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Local Anesthetics

Local anesthetics are among the most versatile drug classes in urology, with applications spanning twelve domains that together touch essentially every facet of functional and reconstructive practice: (1) intraurethral anesthesia for cystoscopy, catheterization, and urethral procedures; (2) periprostatic nerve block for prostate biopsy; (3) intravesical instillation for IC/BPS; (4) penile nerve block for circumcision and penile surgery; (5) vasectomy anesthesia; (6) topical treatment of premature ejaculation; (7) vulvodynia / vestibulodynia management; (8) pudendal nerve block and pelvic-floor trigger-point injection for pelvic pain; (9) transversus abdominis plane (TAP) block and wound infiltration for perioperative analgesia; (10) retrograde ureteral stent placement under local anesthesia; (11) urodynamic testing; and (12) hydrodistension for IC/BPS under local anesthesia.[1][2][3] Lidocaine is the dominant agent, but bupivacaine, ropivacaine, prilocaine, and levobupivacaine each occupy specific urologic niches.

For related classes, see Topical compounded agents, NSAIDs and analgesics, Gabapentinoids, and Tricyclic antidepressants.

Agents at a glance​

The principal agents in the table are amide-type local anesthetics (tetracaine and oxybuprocaine, mentioned below, are esters); they bind the α-subunit of voltage-gated sodium channels from the axoplasmic side, blocking action-potential generation in sensory nerve endings. Onset tracks with pKa (more un-ionized drug at physiologic pH = faster membrane penetration); duration tracks with protein binding and lipid solubility.[2][3][4]

AgentOnsetDurationRelative potencyDose boundaryPrimary urologic role
Lidocaine3–5 min1–2 h1×Injection and urethral-jelly limits differ; see safety sectionUrethral jelly, PNB, intravesical, wound infiltration, pelvic-floor trigger points[2]
Bupivacaine5–10 min4–8 h4×Product-, route- and patient-specificPeriprostatic block, pudendal block, TAP block, wound infiltration[60]
Ropivacaine (S-enantiomer)5–10 min4–8 h3×Infiltration and major-block ranges differTAP block, wound infiltration, analgesic-eluting catheters; less cardiotoxic than bupivacaine[3][5][6]
PrilocaineRapid1–2 h1×Follow the topical product’s amount/site limitsEMLA (with lidocaine); PE spray (Fortacin)[63]
Levobupivacaine (S-enantiomer)IntermediateLong~4×Product-, route- and patient-specificIntravesical instillation for cystoscopy[7]

Three practical principles carry across the applications below:

  • Alkalinization is the pharmacologic rationale for buffered lidocaine. Adding sodium bicarbonate raises pH and the un-ionized fraction, which should improve membrane and urothelial penetration (and systemic absorption). For IC/BPS, a 102-patient randomized trial compared alkalinized lidocaine alone with placebo, and an 18-completer crossover trial compared alkalinized lidocaine plus heparin with placebo; neither compared buffered with plain lidocaine.[8][9][79]
  • Ropivacaine may offer a pharmacologic safety margin over bupivacaine, but both can cause LAST. Choice and dose depend on the block, patient and cumulative exposure.[5][6]
  • Penile epinephrine requires a specific risk assessment. A 95-patient series attributed no complications to its anesthetic, although small-area skin necrosis occurred in 13%.[10]

Intraurethral anesthesia — cystoscopy and catheterization​

Intraurethral cocaine in 1884 was the first local anesthetic used in urology and arguably launched the specialty as an outpatient discipline.[1]

Lidocaine HCl jelly 2% is FDA-approved for prevention and control of pain in procedures involving the male and female urethra and for topical treatment of painful urethritis.[2]

Dosing (FDA label)[2]​

ApplicationDose
Male urethra — pre-cystoscopy~15 mL instilled until tension → penile clamp at corona → additional 15 mL if needed (up to 30 mL / 600 mg total); clamp 5–10 min before scope entry
Female urethra3–5 mL (60–100 mg)
Catheterization5–10 mL (100–200 mg)
Maximum in 12 h600 mg

