Dorsal Penile Nerve Block: Initial Approach

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Put some mild traction on the penis by grabbing the glans penis at the corona and pulling distally towards you. This helps stabilize the otherwise flaccid penis and makes it easier to control the injection.

In this image: The clinician shows the proper way to grasp the glans penis at the corona.

Another technique operators use is to wrap the distal penis in non-sterile two-ply gauze sponge and then pull distally to stabilize the penis.

Inject at the penile base or at about the most proximal skin crease. Place the syringe at about between a 25-45 degree angle from the shaft and puncture the skin at the approximately 1:30-2:00 o'clock position, and then the 10:00 -10:30 o'clock position.

In this image: The clinician injects the analgesia at the 1:30-2 o'clock position on the penile base.

In this image: The practitioner injects the analgesia at the 10-10:30 o'clock position on the penile base.

It helps to stabilize your injecting hand on the restraining board, keeping clear of the infant's leg which may move.

Keep the needle at between 25-45 degree angle and mentally visualize and direct the needle tip to the correction position on the penile shaft. Insert the needle to a depth of about 5-7mm (~1/2 the 13mm needle length).

The goal of the depth of the injection is to be in the deep subcutaneous tissue just at or near the deep fascia of the penis without puncturing it. The dorsal nerves are adhered tightly just underneath the deep fascia of the penis (also known as Buck's fascia). A clue to identification of the needle tip at the level of the deep fascia is that it will give an initial resistance to puncture (compared to subcutaneous fat).

Infiltration of lidocaine in the deep subcutaneous fat is sufficiently deep enough to block the dorsal penile nerves. It is more difficult to puncture the deep fascia of the penis, and still be at the level of the dorsal nerves, without entering the corpus cavernosum. (As stated already, the dorsal penile nerves adhere tightly to the deep side of the penis' deep fascia.)

Note: This is one approach to blocking the dorsal penile nerves. Two other approaches are:

1. The one puncture technique starting at the dorsal midline at the base and then directing the needle to each nerve to infiltrate the local anesthesia, and

2. The subcutaneous, circumferential, ring block technique done near the base of the shaft technique.

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