Epinephrine Injection Associated Scrotal Skin Necrosis
Identifieur interne : 003D28 ( Pmc/Corpus ); précédent : 003D27; suivant : 003D29Epinephrine Injection Associated Scrotal Skin Necrosis
Auteurs : Murat Gul ; Mehmet Kaynar ; Tamer Sekmenli ; Ilhan Ciftci ; Serdar GoktasSource :
- Case Reports in Urology [ 2090-696X ] ; 2015.
Abstract
Male circumcision is among the most frequent surgical interventions throughout history. Although considered as a minor intervention, it may have complications ranging from insignificant to catastrophic. These complications can be attributed to the surgical procedure and anesthesia. In this report we present two cases of scrotal skin necrosis after lidocaine with epinephrine injection using subcutaneous ring block technique prior to circumcision.
Url:
DOI: 10.1155/2015/187831
PubMed: 26185706
PubMed Central: 4491570
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Epinephrine Injection Associated Scrotal Skin Necrosis</title><author><name sortKey="Gul, Murat" sort="Gul, Murat" uniqKey="Gul M" first="Murat" last="Gul">Murat Gul</name><affiliation><nlm:aff id="I1">Department of Urology, Van Training and Research Hospital, 65100 Van, Turkey</nlm:aff></affiliation></author><author><name sortKey="Kaynar, Mehmet" sort="Kaynar, Mehmet" uniqKey="Kaynar M" first="Mehmet" last="Kaynar">Mehmet Kaynar</name><affiliation><nlm:aff id="I2">Department of Urology, Selcuk University School of Medicine, Turkey</nlm:aff></affiliation></author><author><name sortKey="Sekmenli, Tamer" sort="Sekmenli, Tamer" uniqKey="Sekmenli T" first="Tamer" last="Sekmenli">Tamer Sekmenli</name><affiliation><nlm:aff id="I3">Department of Pediatric Surgery, Selcuk University School of Medicine, Turkey</nlm:aff></affiliation></author><author><name sortKey="Ciftci, Ilhan" sort="Ciftci, Ilhan" uniqKey="Ciftci I" first="Ilhan" last="Ciftci">Ilhan Ciftci</name><affiliation><nlm:aff id="I3">Department of Pediatric Surgery, Selcuk University School of Medicine, Turkey</nlm:aff></affiliation></author><author><name sortKey="Goktas, Serdar" sort="Goktas, Serdar" uniqKey="Goktas S" first="Serdar" last="Goktas">Serdar Goktas</name><affiliation><nlm:aff id="I2">Department of Urology, Selcuk University School of Medicine, Turkey</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26185706</idno><idno type="pmc">4491570</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491570</idno><idno type="RBID">PMC:4491570</idno><idno type="doi">10.1155/2015/187831</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">003D28</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">003D28</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Epinephrine Injection Associated Scrotal Skin Necrosis</title><author><name sortKey="Gul, Murat" sort="Gul, Murat" uniqKey="Gul M" first="Murat" last="Gul">Murat Gul</name><affiliation><nlm:aff id="I1">Department of Urology, Van Training and Research Hospital, 65100 Van, Turkey</nlm:aff></affiliation></author><author><name sortKey="Kaynar, Mehmet" sort="Kaynar, Mehmet" uniqKey="Kaynar M" first="Mehmet" last="Kaynar">Mehmet Kaynar</name><affiliation><nlm:aff id="I2">Department of Urology, Selcuk University School of Medicine, Turkey</nlm:aff></affiliation></author><author><name sortKey="Sekmenli, Tamer" sort="Sekmenli, Tamer" uniqKey="Sekmenli T" first="Tamer" last="Sekmenli">Tamer Sekmenli</name><affiliation><nlm:aff id="I3">Department of Pediatric Surgery, Selcuk University School of Medicine, Turkey</nlm:aff></affiliation></author><author><name sortKey="Ciftci, Ilhan" sort="Ciftci, Ilhan" uniqKey="Ciftci I" first="Ilhan" last="Ciftci">Ilhan Ciftci</name><affiliation><nlm:aff id="I3">Department of Pediatric Surgery, Selcuk University School of Medicine, Turkey</nlm:aff></affiliation></author><author><name sortKey="Goktas, Serdar" sort="Goktas, Serdar" uniqKey="Goktas S" first="Serdar" last="Goktas">Serdar Goktas</name><affiliation><nlm:aff id="I2">Department of Urology, Selcuk University School of Medicine, Turkey</nlm:aff></affiliation></author></analytic><series><title level="j">Case Reports in Urology</title><idno type="ISSN">2090-696X</idno><idno type="eISSN">2090-6978</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Male circumcision is among the most frequent surgical interventions throughout history. Although considered as a minor intervention, it may have complications ranging from insignificant to catastrophic. These complications can be attributed to the surgical procedure and anesthesia. In this report we present two cases of scrotal skin necrosis after lidocaine with epinephrine injection using subcutaneous ring block technique prior to circumcision.