Skip to main content

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​

All agents in this article are amide-type local anesthetics — 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 potencyMax dose (no epi)Primary urologic role
Lidocaine3–5 min1–2 h1×4.5 mg/kg (≤300 mg)Urethral jelly, PNB, intravesical, wound infiltration, pelvic-floor trigger points[2]
Bupivacaine5–10 min4–8 h4×2.5 mg/kgPeriprostatic block, pudendal block, TAP block, wound infiltration[3]
Ropivacaine (S-enantiomer)5–10 min4–8 h3×3 mg/kgTAP block, wound infiltration, analgesic-eluting catheters; less cardiotoxic than bupivacaine[3][5][6]
PrilocaineRapid1–2 h1×6 mg/kgEMLA (with lidocaine); PE spray (Fortacin)[4]
Levobupivacaine (S-enantiomer)IntermediateLong~4×2.5 mg/kgIntravesical instillation for cystoscopy[7]

Three practical principles carry across the applications below:

  • Alkalinization increases efficacy — adding sodium bicarbonate raises pH, increases the un-ionized fraction, and improves urothelial penetration. This is the basis for alkalinized intravesical lidocaine for IC/BPS, and also increases systemic absorption.[8][9]
  • Ropivacaine over bupivacaine for large-volume blocks — ropivacaine has higher CNS and cardiac toxicity thresholds, less motor blockade at equianalgesic doses, and intrinsic vasoconstriction that slows systemic absorption. Preferred for TAP blocks and wound infiltration.[5][6]
  • Epinephrine for penile block is no longer taboo. A series of 95 patients receiving penile ring block with ropivacaine / lidocaine + epinephrine showed no ischemic complications and prolonged analgesia — the historical prohibition is increasingly considered obsolete.[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 + meta-analysis, 12 RCTs, n = 1,549 men) — intraurethral lidocaine vs plain lubricant: SMD −0.22 (95% CI −0.39 to −0.05) on a 10-point VAS; effect greater with longer dwell time[11]
  • Aaronson 2009 (meta-analysis, 4 RCTs, n = 411 men) — lidocaine-gel patients were 1.7× more likely to avoid moderate-to-severe pain vs plain lubricant (OR 1.7; 95% CI 1.1–2.8)[12]
  • Desai 2025 multi-site pilot (n = 190) — lidocaine dwell time ≤10 vs >10 min did not change outcomes; real-time visualization and patient-selected music were associated with lower pain and anxiety[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, n = 100) — 4–10 mL of 5 mg/mL mixed to 30 mL and instilled before rigid cystoscopy produced significantly lower VAS than standard lidocaine gel, with higher patient satisfaction and no drug-related side effects[7]
  • Tetracaine jelly + IV anesthesia (Bai 2025 RCT, n = 60) — reduced propofol requirements, shortened procedure time, and improved postoperative oxygenation vs IV anesthesia alone[15]
  • Oxybuprocaine gel (Dong 2022 RCT, n = 192) reduced male-catheterization pain vs liquid paraffin (VAS 32 vs 39 mm; p < 0.05)[16]
  • Ropivacaine-eluting catheter (Jung 2025 RCT, n = 60) — 0.5% ropivacaine released at 2 mL/hr cut catheter-related bladder discomfort from 65% → 21% after urogynecologic surgery (p = 0.018) with no adverse events[17]
  • Pediatric catheterization (Poonai 2015 RCT, n = 133) — intraurethral lidocaine did not reduce pain in children 0–24 months vs non-anesthetic lubricant, and caused significantly more pain during instillation — do not use in this population[18]

Urodynamics​

  • Özel 2018 RCT — 2% lidocaine gel significantly reduced pain during cotton-tipped swab test (1.3 vs 3.6; p < 0.001)[19]

Periprostatic nerve block — prostate biopsy​

Network meta-analysis (Kim 2019, 47 RCTs) ranked local-anesthetic methods for TRUS-guided biopsy pain control:[20]

  1. PNB + IV sedation (rank 1; most effective)
  2. Spinal anesthesia
  3. PPB + intrarectal local anesthetic (IRLA)
  4. PNB + intraprostatic local anesthetic (IPLA)
  5. PPB alone
  6. PNB + IRLA
  7. PNB alone (least effective outpatient option)

In the office, PPB + IRLA, PNB + IPLA, and PNB + IRLA are the most practical combinations.

