According to Orphanet, the European Rare Disease Database pudendal neuralgia affects 4% of patients presenting for consultation for pelvic pain, of whom 30% are men and 70% are women, mostly aged 50 to 70 years.
The pudendal nerve is a nerve of the sensory, motor and autonomic nervous system that emerges from the sacral roots and then travels to the pelvis, giving off its three terminal branches: the spinal nerve of the penis or clitoris, the inferior rectal nerve and the perineal nerve.
Because of its anatomical path, this nerve can be easily compressed by surrounding structures such as the pelvic ligaments, and it is this compression that causes painful symptoms.
Symptoms of pudendal nerve entrapment syndrome
Intense burning, electric shock, piercing sensation, tingling... these are some of the symptoms reported by patients suffering from Pudendal Nerve Entrapment Syndrome , the onset of which can be sudden and remain constant until periods of remission occur.
The topography of pain is perineal, that is, it affects the most intimate parts of the body, from the penis or clitoris to the anus, although it can spread towards the vulva or scrotum.
El pain it appears or worsens in a sitting position and improves when the patient gets up or lies down. For this reason, to avoid pain , patients sit on structures with holes in the middle (for example, on a float), live upright or lie down.
In 2008, clinical criteria for diagnosis, the so-called Nantes criteria, were published:
- The pain should be located in the area innervated by the pudendal nerve: from the clitoris or penis to the anus.
- The sitting position is painful.
- The patient does not wake up at night due to pain.
- On physical examination, there is no objective loss of perineal sensation.
- Nerve blockade with local anesthetic is positive (reduces or eliminates pain)
In some patients, this condition not only manifests itself as pain in the perineum (the area between the vagina and anus), but may also include urinary, sexual or digestive symptoms. Patients are often diagnosed with pelvic muscle pain, which in turn can cause constipation, difficulty urinating, or pain during intercourse.
Clinical case of diagnosis: postoperative neuropathy of the pudendal nerve
Neuropathy of the pudendal nerve is a disease that is a consequence of the development of compression processes affecting the coccygeal plexus and the nerve itself. As a rule, such a disorder occurs against the background of dystrophic changes in the ligaments and muscles of the pelvis. Pathology develops in both men and women of different ages. Despite the prevalence of this problem, neuropathy is diagnosed extremely rarely. This is due to the fact that only a small percentage of patients pay attention to the symptoms of the disease and seek medical help.
Genital neuropathy can affect various nerve fibers surrounding the genital organs (genital femoral, ilioinguinal nerve).
The main etiological factor provoking pudendal neuropathy is pinching of the pudendal nerve, which occurs in the Alcock canal.
Clinical case
Patient S., 68 years old, was admitted for treatment to the II neurological department on January 11, 2021. with complaints of pain in the glans penis, pain in the rectum during defecation, painful urination, pain in the lumbar region. The above complaints intensify as the patient assumes a vertical position.
From the anamnesis it is known that for many years he has been suffering from osteochondrosis of the lumbosacral spine. In 2006 Surgical removal of a herniated intervertebral disc L4-L5 was performed. In 2008 The patient first noted frequent urination. In 2009 Additional examination revealed a bladder formation, and histological findings revealed urothelial cancer G2 with ulceration and inflammation. In 2009 The patient underwent hemiresection of the bladder with ureteroneocystoanastomosis on the left. In 2012 A TUR of the bladder neck and prostate was performed; repeated histological examination did not reveal tumor cells. Since 2013 and to this day, the patient has developed pain along the urethra with irradiation to the head of the penis, painful urination and defecation. Repeatedly consulted urologists, received antibacterial therapy, M-anticholinergics (Vesicar), alpha-blockers (Omnic) with minimal effect.
In 2015 In several medical institutions, the patient underwent a comprehensive additional examination: MRI of the lumbosacral spine: pronounced degenerative changes, posterior central herniation of the L4-L5 intervertebral disc, spinal canal stenosis at the L2-L4 level. FSC: signs of chronic colitis, hemorrhoids. TRUS of the prostate: ultrasound signs of chronic urethroprostatitis, fibrosis, calcification of the prostate parenchyma and bladder neck. Uroflowmetry: hyperactive bladder with reduced functional elasticity. CT scan of the retroperitoneum: CT scan signs of bladder shrinkage, atherosclerosis of the abdominal aorta. A consultation was held at Rostov State Medical University under the leadership of the head. department Urology Doctor of Medicine prof. Kogan M.I., who came to the conclusion that the cause of persistent pain in the genital area is neuropathy of the pudendal nerve. In order to exclude recurrence of bladder cancer, the patient was offered diagnostic surgery, which the patient refused.
