Yuan-Sheng Tzeng¹, Shou-Hung Tang¹, En Meng¹, Teng-Fu Lin², Guang-Huan Sun¹

A 33-year-old male receiving dorsal penile nerve block (DPNB) for circumcision exhibited a postoperative ischemic change over the glans penis. The event occurred nearly 24 hours after the procedure. The patient was treated with intravenous pentoxifyllin and hyperbaric oxygenation. Total reverse of the ischemia was observed. The complications associated with circumcision and DPNB were reviewed and discussed.

The use of dorsal penile nerve block (DPNB) for anesthesia during circumcision was first described in 1978 [1, 2]. DPNB has remained popular, not only for the benefit to the patient, but also because of the ease of performance and the scarcity of reported complications [3]. Since epinephrine may lead to penile ischemia with possible necrosis, the use of epinephrine-containing anesthetics is contraindicated. We present a case of ischemic penis after DPNB for circumcision.

DPNB is a useful technique in providing analgesia for circumcision. Failure rate reported ranges from 4 % to 7 %. The incidence of complications is low and tends to be minor [4]. Small ecchymosis at the injection site, hematoma and mild local edema were frequently seen. However, Sara and Lowry [5] reported two children presenting with gangrene of the skin of penis glans after penile nerve block. In both cases a plain solution of 0.5 % bupivacaine was used. Another report described the inadvertent use of penile block with epinephrine 1:1 000 in a 2-day-old infant [6]. This resulted in pallor of the suprapubic area and the penile shaft and systemic manifestations of epinephrine toxicity.

In the present case, the cause of the presumed temporary ischemia of glans penis may be multifactorial. Surgical trauma, pressure upon the vessels by the anaesthetic solution or local hematoma and prolonged vasospasm can be possible causes. Perivascular pressure due to the mini-compartment syndrome secondary to an anatomical abnormality is unlikely. However, the pressure may come from delayed bleeding with the formation of expanding hematoma. It is improbable that the volume of the analgesic solution (7 mL) would compress the vessels to cause the damage. Damage to the endothelium of the vessels during introducing puncture needle can be considered. Small hematomas may cause vasospasm. The delayed onset of impaired blood supply to glans penis was compatible with the hypothesis. The suture did not appear to play a role in the ischemia, since interrupted sutures do not provide more compression around the approximation than the running suture.

Intracavernous injection of papaverine was used to evaluate the patient's condition. The vasodilator immediately improved his glans color. The test also demonstrated that the patient suffered from an ischemic event, rather than a single hematoma.

Inhalation of hyperbaric oxygen enhances the amount of oxygen carried in the blood by increasing the quantity of oxygen dissolved in the plasma. In this case the poorly-perfused glans responded well to hyperbaric oxygenation.

Penile ischemia after DPNB for circumcision, which is uncommon, may happen after minor trauma. It can be reversed by conservative management.