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

  • Lidocaine 1–2% — standard for PNB; rapid onset, short duration[22]
  • Bupivacaine 0.25–0.5% — effective periprostatic anesthesia (VAS 2.04 vs 4.46 for no anesthesia; p < 0.05)[23]
  • Lidocaine + bupivacaine combination — attenuates the 1-hour rebound pain seen with lidocaine alone (rebound +0.09 vs +0.9; p = 0.0006) and sustains pain reduction through the subsequent week; routine combination use is advocated[24]
  • EMLA (prilocaine + lidocaine) cream intrarectally is more effective than lidocaine gel when combined with PNB[25]
  • Intraprostatic local anesthesia (IPLA) + PNB is superior to PNB alone[26]
  • Tramadol + 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 (Grade B): intravesical lidocaine may be administered for IC/BPS. Lidocaine significantly improves symptoms in the short term (<2 weeks after a course of therapy); sustained benefit is seen in a subset of patients.[8]

Key principles and evidence:

  • Alkalinization increases urothelial penetration and probable efficacy, at the cost of greater systemic absorption; no head-to-head trial compares alkalinized vs plain intravesical lidocaine[8]
  • Lidocaine + heparin and lidocaine + PPS combinations show greater bladder-pain and urgency reduction than lidocaine alone[8]
  • Beyond simple anesthesia (Henry 2015) — intravesical lidocaine has properties that interrupt the neuroinflammatory cycle of IC/BPS at multiple points, and it serves a diagnostic role by confirming the bladder as the pain generator in patients with diffuse pelvic pain[28]
  • LiRIS — 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]
  • TRG-100 — intravesical sustained-release lidocaine + oxybutynin (Raisin 2023) showed significant improvement in VAS, voiding frequency, and O'Leary-Sant scores across IC/BPS, OAB, and stented patients[30]
  • 2025 global consensus lists intravesical lidocaine among the core available instillation therapies alongside DMSO, oxybutynin, and GAG-replenishment agents[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).

APS/ASRA/ASA postoperative-pain guideline (2016) — strong recommendation: "Clinicians should use topical local anesthetics in combination with nerve blocks before circumcision" (moderate-quality evidence).[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 — the highest-risk population
  • Bupivacaine was the most frequently implicated agent
  • Seizures and cardiovascular collapse were the dominant presentations
  • Dose calculation per weight and rigorous aspiration before injection are the key mitigations

Epinephrine in penile block is supported by the Schnabl 95-patient series showing no ischemia and prolonged analgesia — the old dogma is obsolete with modern dilute formulations, though caution remains warranted in vascular compromise.[10]

Vasectomy anesthesia​

AUA vasectomy guideline (2012, reaffirmed): "Vasectomy should be performed with local anesthesia with or without oral sedation." The smallest available needle (25–32 gauge) should be used. Pneumatic no-needle injectors have not clearly been shown to reduce pain vs small-gauge needles.[34]

Technique comparison (Aggarwal 2009, n = 323):[35]

  • Local infiltration anesthesia (LIA) + spermatic cord block (SCB) is the most effective combination
  • Anesthesia-related pain: LIA + SCB (1.7) vs LIA alone (3.3; p < 0.001)

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

  • 1-inch 30-gauge needle with ~2 mL 2% lidocaine without epinephrine, injected directly at the vas
  • 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​

Topical anesthetics are first-line on-demand therapy for PE alongside dapoxetine; two agents have European regulatory approval: dapoxetine (SSRI — see SNRIs) and Fortacin (lidocaine / prilocaine metered-dose spray).[37]

