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Dorsal Nerve Block for Management of Intraoperative Penile Erection
0022-5347 /94/1512-0394$03.00/0 Vol. 151, 394-395, February 1994
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1994 by AMERICAN UROLOGICAL ASSOCIATION, INC.
DORSAL NERVE BLOCK FOR MANAGEMENT OF INTRAOPERATIVE PENILE ERECTION ALLEN D. SEFTEL,* MARTIN I. RESNICK
AND
MARK V. BOSWELL
From the Departments of Urology and Anesthesiology, Case Western Reserve University School of Medicine and Department of Surgery, Section of Urology, Cleveland Veterans Administration Medical Center, Cleveland, Ohio
ABSTRACT
Intraoperative penile erection during general anesthesia can delay or prevent the completion of cystoscopic or penile surgical procedures. The dorsal penile nerve block is offered as a treatment for intraoperative erection. Advantages of this technique include less potential for cardiovascular complications and improved postoperative analgesia. KEY WORDS: penile erection; anesthesia, general; nerve block
Intraoperative penile erection during general anesthesia can delay or prevent the completion of cystoscopic or penile surgical procedures. Various treatments have been proposed to manage intraoperative erections, including intracorporeal injections of vasoactive drugs, such as phenylephrine 1 and metaraminol, 2 or injection of intravenous medications, such as ephedrine 3 and terbutaline. 4 However, because of their vasoactive properties these agents have the potential for serious cardiovascular side effects. We describe our experience with the dorsal penile nerve block, a procedure familiar to most urologists but to our knowledge not previously described as a treatment for intraoperative erection. Advantages of this technique include less potential for cardiovascular complications and improved postoperative analgesia in select cases. CASE HISTORY
A 23-year-old man presented for laser ablation of penile condylomata acuminata. Medical history was otherwise unremarkable and laboratory studies were normal. Physical examination was significant only for 2 condylomata on the penile shaft and 1 at the external meatus. After uneventful induction of mask general anesthesia the surgical field was prepared with povidone-iodine solution. During sterile preparation of the penis a persistent rigid erection developed, making continuation of the procedure difficult. Inasmuch as we routinely perform sublesion injections for postoperative analgesia, local anesthetic agents were readily available on the surgical field. Five ml. of a 1:1 mixture of 1 % lidocaine (without epinephrine) and 0.5% bupivacaine were injected into the subcutaneous/subdartos space on each side of the midline at the base of the penis. The block resulted in immediate and persistent detumescence, which allowed for uneventful completion of the procedure. DISCUSSION
Causes of intraoperative erection during general anesthesia are not well understood but appear to be reflexogenic and psychogenic. 4 Stimulation of the penis by washing and instrumentation during general anesthesia may result in penile erection due to activation of sacral spinal cord parasympathetic pathways that do not seem to be inhibited by general anesthesia. Alternatively, general anesthetic agents may depress cortical centers in the brain that normally inhibit penile erection in the conscious individual,5 enhancing the erectile response to tactile stimulation. It has also been suggested that psychogenic stimuli may occur during the second stage of general anesthesia, 4 a depth of anesthesia characterized by
autonomic imbalance and heightened auditory sensations 6 resulting in intraoperative erection. A number of treatments for intraoperative erection have been described, particularly intracorporeal injection of vasoactive agents, such as phenylephrine,1 ethylephrine, 7 metaraminol, 2 norepinephrine 8 and epinephrine. 9 These agents are believed to produce detumescence by decreasing blood supply to or increasing the blood drainage from the corpora cavernosa through activation of adrenergic receptors. 7 Although reported to be safe, vasoactive drugs have the potential for causing serious systemic complications, particularly in patients with cardiovascular disease. Indeed, "Two intraoperative deaths may have occurred in France owing to complications from acute severe hypertension" following intracorporeal injection of metaraminol.9 The use of penile block for treatment of intraoperative erection during general anesthesia appears to be a novel approach, although this block is widely used by urologists and anesthesiologists to provide postoperative analgesia for surgical procedures on the penis. A dorsal penile block may be readily accomplished by either of 2 techniques. One technique involves injection of several milliliters of a local anesthetic without epinephrine at the base of the penis, deep to Buck's fascia. Bilateral injections at the 11 and 1 o'clock positions are advocated because the dorsal nerves are paired midline structures. 10 Alternatively, a local anesthetic may also be injected subcutaneously at the base of the penis, deep to the membranous layer of the superficial fascia (Dartos fascia) but superficial to Buck's fascia. 11 Indeed, subcutaneous injection has been reported to provide excellent postoperative analgesia after circumcision in infants and children, 12 avoiding the potential risk of hematoma formation in the restricted space formed by Buck's fascia and the corpora cavernosa. In our case we performed simple bilateral injections into the subcutaneous/subdartos space without attempting to inject deep to Buck's fascia. The penis detumesced rapidly, demonstrating a satisfactory block. The most likely mechanism for detumescence was local anesthetic-induced blockade of the afferent impulses to the spinal cord, which interrupted the sacral reflex arc that maintains the erection. In summary, we offer dorsal penile nerve block as a simple and effective method for treating intraoperative erection during general anesthesia. The technique is safe, has the added advan tage of providing postoperative analgesia and may avoid the need for vasoactive medications that can have systemic side effects. REFERENCES
1. Dittrich, A., Albrecht, K., Bar-Moshe, 0. and Vandendris, M.: Treatment of pharmacological priapism with phenylephrine. J. Urol., 146: 323, 1991.
