Caudal anaesthesia as a treatment for penile ischaemia following circumcision

Abstract

SummaryWe report an ischaemic penile glans following circumcision and a dorsal penile nerve block in a 9-year-old boy. Ischaemia of the glans penis is a rare complication associated independently with both circumcision and dorsal penile nerve blocks. There are a number of pathophysiological mechanisms of this ischaemia and its management is varied and not well recorded. We report the successful management of this complication using a caudal epidural block and also discuss technical aspects of penile nerve blocks. Circumcision is a commonly performed surgical procedure with a low complication rate. Penile ischaemia is a rare complication of circumcision and surgical causes include haematoma, vessel ligation, and an excessively tight suture line.The dorsal penile nerve block is a widely used form of regional anaesthesia, particularly in children [1]. It is a simple, easy and effective block that reduces postoperative pain and analgesic requirements. A number of complications have, however, been reported [1][2][3][4]. Ischaemia of the glans penis is a rare complication associated with this block and may arise via a number of mechanisms [3].We report a case of ischaemic glans penis following circumcision and dorsal penile nerve block in a 9-yearold boy which was managed successfully with a caudal block. Case reportA healthy 9-year-old, 38-kg Caucasian boy presented for an elective circumcision. Following intravenous induction of anaesthesia, with the child spontaneously breathing oxygen and isoflurane through a laryngeal mask airway, a dorsal penile nerve block was performed under sterile conditions with a 22-G blunt-bevel needle. The subpubic approach to the dorsal nerves of the penis was used [5], with the child lying in the supine position and the penis pulled inferiorly. Two symmetrical injections 1 cm lateral to the midline, and just below the lower border of the pubis symphysis, were performed. The needle was inserted almost perpendicularly to the skin with slight caudal and medial angulation. After aspiration, to exclude intravenous placement of the needle, 3 ml 0.5% plain bupivacaine was injected on each side. The block appeared uncomplicated. An uneventful classic circumcision was then performed using bipolar diathermy. However, in recovery, the block appeared ineffective and the child required a total of 6 mg morphine to control significant pain. Examination of the penis at this point showed no evidence of bleeding, haematoma or vascular compromise.Four hours later, nursing staff requested urgent surgical and anaesthetic consultations. The boy had ongoing pain and examination revealed a flaccid penis with a significantly ischaemic, poorly perfused, almost black, glans. Significantly, the penile shaft was well perfused and there was no sign of swelling, haematoma or bruising, either at the site of the penile block or at the glans. An urgent duplex Doppler demonstrated good blood flow in both penile arteries distal to the block site. Surgical opinion was that the viability of the glans was threatened but the...

Investigation of the effect of dorsal penile block to penile tissue

“…Despite the low technical failure rate, it is an easy, safe and effective method [1,4]. However, it may lead to several complications, with rates of 0.2-5% [1,5,6,[13][14][15]. Currently, there is not enough evidence of the etiology and pathophysiology of some of these complications, especially penile ischemia.…”

“…Despite its several advantages, DPB may cause hematoma, edema, hemorrhage, osteomyelitis, glanular ischemia, and central nervous system toxicity [4][5][6]. It was also reported that local anesthetics may induce Schwann cell death [7].…”

Ultrasound‐guided dorsal penile nerve block performed in a case of zipper entrapment injury

“…Accidental injection between dartos and Buck's fascia, rather than below Buck's fascia, may lead to inadequate anesthesia, the need for multiple injections, and the use of a larger total volume of anesthetic. There is also a risk of direct injection into the corpus cavernosum, which can cause inflammation or even ischemia . These complications compromise the safety of the “blind” technique.…”

Acute Ischemia of the Glans Penis after Circumcision Treated with Hyperbaric Therapy and Pentoxifylline: Case Report and Revision of the Literature

“…Moreover, the combination of HBO with PTX seems to have a synergistic effect as demonstrated in vitro on skin flaps in rats [9]. Kaplanian et al [10] described a case of glans ischemia after circumcision treated with caudal block to reduce sympathetic tone, improve arterial supply and a well venous drainage. In a case report, Burke et al [11] described ischemia of the glans penis occurring 40 min after DPNB with 0.75% ropivacaine treated with intravenous infusion of vasodilator iloprost (a prostaglandin I2 analogous).…”