Evidence in flexible cystoscopy — statistically real, clinically modest​

  • Raskolnikov 2019 (systematic review and meta-analysis, 12 RCTs, n = 1,549 men). Intraurethral lidocaine versus plain lubricant: SMD −0.22 (95% CI −0.39 to −0.05), pooling 10-point VAS measurements; SMD is a standardized effect, not a 0.22-point VAS difference; effect greater with longer dwell time[11]
  • Aaronson 2009 (meta-analysis, 4 RCTs, n = 411 men). The odds of avoiding moderate-to-severe pain were higher with lidocaine gel than with plain lubricant (OR 1.7; 95% CI 1.1–2.8).[12]
  • Desai 2025 prospective multi-site pilot (n = 190). Lidocaine dwell time ≤10 versus >10 min was not associated with measured pain or anxiety; visualization was associated with lower pain and anxiety than music, while the combined group most often reported no-to-mild pain.[13]
  • Desai 2025 expert review (53 RCTs synthesized). No single intervention eliminates cystoscopy discomfort; multimodal approaches (irrigation pressure, music, visualization, intraurethral lidocaine) provide the best outcomes[14]

Alternative regimens for cystoscopy​

  • Intracavitary levobupivacaine (Pehlivanoğlu 2021 RCT; 100 patients undergoing rigid surveillance cystoscopy after TURBT, 20 per arm): 20–50 mg diluted to 30 mL produced lower VAS than the trial’s 25-mg lidocaine-gel comparator, with higher satisfaction and no reported drug-related side effects.[7]
  • Tetracaine jelly plus IV anesthesia (Bai 2025 RCT, n = 60). Reduced propofol requirements, shortened procedure time, and improved postoperative oxygenation versus IV anesthesia alone[15]
  • Oxybuprocaine gel (Dong 2022 RCT, n = 192) reduced male-catheterization pain versus liquid paraffin (VAS 32 versus 39 mm; p < 0.05)[16]
  • Ropivacaine-eluting catheter (Jung 2025 RCT, 60 women randomized; 58 analyzed after urologic or gynecologic surgery): catheter-related bladder discomfort at 24 h was 65.0% with saline control (20 patients), 36.8% with 0.5% ropivacaine at 1 mL/h (19), and 21.1% at 2 mL/h (19); p = 0.018 for the overall three-arm comparison. The trial excluded bladder and urethral operations, and no catheter- or drug-related adverse events were reported during the 24-h assessment.[17]
  • Ropivacaine-eluting catheter in men (Lee 2025 multicenter RCT, n = 136): catheter-related bladder discomfort at 24 h was 44.4% with saline, 19.6% with 0.5% ropivacaine at 1 mL/h, and 11.1% at 2 mL/h (p = 0.001); the catheter was used for up to 48 h after urologic surgery.[80]
  • Pediatric catheterization (Poonai 2015 RCT, n = 133).[18] Intraurethral lidocaine did not reduce pain in children 0–24 months versus non-anesthetic lubricant, and caused significantly more pain during instillation.[18]

Urodynamics​

  • Özel 2018 RCT in women. Compared with water-based lubricant, 2% lidocaine gel reduced pain during cotton-tipped swab testing (1.3 versus 3.6) and urodynamic catheter placement (1.4 versus 3.9; both p < 0.001).[19]

Local anesthesia for office intradetrusor onabotulinumtoxinA injection​

In women with overactive bladder undergoing office injections, a 2025 crossover RCT found lower procedural pain with alkalinized intravesical lidocaine than saline (41 analyzed; mean 100-mm VAS 21.3 versus 41.6 mm).[75] A second 2025 RCT found no statistically significant difference between buffered and plain lidocaine (73 analyzed; median VAS 16 versus 25 mm, p = 0.21) and was underpowered to detect the observed difference.[76] Across four randomized comparisons, protocol results vary: among 116 patients with idiopathic, neurogenic or bladder-pain indications, buffered lidocaine reduced immediate postinjection pain versus plain lidocaine (2.37 versus 4.44/10), whereas among 54 analyzed patients, buffered solution and lidocaine gel produced similar injection pain (17.11 versus 19.53/100 mm).[75][76][81][82] See intradetrusor botulinum toxin injection for the procedural sequence.

