What type of anesthesia or sedation is used for penile implant procedures?

Anesthesia Options for Penile Implant Surgery

Penile prosthesis implantation can be safely performed under local anesthesia with or without sedation, though general anesthesia remains a common alternative; the choice depends on patient factors, surgical complexity, and institutional protocols.

Primary Anesthetic Approaches

Local Anesthesia Techniques

Local anesthesia is effective and safe for penile prosthesis implantation, with success rates of 93-98% when properly administered. 1, 2

• Dorsal penile nerve block using a subpubic approach with bupivacaine 0.25-0.5% (without epinephrine) combined with multimodal analgesia is recommended 3
• The technique involves a 50-50 mixture of 0.5% bupivacaine and 0.5% lidocaine (without epinephrine) injected into the infrapubic space with additional subcutaneous penile ring infiltration at the penile root 1
• Crural blockade is specifically required for optimal anesthesia of the cavernous nerve during implantation procedures 4
• Pudendal nerve block combined with intracorporeal and local infiltration provides excellent anesthesia with rare need for general anesthesia supplementation 2

Sedation Protocols When Used with Local Anesthesia

When sedation is added to local anesthesia, monitored anesthetic care with IV midazolam is the standard approach:

• For adults under 60 years: titrate slowly starting with no more than 2.5 mg IV over at least 2 minutes, waiting an additional 2+ minutes between doses to evaluate effect; total dose rarely exceeds 5 mg 5
• For patients 60 years or older: start with no more than 1.5 mg IV over at least 2 minutes, with total doses rarely exceeding 3.5 mg 5
• Pre-operative sedation can be achieved with 0.07-0.08 mg/kg IM midazolam (approximately 5 mg) administered up to 1 hour before surgery 5
• Continuous monitoring of respiratory and cardiac function (pulse oximetry) is mandatory 5

General Anesthesia

General anesthesia remains an option, particularly for:

• Patients who fail local anesthesia (occurred in 1.8% of cases in one series) 1
• Complex cases requiring extensive surgical manipulation 1
• Patient preference or anxiety that cannot be managed with local anesthesia alone 6

Clinical Decision Algorithm

Start with local anesthesia plus light sedation for most patients:

1. Good candidates for local anesthesia alone or with minimal sedation:

   • ASA I-II patients under 60 years 1
   • Straightforward implantation without anticipated difficult crural dilatation 1
   • Cooperative patients who understand the procedure 4

2. Require monitored anesthetic care with deeper sedation:

   • Patients 60 years or older 5
   • Those with chronic disease or decreased pulmonary reserve 5
   • Anticipated difficult crural dilatation 1

3. Consider general anesthesia:

   • Patients with severe anxiety despite sedation 1
   • Complex reconstructive cases 6
   • Failed local anesthesia attempts 1

Critical Safety Considerations

• The procedure should always be performed under monitored anesthetic care with pre-operative evaluation as for general anesthesia, even when planning local anesthesia only, because 5-7% of patients may require booster sedation or conversion to general anesthesia 1
• Immediate availability of resuscitative drugs and equipment with personnel trained in airway management is mandatory 5
• Broad-spectrum antibiotics must be administered before incision 7
• Maximum local anesthetic doses must be calculated before administration: lidocaine 4.4 mg/kg without epinephrine (7.0 mg/kg with epinephrine); bupivacaine 1.3 mg/kg without epinephrine (3.0 mg/kg with epinephrine) 3

Advantages of Local Anesthesia Approach

• Reduced cost and morbidity compared to general anesthesia 8, 4
• Minimal fluctuations in blood pressure or pulse rate during surgery 6
• No urinary retention or cardiac side effects postoperatively 6
• Rapid return to preoperative daily activity 4
• Most patients (93%) can be discharged within 24 hours 6

Common Pitfalls to Avoid

• Inadequate crural blockade is the most common cause of intraoperative pain during implantation; ensure specific crural nerve block in addition to standard dorsal penile block 4
• Rushing sedation titration without allowing adequate time (2+ minutes) between doses leads to oversedation and respiratory depression 5
• Using epinephrine-containing local anesthetics in penile blocks (though recent evidence suggests safety, traditional teaching still recommends avoiding it for penile prosthesis surgery) 3, 1
• Failing to have general anesthesia backup immediately available when attempting local anesthesia 1