American Journal of Emergency Medicine 33 (2015) 863.e3863.

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American Journal of Emergency Medicine

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Case Report

Ultrasound-guided dorsal penile nerve block for ED

paraphimosis reduction,,
Abstract
Adequate anesthesia for emergency department management of
painful penile conditions such as paraphimosis or priapism is often
both technically challenging and inconsistent using traditional
landmark-based techniques of the dorsal penile block (DPB). The pudendal nerves branch to form the paired dorsal nerves of the penis providing sensory innervation to the skin of both the dorsal and ventral
aspects of the penis. Blind DPB techniques tend to rely on subtle tactile
feedback from the needle and visual landmark approximation to identify the appropriate subpubic fascial compartment for injection. The
landmark-based DPB is not standardized with options including 10
o'clock and 2 o'clock infrapubic injections with or without ventral inltration or a ring block. Given the lack of standardization and inherent
technical imprecision with the landmark-based DPB, large volumes of
local anesthetic (up to 50 mL) are sometimes required to achieve a clinically adequate block. In addition, inadvertent injection into the corpora
cavernosa may occur. More recently, an ultrasound-guided approach
has been developed. Using ultrasound, the dorsal penile nerves can be
precisely targeted in the fascial compartment just deep to Buck fascia,
potentially increasing block success rate and reducing the need for
large local anesthetic volumes. Herein, we report the rst adult case of
an ultrasound-guided dorsal penile nerve block performed in the emergency department for the reduction of a paraphimosis and review the
relevant penile anatomy and technical details of the procedure.
Penile emergencies such as paraphimosis, phimosis, and priapism
are not uncommon in the emergency department (ED). Pain management is both essential and often challenging. Blind or landmarkbased dorsal penile nerve blocks are the most common techniques for
penile anesthesia [1]. Blind techniques are not standardized, unreliable,
and associated with complications including local anesthetic toxicity,
urethral injury, vascular puncture, and failed anesthesia [2]. Ultrasound
guidance (UG) has become increasingly recognized as the standard of
care for many invasive procedures in the ED including nerve blocks,
joint aspirations, and vascular access [37]. Our case demonstrates a potential improvement to the management of penile pain in the ED by
using UG to preform the dorsal penile nerve block.
A 32-year-old male presented to the ED with penile pain and swelling for 3 days. Exam revealed paraphimosis with an extremely tender,
painful, and swollen glans penis. For pain reduction, and procedural analgesia, an UG dorsal penile nerve block (UDPB) was performed.

Prior presentations: None.

Conicts of interest: The authors report no conicts of interest.
Source of support: None.
0735-6757/Published by Elsevier Inc.

The patient was placed on continuous cardiac monitoring in supine

position. A high-frequency linear transducer (13-6 MHz; SonoSite;
M-Turbo, Bothell, WA) was positioned at the ventral aspect of the
base of the penis in transverse orientation just below the symphysis
pubis. Buck fascia was identied supercial to the corpora cavernosa
(CC). The skin was prepped with chlorehexidine, and a skin wheal of
1% lidocaine was made at the 2 o'clock position. Using a 25-g 1.5-inch
hypodermic needle, with an in-plane, lateral-to-medial approach,
8 mL of 0.5% bupivacaine was injected underneath Buck fascia just
above the tunica albuginea of the CC (Fig. 1). Aspiration and real-time
visualization of local anesthetic spread were used to conrm lack of vascular puncture. Local anesthetic ow was noted to displace the CC
downward and spread circumferentially to the ventral aspect of penis
(Fig. 2). Approximately 15 minutes after block placement, the patient
reported complete reduction of pain. The paraphimosis was reduced
without complication or discomfort.
The UDPB was recently described for pediatric penile anesthesia including circumcision, dorsal slit of the foreskin, penile lacerations, and
reduction of paraphimosis [1,8,9]. Herein we present the rst of an
UDPB in the ED with an adult. The UDPB reported was easy to preform
and quite successful in producing a dense anesthesia of the penis. The
UDPB may be a useful adjunct to oral or parenteral analgesics for painful
ED procedures involving the penis, most commonly, priapism, and
paraphimosis reductions [8]. The UG technique holds promise to increase success rates and decrease complications associated with traditional blind methods for penile nerve blocks.
The primary innervation of the penis derives from the pudendal
nerves (S2-S4) that branch to create the paired dorsal nerves of the
penis that pass under the pubis symphysis traveling just below Buck fascia to supply sensory innervation to the skin of the dorsal and ventral aspects of penis. Additional minor sensory innervation is supplied by
branches of the ilioinguinal, genitofemoral, and posterior scrotal nerves
(Fig. 3). Our technique takes advantage of the continuity of the circumferential fascial compartment beneath Buck fascia that allows a single
injection to spread 360 to include the dorsal and ventral aspects of
the penis.
There are several disadvantages to the blind, landmark procedure.
Blind nerve blocks run the risk of suboptimal injection away from correct fascial compartment or directly into the CC potentially causing injury. Large volumes of local anesthetic are often required raising concerns
for toxicity. Albeit rare, penile ischemia can occur as well [10]. The UG
approach allows for proper visualization of the target fascial compartment just deep to Buck fascia supercial to tunica albuginea of the CC.
Among infants, Faraoni et al [11] reported that the UDPB for infant circumcisions improved its efcacy, in terms of postoperative pain in the
rst hour and time required to rst postoperative analgesia, whereas