Periprostatic nerve block — prostate biopsy​

Current EAU 2026 guidance strongly recommends transperineal prostate biopsy for its lower infectious risk and antibiotic stewardship. It recommends ultrasound-guided periprostatic block; for transperineal biopsy under local anesthesia, it describes approximately 20 mL of lidocaine or bupivacaine, with or without epinephrine, infiltrated into perineal skin and subcutaneous tissue before transperineal periprostatic block. One cited RCT reported lower procedural pain with a perineal nerve block than conventional periprostatic block (2.80 versus 3.98 on a 1–10 scale). Intrarectal cream alone is inferior to periprostatic injection.[66] Calculate the combined local-anesthetic dose.[66]

Network meta-analysis (Kim 2019, 47 RCTs) ranked methods for TRUS-guided biopsy; PNB means periprostatic nerve block, PPB pelvic plexus block, IRLA intrarectal local anesthetic and IPLA intraprostatic local anesthetic:[20]

  1. PNB plus IV sedation (highest network rank, with additional monitoring requirements)
  2. Spinal anesthesia
  3. PPB plus intrarectal local anesthetic (IRLA)
  4. PNB plus intraprostatic local anesthetic (IPLA)
  5. PPB alone
  6. PNB plus IRLA
  7. IV sedation alone
  8. PNB alone (lowest of the effective methods in this network ranking, but a guideline-supported technique)

In the office, PPB plus IRLA, PNB plus IPLA, and PNB plus IRLA were among the studied combinations; feasibility depends on local expertise and monitoring.

Agent selection (Li 2017, 46-RCT meta-analysis):[21]

  • Lidocaine 1–2%. Both concentrations have been used for periprostatic nerve block before prostate biopsy; lidocaine has rapid onset and relatively short duration.[22][24][77]
  • Bupivacaine 0.25–0.5%. Effective periprostatic anesthesia (VAS 2.04 versus 4.46 for no anesthesia; p < 0.05)[23]
  • Lidocaine plus bupivacaine combination. Attenuates the 1-hour rebound pain seen with lidocaine alone (rebound +0.09 versus +0.9; p = 0.0006) with later pain-score differences reported. Routine mixing is not recommended in the current bupivacaine label, and toxicities are additive[24]
  • EMLA (prilocaine plus lidocaine) cream intrarectally is more effective than lidocaine gel when combined with PNB[25]
  • Intraprostatic local anesthesia (IPLA) plus PNB is superior to PNB alone[26]
  • Tramadol plus lidocaine PNB. Lower pain scores (3.6) than lidocaine alone (4.6) or tramadol alone (5.4)[27]

PNB lateral to the neurovascular bundle has better analgesic effect than at the prostate apex.[21]

Intravesical lidocaine — IC/BPS​

AUA 2022 IC/BPS guideline (Statement 17; Option, Evidence Strength Grade B for lidocaine; DMSO and heparin are Grade C): intravesical lidocaine may be administered for IC/BPS. The guideline judges the relief short-term (less than two weeks) and limited to a subset of patients. In its multicenter placebo-controlled trial of alkalinized lidocaine, the response advantage was significant at day 3 (30% versus 10%) but not at day 10 (24% versus 11.5%). Instillation itself can be painful.[8]

Principles and evidence:

  • Alkalinization (sodium bicarbonate-buffered lidocaine) is expected to increase urothelial penetration, at the cost of greater systemic absorption.[9][28]
  • Lidocaine plus heparin: in a double-blind crossover trial (Parsons 2012, n = 18 completers) alkalinized lidocaine with heparin reduced 12-h pain 42% versus 21% with control and urgency 35% versus 13%. The comparator was placebo. AUA lists DMSO, heparin and lidocaine as intravesical options without a hierarchy[8][9]
  • Proposed effects beyond anesthesia (Henry 2015) include anti-inflammatory mechanisms.[28]
  • Investigational LiRIS pilot. A continuous lidocaine-releasing intravesical device designed for 2-week retention (Nickel 2012, n = 16 women meeting NIDDK IC criteria). Both 200 mg and 650 mg doses were well tolerated. Clinically meaningful reductions in pain, urgency, and frequency; Hunner lesions resolved in 5 of 6 subjects with baseline lesions; 64% responder rate at day 14, sustained at 64% two weeks later, with pain reduction maintained several months after device removal[29]
  • Later LiRIS trials (Evans 2021): two multicenter placebo-controlled studies, with 59 and 131 treated women, did not meet their primary pain endpoint four weeks after removal (Hunner-lesion study p=0.142 for two active devices versus two placebo devices; non-Hunner study p=0.505). There was no clear Hunner-lesion reduction.[70]
  • Investigational TRG-100. In an open-label pilot of sustained-release intravesical lidocaine plus oxybutynin (Raisin 2023; 10 IC/BPS, 10 OAB and 16 stented patients), the IC/BPS group had lower pain, voiding frequency and O’Leary-Sant scores; the OAB group had lower frequency, and the stented group had lower pain scores.[30]
  • 2026 global consensus discusses intravesical lidocaine, DMSO and GAG-replenishment agents for IC/BPS; it describes intravesical oxybutynin as a potential therapy with insufficient evidence for current clinical use.[31]

