Journal of the American Medical Association, Volume 241, Issue 24: Pages 2635-2636, 15 June 1979.
Clinical Notes
SEXUAL impotence is a distressing problem in any age group. Acquired impotence occurs rarely after massive pelvic trauma but otherwise results from extirpative surgery for a malignant neoplasm. In the young, sexually active male, unexpected impotence is catastrophic. We recently observed two young men, both of whom were rendered impotent apparently by local anesthesia for elective circumcision.
Case 1. -- In November 1976 a 24-year-old man was seen who had a loss of sexual potency since an elective circumcision performed 18 months previously. His erections were normal at the base and the glans but flaccid in the distal part of the shaft and of insufficient quality to allow penetration. There were no abnormalities diagnosed by examination of the phallus. Photographs taken by the patient at the time of sexual excitement were consistent with his description. Findings remainder of the physical examination were normal. Corpus cavernography was obtained, which demonstrated total obstruction to filling at the distal penile shaft bilaterally (Fig 1). Fibrosis and contracture of the distal corpera were surgically confirmed.
Case 2. -- A robust 23-year-old construction worker was first seen in June 1977 for impotence of three months duration. Immediately after elective circumcision, this patient noted a hard painless lump in the distal right penile shaft. This abnormality had remained constant in size despite sitz baths, attempts at needle aspiration, and finally steroid injections. The mass was firm, painless, easily palpable, and about 2 cm in diameter. The patient had been impotent because of incomplete erection since the surgery While the penile base grew normally turgid with sexual excitement and orgasm was unimpaired, the penile shaft distal to this lump was soft and did not support the glans sufficiently for penetration. When erect the penis was noted to deviate to the right side. Penile plethysmography confirmed erectile activity at the base but absence at the distal shaft. A corpus cavernography (Fig 2) showed a rounded filling defect in the midpenile shaft, with impaired filling of both corpora distal to the lesion.
Further questioning of these patients disclosed that an identical surgical technique had been used in each case. Each had subsequently been treated with local injections of steroids, with no effect. Both dated their impotence from the time of the surgical procedure.
Procedure. -- The method was as follows:
A soft rubber tourniquet was firmly applied at the base of the penile shaft. Five milliliters of 1% lidocaine hydrocloride (without epinephrine hydrocloride was injected into the base of each corpus cavernosum just distal to the tourniquet. A routine circumcision was then performed. When the foreskin had been completely excised, the tourniquet was removed, and individual bleeding points were controlled.
The skin margins were then reapproximated, and a soft sterile dressing was applied. The same technique was reported to have been used by this physician in more than 100 cases without complication.
The tourniquet was usually applied only for a matter of minutes, and no prolonged tourniquet application was remembered in either case.
[cavernograph]
[cavernograph]
Lidocaine, which was introduced in 1948, is one of the most widely used synthetic local anesthetics. Package inserts proscribe against use of lidocaine with epinephine in finger blocks or for circumcisions because of reports of skin necrosis. However, thousands of circumcisions must be performed daily under subcoronal local anesthesia without mishap. In these two cases, the lidocaine was injected directly into the corpora distal to a tourniquet, which was left in place for an estimated five- to ten-minute period. The flaccid penis has an estimated vascular volume of 10 to 15 mL, to which 10 mL of 1% lidocaine was added. This resulted in perhaps a 50% mixture of lidocaine and blood that remained in contact with the vascular endothelium for the duration of tourniquet application. It is postulated that this relatively high concentration of lidocaine irreversibly damaged the endothelium of the corpus cavernosum--bilaterally in case 1 and locally in case 2--resulting in obstruction of the corpora and interfering with the normal erectile process. In both cases, corpus cavernography proved a lesion to be present and showed the site and extent of the corporal block. Cavernography was essential in evaluating these two cases and should be considered in all patients with a localized flaccidity on erection.
Although the eventual outcome in each case in unknown, their clinical importance as a complication of this type of regional anesthesia warrants their early presentation.
From the Departments of Urology (Dr. Palmer) and Radiology (Dr. Link), School of Medicine, University of California, Davis.
Reprint requests to Department of Urology, University of California at Davis Medical Center, Suite 249, Sacramento, CA 95817 (Dr. Palmer.)
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