Penile Block

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.