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S. Flores, et al. / American Journal of Emergency Medicine 33 (2015) 863.e3863.e5

Fig. 1. Top panel: cross-sectional anatomy at the base of the penis showing the injection site for an UDPB. The UDBP involves a single injection beneath Buck fascia (dotted line). Once Buck
fascia is penetrated, local anesthetic readily spreads circumferentially to reach both dorsal and ventral aspects of the penis. Bottom panel: sonogram showing needle tip placement underneath Buck fascia with hypoechoic (black) local anesthetic displacing the CC downward.

O'Sullivan et al [8] reported no difference between UG and landmarkbased techniques. Use of the UDPB has not been previously reported
in adults. The larger girth of the typical adult penis may make the procedure technically easier than that in children.
Complications of the UDPB are similar to the landmark-based dorsal
penile nerve block; however, we anticipate a reduced incidence with
UG [1]. We recommend not using epinephrine which risks inducing penile ischemia [12].
Our case suggests that UDPB is a potentially effective nerve block for
ED management of acute penile pain and penile procedures such as
paraphimosis and priapism reductions. Advantages include real-time
visualization of local anesthetic spread underneath Buck fascia, decreased risks of penile injury or inadvertent neurovascular injection,
and decreased volume of local anesthetic. Perhaps, most importantly,
our experience with UDPB suggests that increased success rates may
be possible with an UG approach vs a landmark-based technique. Prospective study of the UDPB is warranted to better determine the use
of this technique for ED for management of acute penile pain and penile
procedures.
Stefan Flores MD
Department of Emergency Medicine, Highland HospitalAlameda Health
System, Oakland, CA
Corresponding author. Department of Emergency Medicine
Highland HospitalAlameda Heath System, 1411 East 31st St, Oakland
CA 94602-1018. Tel.: +1 510 437 8497; fax: +1 510 437 8322
E-mail address: Stefanos.ores@gmail.com

Andrew A. Herring MD
Department of Emergency Medicine, Highland HospitalAlameda Health
System, Oakland, CA
Department of Emergency Medicine, University of California, San Francisco
San Francisco, CA
http://dx.doi.org/10.1016/j.ajem.2014.12.041

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Fig. 3. Sagittal plane anatomy of the penis showing the pudendal nerve and its dorsal penile branches. Illustration based on the 20th US edition of Gray's Anatomy of the Human
Body, originally published in 1918.

Fig. 2. Top panel: ultrasound image of the penis in longitudinal axis (sagittal imaging
plane) after local anesthetic for penile block. Buck fascia, symphisis pubis, and CC are labeled for identication. The asterisk indicates the spread of local anesthetic injectate underneath the Buck fascia, above the tunica albuginea of the CC. Bottom panel:
ultrasound image of the penis in cross section (coronal imaging plane) after local anesthetic for penile block showing the supercial dorsal vein above Buck fascia with the components of the dorsal neurovascular complexdorsal nerves, arteries, and deep
veinsbeneath Buck fascia surrounded by local anesthetic.

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