Considering the persistence of the above complaints, the patient was routinely hospitalized in Clinical Hospital No. 1 for examination and treatment.
Neurological status at the time of admission: Conscious, alert, oriented. The background mood is reduced. Fixed on his feelings. There are no meningeal signs. CMN: Palpebral fissures D=S. Pupils D=S. Photoreactions are live. Movement of the eyeballs is not limited. There are no sensory disturbances on the face. The exit points of the trigeminal nerve are painless. The face is symmetrical. There is no nystagmus. The pharyngeal reflex is preserved. Swallowing and phonation are not impaired. Tongue in the midline. There are no paresis. Tendon reflexes are low, from the hands, knees S=D, the Achilles reflex on the right is reduced. No pathological foot signs are detected. Moderate defence of the lumbar muscles on both sides. Paravertebral points and spinous processes in the lumbar region are moderately painful. No clear sensitivity disorders are detected (including in the perineal area). Stable in the Romberg position. PNP performs satisfactorily on both sides.
A clinical diagnosis was made: Chronic pelvic pain syndrome: postoperative neuropathy of the pudendal nerve.
The patient was consulted by a urologist and oncologist: at present there is no data on the progression of the oncological process, given the long relapse-free period, FTL is not contraindicated.
The patient received drug treatment, including anticonvulsants (Neurontin), antidepressants (Paxil), muscle relaxants (Sirdalud), vascular drugs (Trental), non-steroidal anti-inflammatory drugs (Arcoxia), metabolic drugs (Kombilipen injections), pain-relieving droppers, including antispasmodics, sedatives, corticosteroids, local anesthetics. Physiotherapeutic methods of treatment, acupuncture, and physical therapy were also included in the complex therapy.
After treatment, the patient's condition improved. The neurological status showed positive dynamics: the paravertebral points and spinous processes in the lumbar region are painless, the lumbar muscle defense has regressed, and the pain syndrome has been relieved. The frequency, intensity and duration of attacks of pain in the area of the glans penis have decreased, and the mood has stabilized.
The patient was discharged home in satisfactory condition with recommendations for outpatient antidepressant, anticonvulsant, and anti-inflammatory therapy for 2 months.
INTRODUCTION
Pineal block during circumcision has gained great popularity due to its ease of implementation and relative safety. The complication rate for this procedure is about 0.18%. Reported complications include urethral trauma, accidental administration of the wrong drug, ischemia and necrosis of the glans penis [1, 2]. The exact etiology of ischemia and necrosis remains unclear in most cases. However, possible causes have been described including spasm of the veins or arteries of the glans penis, thrombosis or hematoma at the injection site, and perforation of a vein or artery leading to endothelial damage and delayed necrosis. Due to the low incidence of such complications, there is no single standardized approach to the treatment of this pathology.
CLINICAL CASE DESCRIPTION
We present a description of a clinical case of a 12-year-old boy, without a burdened medical history, with cicatricial phimosis, who was treated in the surgical department of the Scientific and Practical Center for Specialized Medical Care for Children named after. V.F. Voino-Yasenetsky.
The child was admitted for planned surgical treatment. On physical examination, cicatricial changes in the foreskin were noted with the impossibility of removing the glans penis. Urination is not impaired. Immediately before the operation, a dorsal pineal block was performed with a solution of naropin 0.2%, volume 20 ml, without the use of adrenaline under ultrasound guidance. During the surgical intervention, classical circumcision of the foreskin was performed using monopolar electrocoagulation with a power of 12 W. 8 interrupted Vicril 4/0 sutures were applied. There were no intraoperative changes in the glans and skin of the penis. The postoperative area was treated with betadine solution; a circular bandage was not applied.
