Glycerol Trinitrate Plus Epidural Sympathetic Block in the Ischemia of Glans Penis

Abstract

Circumcision, the oldest and most prevalent surgical procedure in boys, is performed throughout the world for ritual, traditional, or medical reasons. Although circumcision is a minor procedure, the incidence of complications ranges from 1.5% to 5% (1). An 11-yr-old boy who had circumcision 3 days ago was admitted to our hospital complaining of color change and tenderness in his glans penis. Pediatric surgeons determined penile edema and a necrotic appearance and removed surgical sutures to rule out technical problems. Then, the patient was transported to the operating room, and general anesthesia was administered for further examination and pain management. Dorsal penile nerve block was performed with 3 mL of 0.25% bupivacaine solution. Simultaneously, glycerol trinitrate (3 mg/kg, 2 mL) was administered to the cavernous body of the penis to improve postarteriolar smooth muscle relaxation (2). Because little improvement in the necrotic area was observed, continuous epidural sympathetic block was performed with the aim of improving the circulation of the glans. Bupivacaine 0.0625% was administered epidurally for 5 days, and Rheomacrodex infusion 0.3 mL · kg−1 · h−1 was administered for 6 days. Healing started by the third day, and the patient was discharged with full recovery on the seventh day. Pediatric surgeons excluded surgical complications; therefore, this event was considered to be an anesthetic complication. A general practitioner performed the procedure in a private medical center. He stated that for infiltration anesthesia he used a local anesthetic prepared by a nurse, and he thought it was free from vasoconstrictor. However, in all probability, a local anesthetic containing vasoconstrictor was used. In this case, the possibility of glans amputation caused aggressive therapeutic management. Berens and Pontus (3) reported a case that was successfully treated with caudal sympathetic block. Obviously, the local anesthetics used for circumcision should not contain vasoconstrictor. Deniz Özzeybek MD Uğur Koca MD Zahide Elar MD Mustafa Olguner MD Gülce Hakgüder MD