See Intravesical IC/BPS agents and IC/PBS for the broader intravesical armamentarium.

Penile nerve block — circumcision and penile surgery​

Techniques. Dorsal penile nerve block (DPNB; injection at the base of the penis beneath Buck's fascia targeting the dorsal nerves), ring block (subcutaneous circumferential at the base), and the combination (most complete anesthesia).

Infant circumcision: the 2016 APS/ASRA/ASA guideline strongly recommends topical local anesthetic plus penile nerve block (moderate-quality evidence); lidocaine/prilocaine cream can cause methemoglobinemia in infants younger than 3 months, with excessive application, or with other methemoglobin-producing drugs.[32]

LAST in penile nerve block. Systematic review of case reports (Park 2025, 19 patients across 11 reports):[33]

  • 73.7% of cases occurred in infants <1 year.[33]
  • Lidocaine predominated in overdose cases; bupivacaine in presumed inadvertent intravascular absorption
  • Seizures and cardiovascular collapse were the dominant presentations
  • Calculate cumulative dose, inject slowly in increments, aspirate, monitor and have rescue resources; negative aspiration does not exclude intravascular injection

Current bupivacaine/epinephrine labeling advises carefully restricted quantities in the penis and other areas with limited/compromised blood supply; assess vascular disease and the exact technique/formulation.[60][10]

Vasectomy anesthesia​

AUA 2026 vasectomy guideline, Statement 9 (Moderate / Grade C): use local skin infiltration by needle and/or jet injector. Topical anesthetic can lessen injection pain but cannot substitute for perivasal anesthesia. Small needles and buffered lidocaine may improve tolerability; sedation is individualized for anxiety or anticipated difficult vas isolation. Statement 10 favors nonopioid oral postoperative analgesia.[34]

Technique comparison (Aggarwal 2009; 323 vasectomies, 123 returned pain questionnaires: 26 LIA, 25 LIA plus SCB, 72 jet anesthesia):[35]

  • Local infiltration anesthesia (LIA) plus spermatic cord block (SCB) had the lowest procedural pain in this nonrandomized comparison
  • Anesthesia-related pain: LIA plus SCB (1.7) versus LIA alone (3.3; p < 0.001)

Mini-needle technique (Shih 2010):[36]

  • 1-inch 30-gauge needle with about 2 mL of 2% lidocaine without epinephrine in the syringe; one small skin wheal precedes infiltration at the first vas, and the other vas is infiltrated through the same entry site.[36]
  • Mean VAS during anesthesia 1.5 (95% CI 1.3–1.7); during procedure 0.6 (0.5–0.7)
  • Patients consistently report less pain than anticipated

Topical local anesthetics — premature ejaculation​

The AUA/SMSNA 2020 guideline lists topical penile anesthetics, daily SSRIs and on-demand clomipramine or dapoxetine where available among first-line PE medicines .[64] Dapoxetine is an SSRI; Fortacin is the European-labeled lidocaine/prilocaine spray for primary PE in adult men.[63][37]

After first-line pharmacotherapy fails, AUA/SMSNA permits considering on-demand tramadol . Table 2 reports 25–100 mg on demand; the discussion cautions about opioid abuse potential and serotonin syndrome, including with concomitant SSRIs. Alpha-blockers are another option after first-line failure ; see Alpha Blockers.[64]