In the early postoperative period, diapedetic bleeding was noted; a gauze bandage was applied in the dressing room. When examined 2 hours after the operation, the child had no complaints, urination was not impaired, and the head of the penis was pink. 12 hours after the operation, a change in the color of the glans penis was noted with the appearance of multiple dark-colored areas, without priapism (Fig. 1).
Rice. 1. Initial image of the patient’s penis with pronounced signs of edema and ischemia of the glans 1. The original image of the patient's penis with pronounced signs of edema and ischemia of the head
The patient's general condition was not affected; urination was spontaneous and moderately painful. In order to exclude thrombosis of the deep veins of the penis, the child underwent an ultrasound examination of the penis - no pathological changes were detected. The coagulogram showed no signs of blood coagulation disorders.
In order to relieve microcirculatory disorders, the patient was prescribed therapy aimed at improving the rheological properties of blood (pentoxifylline, actovegin, heparin), antibacterial therapy (ceftriaxone), symptomatic treatment, as well as local treatment (heparin ointment) [3].
Therapy was carried out against the background of daily monitoring of activated partial thromboplastin time (aPTT) and prothrombin.
Foreign literature indicates that to prevent possible urethral stenosis after circumcision, it is necessary to install a urethral catheter, as well as remove sutures along the dorsal surface of the penis [4]. In this clinical case, these recommendations were not applied due to the patient’s free urination with a wide stream, as well as the absence of ischemic lesions of the skin of the penis.
On the third postoperative day, against the background of the therapy, positive dynamics were noted, characterized by the appearance of light pink areas on the head (Fig. 2).
Rice. 2. Penis on the third postoperative day 2. Penis on the third postoperative day
The patient was discharged on the 5th postoperative day without complications, with complete restoration of blood supply to the head (Fig. 3).
Rice. 3. Penis on the fifth postoperative day, hemodynamic disturbances have been eliminated 3. Penis on the fifth postoperative day, hemodynamic disorders were eliminated
After a course of conservative therapy, local signs of ischemia associated with surgery were relieved without side effects.
DISCUSSION
The standard for choosing a treatment method for ischemia and necrosis of the glans penis after circumcision has not yet been established. We have not found any analysis of such clinical cases in children in the domestic literature. A number of foreign colleagues have reported several methods of therapy that have been used with successful results. The ultimate goal of all these studies was vasodilation to increase arterial inflow and improve venous outflow, allowing revascularization of ischemic urethral tissue. So, A.V. Aminsharifi described two cases of necrotic changes in the glans penis after circumcision. Patients were treated conservatively with 10% testosterone cream for 4 weeks. After completion of the course of therapy, complications were noted in the form of urethral detachment and the formation of hypospadias. The dimensions of the head remained the same, which can be regarded as a positive result [2]. In 2000, D. Burke analyzed a case of glans ischemia after pineal dorsal blockade with a 0.75% ropivacaine solution; the patient's condition returned to normal within 43 hours as a result of intravenous infusion of the drug Iloprost [5]. L. Elemen and A. Aslan described a severe case of glans ischemia in an 11-year-old boy that occurred 24 hours after circumcision of the foreskin of the penis without the use of a dorsal block. Pentoxifylline was chosen as the drug to relieve hemodynamic disorders and was used for 5 days. No complications were noted after the treatment [6, 7]. In the world literature, it is also proposed to use hyperbaric therapy, antiplatelet drugs, corticosteroids and epidural anesthesia with bladder catheterization in therapy [8-16].
CONCLUSIONS
Surgeons and urologists should always conduct an examination and dynamic monitoring of patients after circumcision in the early postoperative period, assessing the condition of the penis, and determining the presence of microcirculatory disorders of the glans penis. Therefore, significant postoperative pain or any signs of possible vascular injury during a pineal block should alert staff to potential ischemic injury. And knowledge of the topography of the vascular bed and innervation of the penis will minimize the percentage of possible complications.
LITERATURE
- Sara CA, Lowry CJ. A complication of circumcision and dorsal nerve block of the penis. Anaesth Intensive Care 1985(13):79-82.
- Aminsharifi A, Afsar F, Tourchi A. Delayed glans necrosis after circumcision: Role of testosterone in salvaging glans. Indian J Pediatr 2013(80):791-3.
- Ward A, Clissold SP: Pentoxifylline. A review of its pharmacodynamic and pharmacokinetic properties, and its therapeutic efficacy. Drugs 1987(34):50-97.