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Barnes, S" uniqKey="Barnes S">S. Barnes</name></author><author><name sortKey="Ben Chaim, J" uniqKey="Ben Chaim J">J. Ben Chaim</name></author><author><name sortKey="Kessler, A" uniqKey="Kessler A">A. Kessler</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="May, A E" uniqKey="May A">A. E. May</name></author><author><name sortKey="Wandless, J" uniqKey="Wandless J">J. Wandless</name></author><author><name sortKey="James, R H" uniqKey="James R">R. H. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Case Rep Urol</journal-id><journal-id journal-id-type="iso-abbrev">Case Rep Urol</journal-id><journal-id journal-id-type="publisher-id">CRIU</journal-id><journal-title-group><journal-title>Case Reports in Urology</journal-title></journal-title-group><issn pub-type="ppub">2090-696X</issn><issn pub-type="epub">2090-6978</issn><publisher><publisher-name>Hindawi Publishing Corporation</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26185706</article-id><article-id pub-id-type="pmc">4491570</article-id><article-id pub-id-type="doi">10.1155/2015/187831</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Epinephrine Injection Associated Scrotal Skin Necrosis</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Gul</surname><given-names>Murat</given-names></name><xref ref-type="aff" rid="I1"><sup>1</sup></xref><xref ref-type="corresp" rid="cor1"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Kaynar</surname><given-names>Mehmet</given-names></name><xref ref-type="aff" rid="I2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Sekmenli</surname><given-names>Tamer</given-names></name><xref ref-type="aff" rid="I3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Ciftci</surname><given-names>Ilhan</given-names></name><xref ref-type="aff" rid="I3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Goktas</surname><given-names>Serdar</given-names></name><xref ref-type="aff" rid="I2"><sup>2</sup></xref></contrib></contrib-group><aff id="I1"><sup>1</sup>Department of Urology, Van Training and Research Hospital, 65100 Van, Turkey</aff><aff id="I2"><sup>2</sup>Department of Urology, Selcuk University School of Medicine, Turkey</aff><aff id="I3"><sup>3</sup>Department of Pediatric Surgery, Selcuk University School of Medicine, Turkey</aff><author-notes><corresp id="cor1">*Murat Gul: <email>drgulacademics@gmail.com</email></corresp><fn fn-type="other"><p>Academic Editor: Ferdinando Fusco</p></fn></author-notes><pub-date pub-type="ppub"><year>2015</year></pub-date><pub-date pub-type="epub"><day>22</day><month>6</month><year>2015</year></pub-date><volume>2015</volume><elocation-id>187831</elocation-id><history><date date-type="received"><day>14</day><month>4</month><year>2015</year></date><date date-type="accepted"><day>14</day><month>6</month><year>2015</year></date></history><permissions><copyright-statement>Copyright © 2015 Murat Gul et al.</copyright-statement><copyright-year>2015</copyright-year><license xlink:href="https://creativecommons.org/licenses/by/3.0/"><license-p>This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>Male circumcision is among the most frequent surgical interventions throughout history. Although considered as a minor intervention, it may have complications ranging from insignificant to catastrophic. These complications can be attributed to the surgical procedure and anesthesia. In this report we present two cases of scrotal skin necrosis after lidocaine with epinephrine injection using subcutaneous ring block technique prior to circumcision.</p></abstract></article-meta></front><body><sec id="sec1"><title>1. Introduction</title><p>Male circumcision, excising of the foreskin of penis, for traditional, religious, medical, or personal reasons is the most frequently applied surgical procedure in history. Although it can be considered as a minor surgery, it may lead to complications ranging from insignificant to catastrophic [<xref rid="B1" ref-type="bibr">1</xref>]. These complications can be attributed to both surgical procedure and anesthesia.</p><p>Today, circumcision is performed using several local anesthetic techniques such as caudal epidural block [<xref rid="B2" ref-type="bibr">2</xref>], dorsal penile nerve block (DPNB) [<xref rid="B3" ref-type="bibr">3</xref>], subcutaneous ring block (SRB) [<xref rid="B4" ref-type="bibr">4</xref>], and topical anesthesia applications [<xref rid="B5" ref-type="bibr">5</xref>]. We present two cases of scrotal skin necrosis after lidocaine with epinephrine injection using SRB technique prior to circumcision.