Fortacin (lidocaine 150 mg/mL + prilocaine 50 mg/mL)​

  • European approval for lifelong PE; not FDA-approved in the US
  • Label dose: three sprays to the glans; wipe off excess after five minutes before intercourse. Maximum three doses in 24 hours, at least four hours apart. Avoid polyurethane condoms; the label lists compatible alternatives. Review partner allergy, methemoglobinemia risk and conception/pregnancy precautions.[63]
  • Wyllie & Powell 2012 review of two pivotal trials (pooled intention-to-treat n=539). Geometric mean IELT from 0.58 to 3.17 min over 3 months, approximately 3.3 times the placebo final value (placebo from 0.56 to 0.94 min), not a 3.3-fold change from its own baseline (p < 0.001)[38]
  • Cai 2023 dose-finding (n = 91). Three sprays 5 min before intercourse optimized both IELT (221 ± 3.4 sec) and PEDT (7.7 ± 0.3) with the same safety profile as other regimens[39]
  • Boeri 2022 retrospective real-life series (n = 198): 92.9% tried it, 128 men reported regular use at 6 months, and 26.8% reported regular use at 12 months; PEDT improved at 6 and 12 months, while significant IELT improvement was reported at 6 months.[40]

EMLA (lidocaine 2.5% + prilocaine 2.5%) — off-label​

  • Applied to the glans 15–30 min before intercourse, then wiped off or covered with a condom
  • Atan 2006 RCT (n = 84). EMLA monotherapy yielded improvement or cure by patient self-report in 77.3% (22 men) versus 40% with placebo (20 men) after 2 months (reported significant comparison)[41]
  • Adverse effects. Topical anesthetics can reduce penile sensitivity; transfer to a partner can cause female genital anesthesia. Condom protection or washing the penis before penetration may reduce partner transfer (Statement 9 discussion).[42][64] Erectile difficulty has also been reported.[42]

Lidocaine 5% spray — off-label​

  • Abu El-Hamd 2021 RCT (n = 150). Lidocaine 5% spray 10–20 min before intercourse significantly improved AIPE, IELT, and intercourse frequency versus placebo (all p = 0.0001)[43]

Topical delivery can limit systemic exposure. Partner transfer, local numbness/burning and formulation-specific precautions matter.[37]

Glans augmentation with hyaluronic acid, an injectable approach that also aims to reduce glans sensitivity and that AUA/SMSNA classes as experimental, is covered on Glans Augmentation with Hyaluronic Acid.[64]

Vulvodynia and vestibulodynia​

Lidocaine has mixed, indication-specific evidence. Detail lives in Topical compounded agents:

  • Zolnoun’s 2003 uncontrolled series reported intercourse possible in 76% after a mean of seven weeks of nightly 5% lidocaine versus 36% at baseline.[44]
  • Selected breast-cancer survivors with vestibular dyspareunia benefited from 4% aqueous lidocaine in a small RCT discussed by ACOG.[45]
  • Foster 2010 (133 women) found no significant primary tampon-pain benefit from 5% lidocaine, oral desipramine or their combination versus placebo.[67]
  • Morin 2021 (212 women) found multimodal physical therapy superior to overnight 5% lidocaine for provoked vestibulodynia, with a 1.8/10 between-group intercourse-pain difference after treatment and benefit maintained at six months.[68]
  • UPDATe (NCT03844412) is completed (209 enrolled;170 paired primary pain observations); results posted March 19, 2026 showed nonsignificant four-arm comparisons for tampon pain and SF-MPQ change. These are registry results.[46][69]

Pudendal nerve block and pelvic-floor trigger-point injections​

Pudendal nerve perineural injections (PNPIs)​

Local-anesthetic pudendal blocks can contribute to diagnosis and short-term symptom management. For men with pudendal neuralgia-type pain, if a block gives no relief during the anesthetic’s expected duration, check pudendal-territory sensory coverage and reassess the diagnosis and other pelvic pain sources.[72][47] Routine steroid addition is not supported: Labat’s multicenter 201-person randomized trial found three-month response in 11.8% with anesthetic alone versus 14.3% in the steroid-containing groups (p=0.62).[65] Response meant a ≥30-point improvement on a 100-point pain scale.[65] The following uncontrolled studies:

  • Antolak 2016 (retrospective series, 53 men): 41/51 with recorded scores reported less pain 2 h after bupivacaine/steroid PNPI (80.4%; p < 0.0001); greater pudendal sensory-branch coverage tracked larger pain reductions.[47]
  • Fluoroscopy-guided transgluteal pudendal block (Levin 2024): 101 patients were treated; after excluding 5 without follow-up and 15 without initial relief, 49.4% of the remaining 81 initial responders had ≥30% pain relief lasting at least 2 weeks in a worst-case analysis. Some patients separately reported less medication use and improved ADLs.[48]
  • CT-guided pudendal block (Ly 2019, n = 91). Positive MR-neurography findings predicted better response in men (p = 0.005); women had better overall response[49]

Pelvic-floor trigger-point injections​

ACOG's 2020 CPP bulletin (Level B, limited or inconsistent evidence) recommends trigger-point injections of saline, local anesthetic, steroid, or combinations to improve pain and function in myofascial CPP. It notes benefit regardless of injectant and suggests that needle insertion itself may contribute.[50] A 2026 multisociety adult chronic pain guideline recommends considering local anesthetic alone for trigger-point injections (Grade B) because adding corticosteroid has not shown a net benefit that outweighs risk.[74]

  • Hui 2020 (n = 8 men with UCPPS). Weekly ultrasound-guided 1% lidocaine injections to iliococcygeus, pubococcygeus, and puborectalis with concurrent pudendal and posterior femoral cutaneous nerve hydrodissection (first two injections with dexamethasone, next four with Traumeel), while physical therapy continued, were followed by a mean VAS change from 3.3 before treatment to 1.8 at 6 weeks (p < 0.05)[51]

TAP block and wound infiltration in urologic surgery​

TAP block — meta-analytic evidence​

  • Zayed 2021 (20 urologic-surgery RCTs, n = 1,239): versus placebo or no block, TAP reduced pain at 6, 12 and 24 h by 0.55–1.13 points at rest and 0.74–1.32 with movement on an 11-point scale, and reduced 24-h opioid use by 12.25 mg morphine equivalents (p < 0.001); heterogeneity was high (I² 68%–99%).[52]
  • Zako et al. (meta-analysis of 123 RCTs across abdominal surgery). Pooled comparisons found lower pain at 6, 12, and 24 h and lower 24-h morphine consumption with TAP block than with placebo or local wound infiltration. TAP block reduced pain versus epidural only at 12 h and did not differ significantly from intrathecal morphine for any measured outcome.[53]

TAP vs local anesthesia — the UROTAP trial​

Rosen 2022 (RCT, n = 143) compared robot-assisted TAP (RTAP), ultrasound-guided TAP (UTAP), and local anesthesia (LA) for RARP and RAPN.[54] UTAP did not demonstrate superiority to simple wound LA for pain control. RTAP and LA were faster to deliver than UTAP (2.5 versus 6.25 min; p < 0.001).[54] A 2025 Cochrane review in minimally invasive gynecologic surgery found a small, low-certainty 24-h pain reduction with TAP versus local anesthetic injection (11.58/100 mm; six trials, 393 women).[83]

Wound infiltration + TAP for RARP​

Cacciamani 2019 RCT (n = 100). Wound infiltration combined with US-TAP using ropivacaine 0.35% reduced mean NRS within 12 h (1.6 versus 2.6; p = 0.02), opioid use (3.5% versus 18.6%; p = 0.01), LOS (4.27 versus 4.72 d; p = 0.04), and prokinetic requirements (21% versus 72%; p < 0.001).[55]

See ERAS perioperative pharmacology for the broader multimodal framework.

Retrograde ureteral stent placement and exchange under local anesthesia​

EAU Endourology systematic review (Pischetola 2025, 1,725 patients / 1,873 ureteral units):[56]

  • Overall success: 89%; failure 11%[56]
  • Among 876 procedures in studies reporting local-anesthetic complications, 76 complications occurred (8.68%): Clavien I–II, 52 (5.94%); III–IV, 24 (2.74%).[56]
  • Lidocaine jelly is the primary local anesthetic, with adjunct pharmacology in some series
  • Fluoroscopic guidance in 86.3%[56]
  • Significant cost savings versus general anesthesia; patient satisfaction generally high with willingness to repeat
  • Clinical interpretation: A 2026 review of outpatient local-anesthetic stenting (20 studies; 1,945 adults; 2,871 ureteral units) reported 94% technical success for stone-related versus 82% for malignant obstruction; reported failure predictors included trigone or distal-ureter invasion, severe hydronephrosis and ECOG ≥2.[78] Infection status, obstruction anatomy, patient tolerance and rescue/transfer capability inform setting selection.[56][78]