- Pepe P, Pietropaolo F, Candiano G, Pennisi M: Ischemia of the glans penis following circumcision: case report and revision of the literature. Arch Ital Urol Androl 2015(87):93–94.
- Burke D, Joypaul V, Thomson MF. Circumcision supplemented by dorsal penile nerve block with 0.75% ropivacaine: A complication. Reg Anesth Pain Med 2000(25)424-7.
- Elemen L, Topçu K, Gürcan Nİ, Akay A. Successful treatment of post circumcision glanular ischemia-necrosis with hyperbaric oxygen and intravenous pentoxifylline. Actas Urol Esp 2012(36):200-1.
- Aslan A, Karagüzel G, Melikoglu M. Severe ischemia of the glans penis following circumcision: A successful treatment via pentoxifylline. Int J Urol 2005(12):705-1.
- Efe E, Resim S, Bulut BB, Eren M, Garipardic M, Ozkan F, Ozkan KU: Successful treatment with enoxaparin of glans ischemia due to local anesthesia after circumcision. Pediatrics 2013(131):e608–e611.
- Kaplanian S, Chambers NA, Forsyth I: Caudal anaesthesia as a treatment for penile ischaemia following circumcision. Anaesthesia 2007(62):741-743.
- Sterenberg N, Golan J, Ben-Hur N: Necrosis of the glans penis following neonatal circumcision. Plast Reconstr Surg 1981;68:237-239.
- Thom SR: Hyperbaric oxygen: its mechanisms and efficacy. Plast Reconstr Surg 2011;127(suppl 1):131S-141S.
- Nemiroff PM: Synergistic effects of pentoxifylline and hyperbaric oxygen on skin flaps. Arch Otolaryngol Head Neck Surg 1988(114):977-981.
- Tzeng YS, Tang SH, Meng E, Lin TF, Sun GH: Ischemic glans penis after circumcision. Asian J Androl 2004(6):161-163.
- Miernik A, Hager S, Frankenschmidt A: Complete removal of the foreskin – why? Urol Int 2011(86):383-387.
- Krill AJ, Palmer LS, Palmer JS: Complications of circumcision. ScientificWorld J 2011(11):2458-2468.
- Migliorini F, Bianconi F, Bizzotto L, Porcaro AB, Artibani W,: Acute Ischemia of the Glans Penis after Circumcision Treated with Hyperbaric Therapy and Pentoxifylline: Case Report and Revision of the Literature. Urol Int 2018;100(3):361-363. https://doi.org/10.1159/000444399
| Attached file | Size |
| 473.84 kb |
Complications of microsurgical denervation of the penis.
Like any surgical intervention, denervation of the head can be accompanied by complications, the likelihood of which is lower the more experienced the surgeon performs it. The abundance of vessels in close proximity to the crossed nerves creates some risk of their damage with the formation of hematomas and impaired blood supply to the glans penis.
The use of optical magnification and microsurgical instruments allows me to completely eliminate such unpleasant problems. To prevent infectious and inflammatory complications, such as suppuration of a postoperative wound, I use the most modern sterilization methods , in particular, using low-temperature plasma.
The data available in the literature (including on the Internet) about the deterioration of erection after denervation, in my opinion, are associated with the technical features of performing this operation by various surgeons. The denervation technique I use (based on the experience of more than 200 operations performed) has proven itself to be extremely safe and effective.
I have been performing microsurgical denervation of the glans penis for more than 10 years, in most cases, on an outpatient basis, without hospitalization. Within 3 weeks, after the wound has completely healed, you can resume sexual activity. Next, as they say, feel the difference!
Technique of microsurgical denervation of the glans penis.
Of course, I will not reveal here all the nuances and details of this operation, on which its effect largely depends. I will describe only the main basic stages.
In most cases, denervation is performed under local anesthesia (I use the double penile block technique), although, if the patient wishes, the operation can be performed “in sleep”.
Through a small skin incision near the head of the penis, the tissue is gradually dissected to the tunica albuginea of the penis, where the branches of the dorsal nerves of the penis are located, surrounded by vessels of the same name (neurovascular bundle).