Accepted for publication July 2, 1993. * Requests for reprints: Department of Urology, University Hospitals of Cleveland, 2074 Abington Rd., Cleveland, Ohio 44106. 394
DORSAL NERVE BLOCK FOR MANAGEMENT OF INTRAOPERATIVE PENILE ERECTION 2. Tsai, S. K. and Hong, C. Y.: Intracavernosal metaraminol for treatment of intraoperative penile erection. Postgrad. Med. J., 66: 831, 1990. 3. Miyabe, M. and Namiki, A.: Ephedrine for treatment of penile erection during spinal anesthesia. Letter to the Editor. Anesth. Analg., 67: 1019, 1988. 4. Shantha, T. R.: Intraoperative management of penile erection by using terbutaline. Anesthesiology, 70: 707, 1989. 5. Steers, W. D.: Neural control of penile erection. Sem. Urol., 8: 66, 1990. 6. Collins, V. J.: General anesthesia-clinical signs. In: Principles of Anesthesiology, 3rd ed. Philadelphia: Lea & Febiger, pp. 362363, 1993. 7. Serrate, R. G., Prats, J., Regue, R. and Rius, G.: The usefulness of
8. 9. 10. 11. 12.
395
ethylephrine (Efortil-R) in the treatment ofpriapism and intraoperative penile erections. Int. Urol. Nephrol., 24: 389, 1992. de Meyer, J. M. and De Sy, W. A.: Intracavernous injection of noradrenaline to interrupt erections during surgical interventions. Eur. Urol., 12: 169, 1986. Lue, T. F.: Editorial comment. J. Urol., 139: 737, 1988. Katz, J.: Atlas of Regional Anesthesia. Norwalk, Connecticut: Appleton-Century-Crofts, pp. 138-139, 1985. Brown, T. C. K., Weidner, N. J. and Bouwmeester, J.: Dorsal nerve of penis block-anatomical and radiological studies. Anaesth. Intens. Care, 17: 34, 1989. Broadman, L. M., Hannallah, R. S., Belman, A. B., Elder, P. T., Ruttimann, U. and Epstein, B. S.: Post-circumcision analgesiaa prospective evaluation of subcutaneous ring block of the penis. Anesthesiology, 67: 399, 1987.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1994 by AMERICAN UROLOGICAL ASSOCIATION, INC.
DORSAL NERVE BLOCK FOR MANAGEMENT OF INTRAOPERATIVE PENILE ERECTION ALLEN D. SEFTEL,* MARTIN I. RESNICK
AND
MARK V. BOSWELL
From the Departments of Urology and Anesthesiology, Case Western Reserve University School of Medicine and Department of Surgery, Section of Urology, Cleveland Veterans Administration Medical Center, Cleveland, Ohio
ABSTRACT
Intraoperative penile erection during general anesthesia can delay or prevent the completion of cystoscopic or penile surgical procedures. The dorsal penile nerve block is offered as a treatment for intraoperative erection. Advantages of this technique include less potential for cardiovascular complications and improved postoperative analgesia. KEY WORDS: penile erection; anesthesia, general; nerve block
Intraoperative penile erection during general anesthesia can delay or prevent the completion of cystoscopic or penile surgical procedures. Various treatments have been proposed to manage intraoperative erections, including intracorporeal injections of vasoactive drugs, such as phenylephrine 1 and metaraminol, 2 or injection of intravenous medications, such as ephedrine 3 and terbutaline. 4 However, because of their vasoactive properties these agents have the potential for serious cardiovascular side effects. We describe our experience with the dorsal penile nerve block, a procedure familiar to most urologists but to our knowledge not previously described as a treatment for intraoperative erection. Advantages of this technique include less potential for cardiovascular complications and improved postoperative analgesia in select cases. CASE HISTORY
A 23-year-old man presented for laser ablation of penile condylomata acuminata. Medical history was otherwise unremarkable and laboratory studies were normal. Physical examination was significant only for 2 condylomata on the penile shaft and 1 at the external meatus. After uneventful induction of mask general anesthesia the surgical field was prepared with povidone-iodine solution. During sterile preparation of the penis a persistent rigid erection developed, making continuation of the procedure difficult. Inasmuch as we routinely perform sublesion injections for postoperative analgesia, local anesthetic agents were readily available on the surgical field. Five ml. of a 1:1 mixture of 1 % lidocaine (without epinephrine) and 0.5% bupivacaine were injected into the subcutaneous/subdartos space on each side of the midline at the base of the penis. The block resulted in immediate and persistent detumescence, which allowed for uneventful completion of the procedure. DISCUSSION
Causes of intraoperative erection during general anesthesia are not well understood but appear to be reflexogenic and psychogenic. 4 Stimulation of the penis by washing and instrumentation during general anesthesia may result in penile erection due to activation of sacral spinal cord parasympathetic pathways that do not seem to be inhibited by general anesthesia. Alternatively, general anesthetic agents may depress cortical centers in the brain that normally inhibit penile erection in the conscious individual,5 enhancing the erectile response to tactile stimulation. It has also been suggested that psychogenic stimuli may occur during the second stage of general anesthesia, 4 a depth of anesthesia characterized by
