Recommended Local Anesthetic and Technique for Penile Block
For penile block procedures, lidocaine 1% or bupivacaine 0.25-0.5% without epinephrine is recommended as the local anesthetic of choice, administered using a bilateral technique at the base of the penis with additional subcutaneous infiltration around the penile root for optimal analgesia.
Local Anesthetic Selection
- Bupivacaine 0.25-0.5% without epinephrine provides longer duration of analgesia (approximately 10 hours) compared to lidocaine, making it ideal for procedures requiring extended post-operative pain control 1, 2
- Lidocaine 1% is suitable for shorter procedures with a faster onset of action 2
- Ropivacaine 0.2% is an alternative option with intermediate duration of action 3
- Maximum recommended doses should be calculated before administration to prevent local anesthetic toxicity:
Technique Options
Bilateral Technique (Preferred)
- Block each penile nerve separately at the level of the penile root 1
- Additional subcutaneous infiltration around the penile root improves quality of analgesia 1, 4
- This technique provides more reliable anesthesia than the median approach, as contralateral diffusion occurs in only 60% of patients with unilateral injection 1
Median Technique (Alternative)
- Single injection in the subpubic space near the posterior inferior aspect of the symphysis 1
- Requires less injections but may have higher failure rate than bilateral technique 1
- Still requires additional subcutaneous infiltration at penile root for optimal results 1
Infrapubic Approach
- Using a 23-gauge needle to access the infrapubic space 4
- A 50-50 mixture of 0.5% bupivacaine and 0.5% lidocaine without epinephrine can be effective 4
- Additional subcutaneous penile ring infiltration at the level of the penile root is recommended 4
Volume Considerations
- For children: 0.1 mL/kg of local anesthetic is typically sufficient 2
- For adults: 10-20 mL total volume is generally adequate 1, 4
Epinephrine Use in Penile Block
- Contrary to traditional teaching, recent evidence suggests epinephrine can be safely used in penile blocks 3, 5
- A retrospective study examining epinephrine use in penile ring blocks found no anesthetic-related complications 3
- Benefits include prolonged anesthetic effect, reduced bleeding, and improved surgical field visualization 5
- However, the evidence supporting epinephrine use is limited to a single retrospective study and clinical experience 3
- Caution: If using epinephrine, use the lowest effective concentration to provide pain control and vasoconstriction 3
Additional Considerations
- Adding sodium bicarbonate to local anesthetic reduces pain during infiltration 3
- For pediatric patients, penile block is recommended as a basic level regional anesthesia technique for procedures such as hypospadias repair 3
- For patients requiring additional sedation, ensure appropriate monitoring is available 4
- Calculate total dose in mg/kg to ensure it remains below toxic threshold 3
- Aspirate before injection to avoid intravascular administration 6
Potential Complications
- Vascular puncture and hematoma formation (13% in one study) 5
- Transient paresthesia (13% initially, 7% persistent up to 6 months) 5
- Inadequate anesthesia requiring supplemental sedation (5-7% of cases) 5, 4
- Post-procedure pain (19% of patients) 5
- Have lipid emulsion available for treatment of local anesthetic systemic toxicity 3