Next, an extremely careful selection of nerve fibers from this bundle is carried out, followed by their intersection. At this important stage, it is important not to damage the arteries and veins running next to the nerves, which provide blood supply to the head of the penis.
To achieve maximum efficiency, it is possible not just to intersect the nerves, but to excise a small section of the nerve fiber, which slows down the process of fusion and restoration of sensitivity.
The previously used technique of suturing the crossed ends of nerves is now practically not used, since it has been shown that nerve fibers already tend to grow together. After a thorough inspection and intersection of all accessible nerve branches, the wound is sutured layer-by-layer using synthetic self-absorbing suture material. The operation ends with the application of a circular aseptic dressing.
How it works?
The essence of the operation of microsurgical denervation of the glans penis is the intersection of the nerves that provide sensitivity to the glans. Due to this, a significant decrease in sensitivity is achieved and, accordingly, an increase in the duration of sexual intercourse.
Over time, according to the laws of physiology, nerve fibers grow together, and sensitivity is gradually restored. This period takes from 6 to 10 months or more. During this time, provided that sexual activity is fairly regular, the reflex is “reprogrammed” for longer sexual intercourse, which then persists for life.
As you can see, glans denervation is a surprisingly logical and therefore effective operation.
METHOD OF NERVE BLOCK DURING UROLOGICAL SURGERY
18.09.13
EQUIPMENT AND DRUGS
When performing a nerve block, the following accessories are required: 1) an endotracheal tube to combat airway obstruction; 2) a breathing bag and a mask for artificial respiration; 3) a device for measuring blood pressure and pulse; 4) cardiopulmonary resuscitation kit; 5) diazepam 2.5 mg and phenobarbital solution for intravenous administration in case of seizures; 6) antihistamines in case of mild allergic reactions and adrenaline in case of severe ones; 7) 5-30 mg of ephedrine in case of hypotension due to suppression of cardiovascular activity, while the lower extremities are placed in an elevated position and fluids are administered intravenously. Monitor blood pressure and, if possible, record an ECG. It is also advisable to monitor skin color, pulse, breathing and sweating.
LOCAL ANESTHESIA
A water-oil emulsion (1:1) of lidocaine and prilocaine hydrochloride can be used as a local anesthetic cream. For example, the emulsion is applied to the skin and mucous membrane before meatotomy and separation of the labia fusion (1 hour before).
INTERCOSTAL BLOCK
Fig.1. Anatomical relationships
Anatomical relationships. The intercostal nerves pass under the corresponding rib outside the internal pectoral fascia. After passing the angle of the rib, the nerve is directed in the costal groove between the external and internal intercostal muscles, located below the intercostal artery and vein. Technique. The patient is placed on his side, the hand on the side of anesthesia is placed behind the head. The lower edge of the rib is palpated immediately after the costal angle. Insert a thin needle vertically until it rests on the lower half of the rib. With your free hand, pull the skin along with the inserted needle down until you feel that the end of the needle is slipping off the rib. Draw the needle another 3 mm until you feel a click. Then the needle is directed upward 2-3 cm under the lower edge of the rib. Pull back the syringe plunger to prevent the needle from entering the vessel or pleural cavity. 5 ml of anesthetic is administered, preferably a 0.5% solution of bupivacaine with adrenaline. If the rib is difficult to palpate or if the needle is inserted too deeply, a pneumothorax may occur, even a tension pneumothorax.
PENIS NERVE BLOCK
Blockade of the nerves of the penis is used during operations on it. The block also prevents the erection that occurs with general anesthesia (Seftel et al., 1994).
Fig.2. The right and left dorsal nerves of the penis arise from the pudendal nerve
The right and left dorsal nerves of the penis arise from the pudendal nerve, pass under the pubic symphysis, penetrate the suspensory ligament of the penis and are located under the deep fascia (Buck's fascia). Technique. The pubic symphysis is palpated. A short 22-gauge needle is inserted on one side of the midline at the 10 o'clock position until the lower edge of the symphysis is reached. The needle is pulled back and passed under it. Buck's fascia is pierced. After a control retraction of the piston, 10 ml of a 1% lidocaine solution is injected. The solution is administered in a similar manner for 2 hours.