</p><p>The guardians of both cases reviewed the case report and gave their written consent to the corresponding author for publication of the present report.</p></sec><sec id="sec2"><title>2. Case 1</title><p>A 2-year-old toddler was referred to our clinic with micturition complaints. His physical examination revealed phimosis and immediate circumcision was decided. Blood test was normal (PT, PTT, and INR). Prior to circumcision, local anesthesia was performed with lidocaine 1% containing epinephrine 1 : 200,000 subcutaneously using subcutaneous ring block anesthesia technique by a 27-gauge conventional Tuberculin Syringe. On the 5th postoperative day the patient was brought into the clinic with a crusty wound just below the penoscrotal junction. Conservative wound management was attempted using I.V. antibiotics and anti-inflammatory treatment. Sterile culture from the site of necrosis was obtained (<xref ref-type="fig" rid="fig1">Figure 1(a)</xref>). However, surgical intervention was decided when the site of necrosis enlarged one week later. Under laryngeal mask anesthesia necrotic lesion and tissue were excised and incision closed vertically (<xref ref-type="fig" rid="fig2">Figure 2(a)</xref>). During the control on the 6th postoperative day, it was seen that the patient's wound healed completely without any complication.</p></sec><sec id="sec3"><title>3. Case 2</title><p>A one-year-old toddler was admitted to our clinic with micturition complaints as in case 1 (<xref ref-type="fig" rid="fig1">Figure 1(b)</xref>). His circumcision was made using the same local anesthetic drug and technique. After 4 days patient was brought in with a fallen shell wound just below the penoscrotal junction. In this case, no conservative management was attempted and the second surgery was performed immediately. His wound also healed completely without any complication (<xref ref-type="fig" rid="fig2">Figure 2(b)</xref>).</p></sec><sec id="sec4"><title>4. Discussion</title><p>Circumcision indisputably is worldwide the most frequently performed minor male surgery [<xref rid="B6" ref-type="bibr">6</xref>]. Like any other surgical intervention, circumcision may have complications related to either surgery or anesthesia. These are bleeding, infection, skin bridge, urinary retention, meatitis, chordee, lymphedema, fistulas, and necrosis. Among these, the most common ones are easily handled bleeding and infections. But sometimes serious complications need surgical or reconstructive interventions [<xref rid="B7" ref-type="bibr">7</xref>]. In the relevant departments, within the last five years around 500 circumcisions were performed without major complications.</p><p>Necrosis following circumcision is a rare complication of glans penis due to infection, local anesthesia solutions with epinephrine, tight dressing, and reckless cauter use [<xref rid="B8" ref-type="bibr">8</xref>]. In the present cases skin necrosis developed on 5th and 4th postcircumcision day, respectively. Local anesthesia containing epinephrine is considered to be the underlying reason. There are some contradictory reports about the usage of epinephrine combined with or without lidocaine using SRB technique for circumcision. Epinephrine use for penile block is considered to be contraindicative. Actually a vast number of studies reported penile block without epinephrine [<xref rid="B9" ref-type="bibr">9</xref>]. On the other hand, there are some large series that have reported the safe use of epinephrine [<xref rid="B10" ref-type="bibr">10</xref>, <xref rid="B11" ref-type="bibr">11</xref>].</p><p>More recent studies showed that penis has a more complicated vascular system than earlier considered and less terminal vessels. Hence, epinephrine combined with lidocaine use has been considered as a safe SRB technique prior to circumcision [<xref rid="B9" ref-type="bibr">9</xref>]. Therefore, today epinephrine administration with local anesthetics has regained wide currency. Besides, due to the ease of use and prolonged postoperative pain control local anesthesia combination was preferred in the present cases. Previously, no scrotal skin necroses were experienced.</p><p>Circumcision might be performed with different local analgesic applications than the one described previously. These are topically applied lidocaine-prilocaine cream, dorsal penile nerve bloc (DPNB), and SRB. Yet, there are some reports that topical use of lidocaine-prilocaine and DPNB with prilocaine may lead to methemoglobinemia [<xref rid="B5" ref-type="bibr">5</xref>, <xref rid="B12" ref-type="bibr">12</xref>]. Lidocaine usage on skin may also result in some complications including skin redness, rash, dry skin, blister, contact, and exfoliative dermatitis [<xref rid="B13" ref-type="bibr">13</xref>].