What is the recommended anesthetic approach for an adult patient with a history of chronic pain and anxiety undergoing a genital procedure, such as circumcision or episiotomy, and potentially having underlying medical conditions like diabetes, hypertension, or cardiovascular disease?

Genital Nerve Block for Adult Genital Procedures

Primary Recommendation

For adult circumcision and other genital procedures, use a combination of dorsal penile nerve block (DPNB) with ventral/frenular infiltration using local anesthetics with epinephrine (1:100,000 to 1:200,000), as this provides superior anesthesia compared to DPNB alone and is safe even in patients with stable cardiovascular disease. 1, 2, 3

Optimal Anesthetic Technique

Block Technique Selection

• Subcutaneous ring block OR dorsal penile nerve block combined with frenular infiltration are the most effective approaches, with failure rates of only 4-6% compared to 82-86% failure with dorsal block alone 2, 4

• The dorsal block alone consistently fails to anesthetize the ventral penis, frenulum, and ventral foreskin in most patients, requiring supplemental ventral infiltration for pain-free surgery 3

• Pudendal nerve block provides superior postoperative analgesia compared to dorsal penile nerve block alone, with significantly lower pain scores and reduced analgesic consumption (0% vs 17% requiring rescue analgesia) 5

Local Anesthetic Selection

• Use lidocaine 2% or ropivacaine 0.25% combined with epinephrine at concentrations of 1:100,000 to 1:200,000 1, 6

• Epinephrine is safe for penile procedures based on retrospective data showing no anesthetic-related complications during penile ring blocks for circumcision 1

• The addition of epinephrine prolongs anesthetic duration by approximately 200% and provides hemostatic benefits 1

Specific Technique Details

• For dorsal penile nerve block: Use the subpubic approach with total volume of 3-5 mL of local anesthetic 6, 4

• Add ventral infiltration: Inject at the site of incision and frenulum to ensure complete anesthesia of ventral structures 4, 3

• Alternative approach: Subcutaneous ring block around the penile shaft provides reliable surgical anesthesia with low failure rates 2

Management of Comorbidities

Cardiovascular Disease Considerations

• Epinephrine-containing local anesthetics are safe in patients with stable, controlled cardiovascular conditions including hypertension, ischemic heart disease, arrhythmias, and chronic coronary disease 1

• Use small volumes (typically 3-5 mL for penile blocks) and the lowest effective epinephrine concentration 1, 6

• If uncertainty exists about cardiovascular stability, consult cardiology before proceeding 1

Diabetes Management

• No specific contraindications to regional anesthesia exist for diabetic patients undergoing genital procedures 1

• Standard local anesthetic techniques apply without modification 1

Anxiety Management

Preoperative Anxiolysis

• Administer anxiolytics preemptively for procedure-related anxiety when feasible 1

• Provide detailed preprocedure patient education on procedure details and pain management strategies, as patients tolerate procedures better when they know what to expect 1

• Written instructions regarding pain management options should be provided to patients and family members 1

Multimodal Approach

• Consider combining local anesthesia with sedation for highly anxious patients, though deep sedation must be performed only by trained professionals 1

• Nonpharmacologic interventions including cognitive modalities promote sense of control and reduce helplessness 1

Chronic Pain Considerations

Patients with Pre-existing Chronic Pain

• Use multimodal analgesia combining local anesthesia with scheduled acetaminophen (1g) and NSAIDs if no contraindications exist 1, 7

• For patients already on opioids, continue baseline opioid regimen and provide supplemental immediate-release opioids (10-20% of 24-hour requirement) for breakthrough pain only 7, 8

• Prophylactic laxatives must be prescribed with any opioid use 7, 8

Postoperative Pain Management

• Multimodal opioid-sparing analgesia should be the standard, combining scheduled NSAIDs, acetaminophen, and local anesthetic techniques 1

• Home-going opioid prescriptions should be minimized; patients not requiring opioids in hospital do not need home opioid prescriptions 1

• For neuropathic pain components, initiate gabapentinoids (gabapentin or pregabalin) 7

Critical Pitfalls to Avoid

• Never rely on dorsal penile nerve block alone—this results in 82-86% failure rates due to inadequate ventral anesthesia 2, 4

• Do not omit ventral/frenular infiltration—the frenulum and ventral structures remain sensate after dorsal block in 90% of patients 3

• Avoid excessive epinephrine concentrations—use the lowest effective concentration (1:100,000 to 1:200,000) as sensitivity varies and higher concentrations may cause palpitations and anxiety 1

• Do not perform neuroaxial blocks without checking coagulation status in patients on anticoagulants or antiplatelet agents 1

• Ensure adequate time for local anesthetic effectiveness as per package insert before proceeding with surgery 1