Hydrodistension under local anesthesia for IC/BPS​

AUA Statement 18 (Option, Grade C) describes cystoscopy under anesthesia with short-duration (under 10 minutes), low-pressure (60 to 80 cm H2O) hydrodistension, and Statement 25 advises against high-pressure, long-duration distension. The guideline does not specify the anesthetic type;[8] local-anesthetic approaches have been studied for selected patients:

  • Aihara 2009 (36 enrolled; 30 evaluated). Hydrodistension 10 min after 10 mL 4% lidocaine was feasible; therapeutic efficacy at 1 month was reported in 21 of 30 evaluated patients, with a median efficacy period of 20 weeks and no admissions for adverse events[57]
  • Electromotive drug administration (EMDA) of lidocaine (Rose 2005, n = 21) allowed more office-based distensions to completion than simple alkalinized instillation (7/11 versus 4/10) and greater bladder expansion (135% versus 70% of cystometric capacity)[58]
  • Transvaginal trigonal block with bupivacaine plus xylocaine (Hoke 2017): 106 of 183 hydrodistension patients were analyzed after 77 exclusions (48 block, 58 no block); both groups had lower pain scores at 1 month, with no significant between-group difference in change from baseline (−2.9 vs −2.6; p = 0.694)[59]

Safety — Local Anesthetic Systemic Toxicity (LAST)​

LAST is the most serious adverse event in this drug class and is particularly relevant in urology given mucosal absorption and the large volumes occasionally used.[2][33]

Urologic-specific risk factors:

  • Mucosal application. Lidocaine absorption through urethral and bladder mucosa varies with concentration, dose, site and duration; its 2% jelly label calls for extreme caution with sepsis or severely traumatized mucosa because rapid systemic absorption can occur.[2]
  • Alkalinized intravesical instillation. Increases urothelial penetration and can increase systemic absorption; no published study has directly compared its IC/BPS efficacy with plain intravesical lidocaine.[8]
  • Repeated doses / continuous delivery (e.g., analgesic-eluting catheters, LiRIS). Slow accumulation can produce meaningful plasma concentrations; reduce doses in the debilitated, elderly, and acutely ill[2]
  • Penile block in infants <1 year. Infants accounted for 14 of 19 published LAST cases in this review. Lidocaine predominated in overdose cases and bupivacaine in presumed intravascular cases.[33]

Formulation- and route-specific dose limits​

There is no single maximum-dose table valid for every route. Calculate the total milligrams from all gels, blocks and infusions, account for additive toxicity, and use the exact product’s label plus an anesthesia plan. A listed limit is not a target or a guarantee against LAST.[2][3][60][61]

Product / settingLabel boundary and limitation
Plain lidocaine injection, normal healthy adult4.5 mg/kg, generally no more than 300 mg; use lower doses when required by patient or block characteristics[61]
Lidocaine with epinephrine, healthy adult7 mg/kg, generally no more than 500 mg. In penile or other areas with limited or compromised blood supply, assess perfusion and use carefully restricted quantities; ischemic injury can occur (see penile block above).[71]
Lidocaine 2% urethral jellySeparate adult urethral directions above; no more than 600 mg in 12 h. The label's 4.5 mg/kg limit appears in its pediatric section. Account for lidocaine from all formulations, and do not transfer the jelly limit to injection.[2]
Bupivacaine infiltration / peripheral block in adultsLabel table allows up to 175 mg plain (225 mg with epinephrine 1:200,000) for these routes, individualized; repeat no more often than every 3 h and never exceed 400 mg in 24 h. Not recommended below age 12. Contraindicated for obstetric paracervical block; the 0.75% concentration is not recommended for obstetric anesthesia (boxed warning). Cumulative toxicity still applies[60]
Ropivacaine infiltrationLabel range up to 200 mg; major-block and epidural ranges differ. The reported 770 mg/24 h experience concerns intraoperative block plus postoperative epidural infusion, not a single injection or a general office ceiling[3]
Prilocaine-containing creams/sprays and levobupivacaineUse the actual jurisdiction/product label. A generic mg/kg injection ceiling must not be transferred to genital cream or spray use[63]

