A wide range of urologic procedures are performed using local
or regional anesthesia. This includes an orchiectomy, inspection
of the painful testis, release of a paraphimosis, dorsal
slit, circumcision, and even a hydrocelectomy or varicocelectomy
done in the Operating Room. Emergency Physicians can utilize some
of the same anesthetic techniques, namely the penile or spermatic
cord blocks, to safely and painlessly perform many procedures in
the Emergency Department. These techniques are easy to learn, simple
to perform, and have a low risk of serious complications.
Innervation of the penis arises from the pudendal nerve that
is derived from sacral levels 2 to 4. The pudendal nerve divides
into the perineal and the inferior rectal nerves. The perineal nerve
further divides into the right and left dorsal nerves of the penis.
The dorsal nerves of the penis pass under the pubic symphysis to
penetrate the suspensory ligament of the penis.1 They travel
under Buck’s fascia to supply sensory innervation to the
entire penis (Figure 125-1).
Transverse section through the base of the penis.
The primary nerve supply of the testis and epididymis are from
the ilioinguinal and genitofemoral nerves. The ilioinguinal nerve
is derived from the first lumbar spinal nerve. It arises slightly
inferior and medial to the anterior superior iliac spine and courses
toward the pubic tubercle, between the internal and external oblique
muscles.1,2 It enters the inguinal canal on the anterior
surface of the spermatic cord. The ilioinguinal nerve provides sensory
innervation to the skin of the upper thigh, base of the penis, and
the upper scrotum.3 It also provides sensory innervation
to the spermatic cord and testicle. The genitofemoral nerve is derived
from the first two lumbar spinal nerves. It divides into the genital
branch and the femoral branch. The genital branch enters the inguinal
canal at the external inguinal ring and travels with the spermatic
cord. It provides sensory innervation to the lower scrotum, cremaster
muscle, spermatic cord, and scrotum. The femoral branch supplies
the skin of the anteromedial thigh.3
Emergency Department procedures that are facilitated by local
anesthesia of the penis include dorsal slit of the foreskin, release
of a phimosis or paraphimosis, repair of penile lacerations, and the
release of penile skin entrapped in zippers. Local anesthesia can
also be used before performing a circumcision. However, this procedure
is usually performed by a Urologist.
Emergency Department indications for a spermatic cord block include
the relief of epididymal pain, the facilitation of a manual or ultrasound
examination when differentiating between torsion and epididymitis,
and to inspect the testis following trauma. Manual detorsion of
a testis may be enabled by local anesthesia when a patient cannot
tolerate the pain of palpation. However, the risk of compromising
the blood supply to the testis and the loss of ...