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LETTER TO EDITOR
Year : 2017  |  Volume : 11  |  Issue : 3  |  Page : 376-377

Ultrasound-guided penile nerve block in pediatrics: An answer to intraoperative priapism


1 Department of Anaesthesia and Critical Care, AIIMS, Patna, Bihar, India
2 Department of Paediatric Surgery, AIIMS, Patna, Bihar, India

Correspondence Address:
Chandni Sinha
Department of Anaesthesia and Critical Care, AIIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_138_17

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Date of Web Publication29-Jun-2017
 


How to cite this article:
Bara M, Kumar A, Sinha C, Sinha AK. Ultrasound-guided penile nerve block in pediatrics: An answer to intraoperative priapism. Saudi J Anaesth 2017;11:376-7

How to cite this URL:
Bara M, Kumar A, Sinha C, Sinha AK. Ultrasound-guided penile nerve block in pediatrics: An answer to intraoperative priapism. Saudi J Anaesth [serial online] 2017 [cited 2017 Jul 21];11:376-7. Available from: http://www.saudija.org/text.asp?2017/11/3/376/206783



Sir,

Intraoperative penile erections, though rare, is a troublesome entity and can lead to postponement of surgeries. It is mostly reported in adults during the transurethral procedure or penile surgeries.[1] It is also though less frequently seen in pediatric patients.[2] We present a case of intraoperative priapism in a child managed successfully with ultrasound (USG)-guided penile nerve block (PNB).

A 5-year-old child weighing 14 kg was posted for urethroplasty under general anesthesia. After administering general anesthesia and caudal analgesia (7 ml of 0.125% bupivacaine), he developed priapism after around 10 min. Despite various maneuvers such as deepening the plane of anesthesia, intravenous administration of fentanyl and glycopyrrolate, priapism persisted. Following this, we decided to give USG-guided dorsal PNB. A high-frequency linear transducer was used to visualize the subpubic space [Figure 1]. The subpubic space is bounded by buck's fascia posteriorly, pubic symphysis superiorly, and fascia Scarpa/dartos fascia anteriorly. An in-plane technique was used to inject 4 ml of 0.125% bupivacaine in subpubic space bilaterally. After few minutes, the erection subsided, and the surgeon proceeded with their surgery.
Figure 1: Ultrasound-guided dorsal penile nerve block

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Persistent penile erection unrelated to sexual excitation is called priapism. Prolonged priapism can lead to edema and necrosis of penis.[3] Prognosis depends on the type of priapism and the duration of time elapsed before the therapeutic intervention. There are two main types of priapism: (1) Low flow or ischemic priapism: this is more painful and is seen in sickle-cell disease, leukemia, malaria, etc., (2) High flow or nonischemic priapism: this is less painful and is mostly seen in trauma patients and during surgery.

Priapism following spinal or epidural anesthesia is reflexogenic especially if the sympathetic blockade extends above the mid-thoracic level. Instrumentation before adequate sensory blockade can also stimulate pudendal nerve (S2, S3, S4) and lead to priapism.[4] The various mechanisms to relieve this include (1) Deepening the plane of anesthesia (2) Ice packs, (3) Removing the blood, and (4) Medicines such as oral terbutaline, inhalation of amyl nitrate, intravenous glycopyrrolate.[2],[4] PNBs not only relieve priapism but also anesthetize the penis and improve patients' cooperation if injections are required. It is a relatively safe procedure avoiding the use of vasoactive substances. Few articles have described USG-guided PNBs for pediatric circumcisions.[5] We have used USG to block dorsal nerve of penis real time in a child with intraoperative priapism. Hence, we recommend USG-guided PNB as a maneuver to prevent and treat priapism.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Şenayli Y, Senayli A. Survey on intraoperative penile erections of four children. Açta Oncol Turcica 2008;41:45-8.  Back to cited text no. 1
    
2.
Gerber F, Schwöbel MG, Jöhr M. Successful treatment of intraoperative erection in a 15-month-old child with intracavernous epinephrine. Paediatr Anaesth 2001;11:506-7.  Back to cited text no. 2
    
3.
Baltogiannis DM, Charalabopoulos AK, Giannakopoulos XK, Giannakis DJ, Sofikitis NV, Charalabopoulos KA. Penile erection during transurethral surgery. J Androl 2006;27:376-80.  Back to cited text no. 3
    
4.
Staerman F, Nouri M, Coeurdacier P, Cipolla B, Guille F, Lobel B. Treatment of the intraoperative penile erection with intracavernous phenylephrine. J Urol 1995;153:1478-81.  Back to cited text no. 4
    
5.
Sandeman DJ, Dilley AV. Ultrasound guided dorsal penile nerve block in children. Anaesth Intensive Care 2007;35:266-9.  Back to cited text no. 5
    


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