Recognize and treat LAST​

Stop administration, call for help and support oxygenation/ventilation. Neurologic symptoms can include tinnitus, circumoral numbness, altered consciousness or seizure; cardiovascular collapse can occur without a clear prodrome. Follow the ASRA LAST checklist, which differs from standard ACLS: consider 20% lipid emulsion early, use benzodiazepines preferentially for seizures, and use smaller epinephrine doses when indicated. The checklist also identifies resuscitation drugs to avoid and post-event observation intervals. Keep it and a stocked rescue kit immediately available.[62]

Lipid emulsion dosing (ASRA 2020 checklist, 20% emulsion). Over 70 kg: bolus about 100 mL over 2–3 min, then infuse about 250 mL over 15–20 min. Under 70 kg: bolus 1.5 mL/kg over 2–3 min, then 0.25 mL/kg/min. If still unstable, repeat the bolus and double the infusion; continue for at least 15 minutes after stability, to a maximum of 12 mL/kg. For arrhythmia or hypotension, use epinephrine in smaller-than-usual doses (start below 1 mcg/kg) and avoid vasopressin, calcium-channel blockers, beta-blockers and further local anesthetic. Prefer a benzodiazepine for seizure; if only propofol is available, use low doses (about 20 mg increments). Observe at least 2 h after a seizure and 4–6 h after cardiovascular instability.[62]

Bupivacaine is the most cardiotoxic amide in common use. Its high protein binding and slow dissociation from cardiac sodium channels make arrhythmia and resuscitation-resistant arrest more likely than with lidocaine after inadvertent intravascular injection. This is the basis of the obstetric 0.75% boxed warning; ropivacaine and levobupivacaine have wider margins but are not risk-free.[60][5]

Methemoglobinemia is a separate toxicity. Labels for lidocaine and bupivacaine list G6PD deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants under 6 months and concurrent oxidizing drugs as susceptibility factors. Prilocaine (EMLA, Fortacin) and benzocaine are the agents most often implicated, and the Fortacin SmPC warns of accentuation with methemoglobin-inducing drugs such as sulfonamides. Unexplained cyanosis needs urgent assessment rather than being assumed to be ordinary hypoxemia; clinically significant methemoglobinemia may require intravenous methylene blue.[2][63] PROVAYBLUE is contraindicated in G6PD deficiency and carries a boxed warning for serotonin syndrome with serotonergic drugs and opioids.[73]

Allergy, pregnancy and interactions​

  • Allergy: the lidocaine label contraindicates use with a known amide-type hypersensitivity.[61] Ester agents (tetracaine, oxybuprocaine, benzocaine) are metabolized to para-aminobenzoic acid and cause allergic reactions more often than amides, so an ester allergy does not preclude an amide, and the reverse is also true. Preservatives are a separate allergen: the 2% jelly contains methylparaben and propylparaben.[2]
  • Pregnancy: local anesthetics cross the placenta. Bupivacaine is contraindicated for obstetric paracervical block because of fetal bradycardia and death; use the lowest effective dose for pudendal or pelvic blocks in pregnancy. Fortacin advises avoiding use in pregnancy unless the man uses an effective male barrier contraceptive.[60][61][63]
  • Hepatic and elderly patients: reduce doses in debilitated, elderly and acutely ill patients, and monitor for toxicity in hepatic impairment.[2][60]
  • Epinephrine-containing injections: review tricyclic antidepressants and monoamine oxidase inhibitors; product labels warn of severe, prolonged hypertension and advise generally avoiding concurrent use.[60][71]

Clinical positioning​

  • Choose the agent, formulation, route and cumulative dose together. Mucosal gel, infiltration, peripheral block and epidural infusion are not interchangeable dosing contexts.
  • Cystoscopy lidocaine benefit is modest on average; combine respectful explanation, lubrication and other patient-centered measures without promising a painless procedure.[11][13][14]
  • Intravesical lidocaine is an AUA IC/BPS option for short-term relief.[8]
  • For robotic procedures, UROTAP did not show superior analgesia with TAP over wound infiltration and stopped early. This supports considering simpler infiltration.[54]
  • Use current product precautions for penile blocks and ready access to LAST rescue; neither a negative aspiration nor a dose below a table limit excludes toxicity.[33][60][62]

See Also​

References​

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