BLOCK OF THE ILIOHINGUINAL, ILIOHYPOGASTIC, GENITAL FEMOROMAL NERVES FOR ORCHIPEXY AND HERNIA REPAIR
Typically, patients over 16 years of age are selected. The patient should not take food or liquid for 12 hours before surgery. It is advisable to shave the surgical field and administer the drug in the preoperative room so that it has time to take effect.
Fig.3. Anatomical relationships
Anatomical relationships. The iliohypogastric nerve arises from the THC and Lt segments and exits through the transversus abdominis muscle medial to the anterior superior iliac spine. The ilioinguinal nerve originates from the Lb segment, runs slightly lower and parallel to the iliohypogastric nerve and is directed between the external and internal oblique abdominal muscles. The genital femoral nerve originates from the Lt and Ln segments, passes along the surface of the psoas major muscle and, above the inguinal ligament, divides into the genital and femoral branches. The genital branch enters the inguinal canal behind the spermatic cord. For intracorporeal blockade of the penis, a tourniquet is applied to its base, and 20-25 ml of a 1% lidocaine solution is injected into the corpus cavernosum using a venous butterfly needle. After 1 minute, the tourniquet is removed.
Fig.4. Before blockade of the iliohypogastric and ilioinguinal nerves during surgery
Technique. Before blocking the iliohypogastric and ilioinguinal nerves during operations on the scrotum, the anterior superior iliac spine is palpated, a point located 2.5-3 cm more medial and 2-3 cm below it is noted. Using a 22-gauge needle 4 cm long, held until it touches the inner surface of the ilium, 5-7 ml of a 1% solution of bupivacaine (or a mixture of equal parts of 0.5% bupivacaine and 1% lidocaine) is injected. The solution is continued to be injected while the needle is pulled out. The injection is repeated more medially, injecting 5-7 ml of solution under the fascia of the 3 muscle layers. To block the genitofemoral nerve, the pubic tubercle is palpated as a landmark and 5-7 ml of anesthetic solution is injected into the muscles lateral, medial and cranial from it. Additionally, the subcutaneous tissue is infiltrated laterally to the inguinal fold and medially to the midline to anesthetize the skin innervated by the pudendal nerve and perineal branches of the posterior cutaneous nerve of the thigh. Alternatively, a hypogastric and ilioinguinal nerve block can be performed by injecting 0.5% bupivacaine at the level of the iliac crest using an 8-cm 22-gauge lumbar puncture needle. 10 ml of anesthetic is injected into the area of the internal inguinal ring at a point located 2 cm medial and 2 cm caudal to the anterosuperior iliac spine. The aponeurosis of the external oblique abdominal muscle is pierced with a needle (which is felt as a click), and the syringe plunger is pulled back to make sure that the needle does not enter the vessel. Half of the solution is injected above the aponeurosis, the other half - under the aponeurosis.
TESTICAL NERVE BLOCK
To block the nerves of the testicle, you need to stand to the right of the patient. The testicle is pulled down to relax the levator muscle. The spermatic cord is grasped with the left hand, placing the thumb in front and the index finger in the back at the base of the scrotum. The spermatic cord is infiltrated with a 1% lidocaine solution without adrenaline using a 25-gauge needle 5 cm long, which is advanced towards the index finger. Alternatively, the spermatic cord is infiltrated above the pubic symphysis as it exits the external inguinal ring.
PENAL NERVE BLOCK
Fig.5. The pudendal nerve emerges from segments SII, SIII, Sff, passes laterally
Anatomical relationships. The pudendal nerve emerges from segments SII, SIII, Sff, passes lateral and dorsal to the ischial spine and sacrospinous ligament and divides into the inferior rectal and perineal nerves. The pudendal nerve block should be performed at the level of the ischial spine.
Fig.6. The patient is positioned as for lithotomy, the index finger is inserted into the rectum
Technique. The patient is positioned as for lithotomy, the index finger is inserted into the rectum and the ischial spine is palpated. A nodule is made on the skin 2-3 cm posterior and medial to the ischial tuberosity. A 20-gauge needle, 12 to 15 cm long, with a 10-mL syringe is inserted posterolaterally to pierce the sacrospinous ligament. The position of the end of the needle and its contact with the ischial tuberosity are controlled with the index finger. Pull back the syringe plunger and, making sure that the needle is not in the lumen of the vessel, inject 5-10 ml of local anesthetic laterally and under the ischial tuberosity to block the lower branch of the pudendal nerve. Then the needle is advanced medial to the ischial tuberosity and 10 ml of local anesthetic is injected. Next, the needle is advanced 2-3 cm into the ischiorectal fossa and 10 ml of anesthetic is injected, after which the needle is directed back and laterally to the ischial tuberosity, the ischiospinous ligament is pierced and, making sure that the needle is not in the vessel, 5-10 ml is injected anesthetic. The blockade is performed in the same way on the other side.