</p><p>Normally SRB is defined as a subcutaneous circumferential ring injection of local anesthetic at the mid shaft of penis and SRB with lidocaine was shown to be the most effective anesthetic technique through all stages of the circumcision [<xref rid="B14" ref-type="bibr">14</xref>]. Therefore in our clinics this technique is preferred and applied as in these two cases. To our best knowledge, these are the first scrotal skin necrosis cases developing after local anesthetics' injection for circumcision analgesia. Therefore in the first case a conservative approach was attempted with I.V. antibiotics and anti-inflammatory treatment. However, the site of necrosis enlarged and limited itself but did not show any sign of healing. Eventually necrotic site was removed and complete recovery achieved after second surgery. Our experience with the first case made us avoid conservative treatment attempt and move on with the second surgical intervention.</p></sec><sec id="sec5"><title>5. Conclusion</title><p>Although circumcision using epinephrine is considered as a safe and painless procedure, epinephrine injection associated scrotal skin necrosis of the injection site should not be disregarded. Hence, general anesthesia with caudal blocks for postoperative pain relief can be considered in appropriate cases.</p></sec></body><back><sec><title>Disclosure</title><p>This report was previously presented partially at the 23rd National Urology Congress in 2014.</p></sec><sec sec-type="conflict"><title>Conflict of Interests</title><p>Murat Gul, Mehmet Kaynar, Tamer Sekmenli, Ilhan Ciftci, and Serdar Goktas reported no conflict of interests.</p></sec><sec><title>Authors' Contribution</title><p>Murat Gul, Mehmet Kaynar, Tamer Sekmenli, Ilhan Ciftci, and Serdar Goktas approved the final paper.</p></sec><ref-list><ref id="B1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Barnes</surname><given-names>S.</given-names></name><name><surname>Ben Chaim</surname><given-names>J.</given-names></name><name><surname>Kessler</surname><given-names>A.</given-names></name></person-group><article-title>Postcircumcision necrosis of the glans penis: gray-scale and color Doppler sonographic findings</article-title><source><italic>Journal of Clinical Ultrasound</italic></source><year>2007</year><volume>35</volume><issue>2</issue><fpage>105</fpage><lpage>107</lpage><pub-id pub-id-type="doi">10.1002/jcu.20271</pub-id><pub-id pub-id-type="other">2-s2.0-33846991576</pub-id><pub-id pub-id-type="pmid">17195193</pub-id></element-citation></ref><ref id="B2"><label>2</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>May</surname><given-names>A. 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K.</given-names></name></person-group><source><italic>Meyler's Side Effects of Drugs Used in Anesthesia</italic></source><year>2008</year><publisher-loc>New York, NY, USA</publisher-loc><publisher-name>Elsevier</publisher-name></element-citation></ref><ref id="B14"><label>14</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lander</surname><given-names>J.</given-names></name><name><surname>Brady-Fryer</surname><given-names>B.</given-names></name><name><surname>Metcalfe</surname><given-names>J. B.</given-names></name><name><surname>Nazarali</surname><given-names>S.</given-names></name><name><surname>Muttitt</surname><given-names>S.</given-names></name></person-group><article-title>Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial</article-title><source><italic>Journal of the American Medical Association</italic></source><year>1997</year><volume>278</volume><issue>24</issue><fpage>2157</fpage><lpage>2162</lpage><pub-id pub-id-type="doi">10.1001/jama.1997.03550240047032</pub-id><pub-id pub-id-type="other">2-s2.0-0031469365</pub-id><pub-id pub-id-type="pmid">9417009</pub-id></element-citation></ref></ref-list></back><floats-group><fig id="fig1" orientation="portrait" position="float"><label>Figure 1</label><caption><p>(a) Skin necrosis with a crusty wound just below the penoscrotal junction following lidocaine injection in case 1. (b) Skin necrosis with a fallen shell wound just below the penoscrotal junction following lidocaine injection in case 2.</p></caption><graphic xlink:href="CRIU2015-187831.001"></graphic></fig><fig id="fig2" orientation="portrait" position="float"><label>Figure 2</label><caption><p>(a) Appearances of case 1 and (b) case 2 following second surgery.</p></caption><graphic xlink:href="CRIU2015-187831.002"></graphic></fig></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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