autonomic imbalance and heightened auditory sensations 6 resulting in intraoperative erection. A number of treatments for intraoperative erection have been described, particularly intracorporeal injection of vasoactive agents, such as phenylephrine,1 ethylephrine, 7 metaraminol, 2 norepinephrine 8 and epinephrine. 9 These agents are believed to produce detumescence by decreasing blood supply to or increasing the blood drainage from the corpora cavernosa through activation of adrenergic receptors. 7 Although reported to be safe, vasoactive drugs have the potential for causing serious systemic complications, particularly in patients with cardiovascular disease. Indeed, "Two intraoperative deaths may have occurred in France owing to complications from acute severe hypertension" following intracorporeal injection of metaraminol.9 The use of penile block for treatment of intraoperative erection during general anesthesia appears to be a novel approach, although this block is widely used by urologists and anesthesiologists to provide postoperative analgesia for surgical procedures on the penis. A dorsal penile block may be readily accomplished by either of 2 techniques. One technique involves injection of several milliliters of a local anesthetic without epinephrine at the base of the penis, deep to Buck's fascia. Bilateral injections at the 11 and 1 o'clock positions are advocated because the dorsal nerves are paired midline structures. 10 Alternatively, a local anesthetic may also be injected subcutaneously at the base of the penis, deep to the membranous layer of the superficial fascia (Dartos fascia) but superficial to Buck's fascia. 11 Indeed, subcutaneous injection has been reported to provide excellent postoperative analgesia after circumcision in infants and children, 12 avoiding the potential risk of hematoma formation in the restricted space formed by Buck's fascia and the corpora cavernosa. In our case we performed simple bilateral injections into the subcutaneous/subdartos space without attempting to inject deep to Buck's fascia. The penis detumesced rapidly, demonstrating a satisfactory block. The most likely mechanism for detumescence was local anesthetic-induced blockade of the afferent impulses to the spinal cord, which interrupted the sacral reflex arc that maintains the erection. In summary, we offer dorsal penile nerve block as a simple and effective method for treating intraoperative erection during general anesthesia. The technique is safe, has the added advan tage of providing postoperative analgesia and may avoid the need for vasoactive medications that can have systemic side effects. REFERENCES
1. Dittrich, A., Albrecht, K., Bar-Moshe, 0. and Vandendris, M.: Treatment of pharmacological priapism with phenylephrine. J. Urol., 146: 323, 1991.
Accepted for publication July 2, 1993. * Requests for reprints: Department of Urology, University Hospitals of Cleveland, 2074 Abington Rd., Cleveland, Ohio 44106. 394
DORSAL NERVE BLOCK FOR MANAGEMENT OF INTRAOPERATIVE PENILE ERECTION 2. Tsai, S. K. and Hong, C. Y.: Intracavernosal metaraminol for treatment of intraoperative penile erection. Postgrad. Med. J., 66: 831, 1990. 3. Miyabe, M. and Namiki, A.: Ephedrine for treatment of penile erection during spinal anesthesia. Letter to the Editor. Anesth. Analg., 67: 1019, 1988. 4. Shantha, T. R.: Intraoperative management of penile erection by using terbutaline. Anesthesiology, 70: 707, 1989. 5. Steers, W. D.: Neural control of penile erection. Sem. Urol., 8: 66, 1990. 6. Collins, V. J.: General anesthesia-clinical signs. In: Principles of Anesthesiology, 3rd ed. Philadelphia: Lea & Febiger, pp. 362363, 1993. 7. Serrate, R. G., Prats, J., Regue, R. and Rius, G.: The usefulness of
8. 9. 10. 11. 12.
395
ethylephrine (Efortil-R) in the treatment ofpriapism and intraoperative penile erections. Int. Urol. Nephrol., 24: 389, 1992. de Meyer, J. M. and De Sy, W. A.: Intracavernous injection of noradrenaline to interrupt erections during surgical interventions. Eur. Urol., 12: 169, 1986. Lue, T. F.: Editorial comment. J. Urol., 139: 737, 1988. Katz, J.: Atlas of Regional Anesthesia. Norwalk, Connecticut: Appleton-Century-Crofts, pp. 138-139, 1985. Brown, T. C. K., Weidner, N. J. and Bouwmeester, J.: Dorsal nerve of penis block-anatomical and radiological studies. Anaesth. Intens. Care, 17: 34, 1989. Broadman, L. M., Hannallah, R. S., Belman, A. B., Elder, P. T., Ruttimann, U. and Epstein, B. S.: Post-circumcision analgesiaa prospective evaluation of subcutaneous ring block of the penis. Anesthesiology, 67: 399, 1987.