TRANSSACRAL BLOCK
Fig.7. In the space between the two layers lining the sacral canal
Anatomical relationships. In the space between the two layers lining the sacral canal there is richly vascularized adipose tissue. This space is a continuation of the lumbar epidural; it contains the posterior branches of the sacral nerves, which emerge from the posterior sacral foramina and innervate the buttocks, and the anterior branches, emerging from the anterior sacral foramina and innervating the perineum and partly the legs. Technique (see the section on implantation of a bladder electrical stimulator). After premedication, the patient is placed on his stomach, with a pillow placed under the pelvis. Both posterior superior iliac spines are palpated and marked. From a point 1.5 cm more medial and 1.5 cm more cranial than the one that corresponds to the location of the 1st sacral foramen, draw a line along the outer edge of the intermediate sacral crest. The remaining 3 sacral foramina are located along this line with an interval of 2 cm from the 1st foramen.
Fig.8. After premedication, the patient is placed on his stomach
An anesthetic is injected subcutaneously until a nodule forms. Using a 22-gauge 12 cm long lumbar puncture needle with a mandrel, the skin is pierced perpendicular to the surface until it comes into contact with the edge of the selected hole. The rubber mark on the needle is removed from the skin by 1.5 cm. The needle is slightly pulled back and inserted at an angle of 45° caudally and medially so that it penetrates the hole to the level of the rubber mark to a depth of 1.5 cm. 1.5-2 ml of local anesthetic. For complete caudal anesthesia, 15-25 ml is injected. Possible complications include injection of anesthetic into the subarachnoid space or into a large venous plexus.
Ultrasound-guided prostate nerve block (Nash-Shinohara)
Fig.9. Neurovascular bundles penetrate the prostate gland in the posterior section
Anatomical relationships. Neurovascular bundles penetrate the prostate gland in the posterior part of its base at points approximately corresponding to 5 and 7 o'clock on the dial. Technique. The patient is placed on his side. Prepare a 10-milliliter syringe with a 22-gauge lumbar puncture needle, 16 cm long. Draw up a solution consisting of equal parts (50:50) of 1% lidocaine solution and 0.5% bupivacaine solution. Under two-dimensional ultrasound control with a rectal sensor, an anesthetic solution is injected into the area of the neurovascular bundle at the base of the prostate gland, lateral to its junction with the seminal vesicles on each side.
Commentary by W. McKay
This concise and easy-to-read section provides information that is difficult to find in any one book. In most manuals, the sections on nerve blocks generally do not address the anatomy of the genitourinary system. It is becoming increasingly clear that conduction anesthesia not only allows surgery to be performed, but also relieves post-operative pain for a long time. There is more and more evidence that patients who have undergone surgery under general anesthesia are much more able to tolerate pain after repeated operations. This may be due to the suppression of structures in the dorsal horns of the spinal cord, which are activated by pain impulses and “remember” pain. I am increasingly convinced that patients who underwent surgery under general anesthesia tolerate the postoperative period more easily and experience less discomfort than those operated on under general anesthesia. This is also confirmed by literature data. I would like to add one more point to what has been said about conduction anesthesia. You will strengthen the patient's trust in you and increase the chances of a successful nerve block if you give the first injection painlessly. To do this, I use the smallest gauge needles, such as 27 or 30 gauge, and also change the pH of the solution depending on the local anesthetic. So, when using lidocaine, I add 1 ml of sodium bicarbonate to 10 ml of anesthetic solution (at the rate of 1 mmol per 1 ml). This should not be done when choosing bupivacaine, as it precipitates when sodium bicarbonate is added. In this case, you can first use an alkaline solution of lidocaine for infiltration, and then perform a block with bupivacaine.