# Penile Subcutaneous Ring Block

## Overview

This module describes how to anaesthetise the penis using a subcutaneous ring block.

## Indications

1. Penile anaesthesia for minor procedures

## Contraindications

1. Overlying infection

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I need to give you an injection that will stop your penis from feeling pain while we do the procedure.”

### What can my patient expect?

“I am going to prick your skin three times with a needle and inject numbing medication around the base of the penis. Each injection might sting a bit, but after that your whole penis will be numb for a short while. The numbness will wear off by itself.”

### What is my patient’s role?

“Let me know if you have any allergies. Fearing blood or needles is normal, but tell me if you have fainted from it. Try to keep still while I give you the injections.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

1. Non-sterile gloves
   Non-sterile gloves

   This procedure may be done as part of a surgical procedure, in which case surgical skin preparation, draping, scrubbing and gowning, and sterile gloves would be used.

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. 10 ml syringe, alcohol swab, aspiration needle (ideally blunt fill), injection needle & choice of

   local anaesthetic
   local anaesthetic

   It is current best practice to avoid the use of adrenaline in the penis and digits due to concerns of ischaemia; however, this seems to be controversial in the literature.

5. Alcohol swab

## Site & Positioning

Position the patient supine.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene and don non-sterile gloves.

2. Clean the skin around the base of the penis with an alcohol swab and allow it to dry.

3. Draw up

   local anaesthetic
   local anaesthetic

   Remember to calculate the maximum dosage of local anaesthetic.

   in a 10 ml syringe.

4. Insert the needle into the 12 o’clock position at the base of the penis. Guide the needle towards the lateral aspect of the base of the penis.

5. Aspirate to check for blood.

6. While withdrawing back to the skin, inject ¼ of the local anaesthetic.

7. Staying just under the skin, guide the needle to the contralateral side of the penis.

8. Aspirate to check for blood.

9. While withdrawing back to the skin, inject ¼ of the local anaesthetic.

10. Insert the needle into the 3 o’clock position. Guide the needle inferiorly to the

    6 o’clock position
    6 o’clock position

    Inserting the needle directly at the 6 o'clock position is not recommended as there is a risk of urethral injury.

    .

11. Aspirate to check for blood.

12. While withdrawing back to the skin, inject ¼ of the local anaesthetic.

13. Insert the needle into the 9 o’clock position. Guide the needle inferiorly to the 6 o’clock position.

14. Aspirate to check for blood.

15. While withdrawing back to the skin, inject ¼ of the local anaesthetic.

16. Wait 5-10 minutes.

17. Dispose of medical waste safely.

18. Record the completion of the procedure in patient notes.

## Troubleshooting

My patient is still feeling pain.

Make sure you wait a full 10 minutes before testing the patient’s sensation. If there is still pain, make sure you injected enough anaesthetic into the entire area. Check the anaesthetic expiry date. Local infection can also reduce the effectiveness of local anaesthetics. Rarely, some patients may be resistant to local anaesthetics.

## Risks

1. Minor pain, bleeding & haematoma

2. Intravascular injection of local anaesthetic

3. Allergy to local anaesthetic

4. Penile ischaemia

5. Local infection

6. Sharps injury to healthcare provider

## References

1. Palinrungi MA, Palinrungi ALR, Christeven R, Faruk M. Penile Ischemia as a Complication of Epinephrine Use in Penile Nerve Block: Truth or Myth?. Res Rep Urol. 2021;13:553-555. Published 2021 Aug 4. doi:10.2147/RRU.S308428

2. Holman JR, Stuessi KA. Adult circumcision. Am Fam Physician. 1999;59(6):1514-1518.

3. World Health Organization. Circumcision Methods for Adolescent Boys and Men. In: Manual for Male Circumcision Under Local Anaesthesia and HIV Prevention Services for Adolescent Boys and Men. 2009.

4. Rosen DA, Broadman LM. Ring Block of the Penis: A Proven Addition to Multimodal Pain Relief for Newborn Circumcision. Pediatrics. 2017;140(6):e20172678; DOI: 10.1542/peds.2017-2678