - Patients with bleeding problems, such as hemophilia or platelet abnormalities, may not be good candidates for a dorsal penile nerve block since there is a chance that too much blood will come out at the injection site.

• Uncooperative Patient - The risk of problems increases and the operation may not be safe to execute if the patient is unwilling to comply or remain still.

• Refusal of the Procedure by the Patient - If the patient declines to have the treatment done after being properly informed of the risks and advantages, their choice should be respected.

• Anatomical Differences - The penile region's anatomical variances may make it difficult or dangerous to complete the treatment precisely, increasing the likelihood of problems.

What Is the Technique of Dorsal Nerve Block?

• The main objective of this technique is to appropriately inject a local anesthetic into the bilateral gaps under the fascia on each side of the suspensory ligament. Using a fine-gauge needle, a little amount of local anesthetic is first injected into the skin on the dorsum at the base of the penis. This first stage causes a localized "bleb" or wheel of the anesthetic fluid to develop. The anesthetic bleb is then penetrated, with the possibility of switching to a bigger gauge needle if necessary. The pubic symphysis is the point at which the needle makes contact. The practitioner might use this process to determine the necessary depth for the procedure's future steps.

• After aspirating the syringe to make sure the needle tip is not in an artery or vein, the local anesthetic is injected. After that, the needle is gently withdrawn and guided to pass below the pubic symphysis, somewhat laterally, and about 3 to 5 mm (millimeters) deeper in order to access the proper space. Repeat the operation for the contralateral area, being careful to remove the needle to protect the dorsal venous systems and suspensory ligaments from accidental harm.

• Different practitioners put forth different strategies for the process. One team of doctors may decide to use a midline method to complete the entire block in order to cut down on the number of needle passes. Accessing the left and right dorsal nerves under the symphysis requires adjusting the needle angle to avoid midline structures. While another group places more emphasis on risk reduction, and therefore, they repeat the same process just a little bit lateral to the midline. This precaution ensures the preservation of midline structures but necessitates multiple injections to effectively administer the block.

What Are the Complications of Dorsal Penile Nerve Block?

• Patients complaining of pain during following treatments is the main problem that commonly arises. This discomfort may result from a number of factors, including an inadequate nerve block where the patient still feels touched. Alternatively, it can be the result of not giving the block enough time to work at full capacity, which normally takes ten to 15 minutes. It is best to deliver the local anesthetic at a slower rate in order to lessen the pain felt during the injection.

• Hematomas and bleeding are common problems, and for the most part, they can be controlled with pressure and the right dressings.

• The use of local anesthetics in conjunction with adrenaline or epinephrine should be avoided since this combination has been associated with ischemia problems and probable tissue damage.

What Are the Clinical Significance of a Dorsal Penile Nerve Block?

The effectiveness of dorsal penile nerve blocks makes them a significant therapeutic tool. They provide quick-onset anesthesia, making it easier to treat penile problems in both elective and emergency situations. The need for general anesthesia can be avoided by carefully using these blocks, allowing patients to get prompt care inside the emergency room. In order to avoid possible issues, nurse practitioners and primary care doctors who wish to do dorsal penile nerve blocks must have a good understanding of penile anatomy.

A thorough meta-analysis provides strong Level 1 evidence that dorsal penile nerve blocks outperform the eutectic mixture of local anesthetic (EMLA) blocks in terms of pain relief. Notably, dorsal penile nerve blocks have a low rate of hemorrhage at five percent and a modest incidence of failure, ranging from four percent to eight percent.

Conclusion

In conclusion, the dorsal penile nerve block is an effective method frequently used in a range of genital-region-related medical operations. This localized anesthesia efficiently numbs the region by focusing on the dorsal penile nerve, minimizing pain and suffering during operations like circumcision or other surgical treatments. Its advantages include offering a substitute for general anesthesia, reducing the dangers of systemic sedation, and facilitating improved postoperative pain control. To guarantee patient safety and the best results, the dorsal penile nerve block must be administered carefully by qualified doctors, just like any other medical operation.