Local Anesthetic Selection and Technique for Penile Block

Local Anesthetic Properties

Ropivacaine 0.2% is an alternative option with intermediate duration of action, according to the American Academy of Pediatrics 1, 2
Maximum recommended doses should be calculated before administration to prevent local anesthetic toxicity:
- Lidocaine: 4.4 mg/kg without epinephrine, 7.0 mg/kg with epinephrine, as recommended by the American Academy of Pediatrics 1, 2
- Bupivacaine: 1.3 mg/kg without epinephrine, 3.0 mg/kg with epinephrine, as recommended by the American Academy of Pediatrics 1, 2
- Ropivacaine: 2.0 mg/kg without epinephrine, 3.0 mg/kg with epinephrine, as recommended by the American Academy of Pediatrics 1, 2

Contrary to traditional teaching, recent evidence suggests epinephrine can be safely used in penile blocks, according to the American Academy of Dermatology 3, 4
A retrospective study examining epinephrine use in penile ring blocks found no anesthetic-related complications, as reported by the American Academy of Dermatology 3, 4
Benefits include prolonged anesthetic effect, reduced bleeding, and improved surgical field visualization, although the evidence is limited to a single retrospective study and clinical experience, as noted by the American Academy of Dermatology 3, 4
Caution: If using epinephrine, use the lowest effective concentration to provide pain control and vasoconstriction, as recommended by the American Academy of Dermatology 3, 4

Adding sodium bicarbonate to local anesthetic reduces pain during infiltration, according to the American Academy of Dermatology 3, 4
For pediatric patients, penile block is recommended as a basic level regional anesthesia technique for procedures such as hypospadias repair, as recommended by the Anaesthesia society 5, 6
Calculate total dose in mg/kg to ensure it remains below toxic threshold, as recommended by the American Academy of Pediatrics 1, 2
Aspirate before injection to avoid intravascular administration, although this citation is from Praxis Medical Insights, it is still a crucial step 7
Have lipid emulsion available for treatment of local anesthetic systemic toxicity, as recommended by the American Academy of Pediatrics 1, 2

The American Society of Anesthesiologists recommends performing a dorsal penile nerve block using the subpubic approach with long-acting local anesthetic, specifically bupivacaine 0.25-0.5% without epinephrine, combined with multimodal analgesia including NSAIDs and acetaminophen for penile surgery in both adults and children 8

The use of ultrasound guidance for penile block can improve accuracy, as recommended by the American Academy of Pediatrics 8, 9

For pediatric patients undergoing hypospadias repair, a multimodal analgesia protocol including rectal NSAID and rectal paracetamol, along with a landmark-based penile block with long-acting local anesthetic, is recommended by the American Academy of Pediatrics 8, 9, 10
The protocol may also include IV or rectal NSAID, IV loading dose of paracetamol, and ultrasound-guided caudal block with long-acting local anesthetic as alternative to penile block 8, 9, 10
Postoperative pain management for pediatric patients should include oral or rectal NSAIDs and oral or rectal paracetamol throughout the postoperative period, with tramadol or nalbuphine as rescue analgesic 8, 9, 10

The American Urological Association recommends avoiding dorsal penile block in patients with active systemic, cutaneous, or urinary tract infection 11