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

  • European approval for lifelong PE; not FDA-approved in the US
  • Applied 5 min before intercourse; reduces glans sensitivity via peripheral Na-channel blockade
  • Wyllie & Powell 2012 (phase III, n = 539) — geometric mean IELT 0.58 → 3.17 min over 3 months, a 3.3-fold increase vs placebo (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 real-life use (n = 198) — 92.9% tried it, 66.4% regular use at 6 months, 26.8% continued at 12 months; significant IELT and PEDT improvement sustained at both timepoints[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 effectiveness 77.3% vs placebo 40% (p = 0.00); equivalent to sildenafil + EMLA[41]
  • Adverse effects: loss of penile sensitivity, erectile difficulty, and female genital anesthesia from partner transfer (use condom protection)[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 vs placebo (all p = 0.0001)[43]

The AUA/SMSNA Disorders of Ejaculation guideline (2022) lists topical anesthetics among first-line on-demand options for PE, with their primary advantages being absence of systemic effects and flexible dosing.[37]

Vulvodynia and vestibulodynia​

Topical lidocaine has the strongest evidence of any pharmacologic agent for vulvodynia. Detail lives in Topical compounded agents; the three anchor trials are:

  • Overnight 5% lidocaine ointment (Zolnoun 2003) — intercourse possible in 76% vs 36% at baseline (p = 0.002)[44]
  • 4% aqueous lidocaine pre-intercourse (ACOG 2021 breast-cancer-survivor consensus) — 88% dyspareunia reduction vs 38% placebo[45]
  • Vestibulodynia UPDATe trial (NCT03844412) — multicenter RCT of 5% lidocaine + 0.02% oestradiol vs nortriptyline vs combined vs placebo, the first large trial of a topical compound for vestibulodynia[46]

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

Pudendal nerve perineural injections (PNPIs)​

Bupivacaine + corticosteroid injections serve both diagnostic and therapeutic roles in suspected pudendal neuralgia:

  • Antolak 2016 (n = 53 men) — PNPIs significantly reduced pain (p < 0.001); quality measures for proper injection technique were defined[47]
  • Fluoroscopy-guided transgluteal pudendal block (Levin 2024, n = 101) — 49.4% achieved ≥30% pain relief at 2 weeks with reduced 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 CPP Practice Bulletin (2020) — recommended: trigger-point injections of saline, anesthetic, steroid, or combinations are recommended to improve pain and function in myofascial CPP. Benefit appears regardless of injectant, raising the possibility that needle insertion itself exerts a substantial effect.[50]

  • Hui 2020 (n = 8 men with UCPPS) — ultrasound-guided 1% lidocaine to iliococcygeus, pubococcygeus, and puborectalis with concurrent pudendal-nerve hydrodissection reduced VAS 3.3 → 1.8 (p < 0.05)[51]

TAP block and wound infiltration in urologic surgery​

TAP block — meta-analytic evidence​

  • Zayed 2021 (20 RCTs, n = 1,239) — TAP block significantly reduced postoperative pain at all timepoints (MD 0.55–1.13 at rest; 0.74–1.32 on movement) and cut 24-h opioid consumption by 12.25 mg morphine equivalents (p < 0.001)[52]
  • Zako 2025 (123 RCTs, comprehensive meta-analysis) — TAP block superior to both placebo and local wound infiltration for pain at 6, 12, and 24 h and for 24-h morphine use; not superior to epidural (except at 12 h) or intrathecal morphine[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. UTAP did not demonstrate superiority to simple wound LA for pain control. RTAP and LA were faster to deliver than UTAP (2.5 vs 6.25 min; p < 0.001).[54] The practical takeaway: for minimally invasive urologic surgery with modern ERAS pathways, well-executed wound infiltration may be as effective as an ultrasound-guided TAP at a fraction of the setup time.

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 vs 2.6; p = 0.02), opioid use (3.5% vs 18.6%; p = 0.01), LOS (4.27 vs 4.72 d; p = 0.04), and prokinetic requirements (21% vs 72%; p < 0.001).[55]

See ERAS perioperative pharmacology for the broader multimodal framework.

Retrograde ureteral stent placement under local anesthesia​

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

  • Overall success: 89%; failure 11%
  • Complications 8.68% (predominantly Clavien I–II at 5.94%; III–IV at 2.74%)
  • Lidocaine jelly is the primary local anesthetic, with adjunct pharmacology in some series
  • Fluoroscopic guidance in 86.3%
  • Significant cost savings vs general anesthesia; patient satisfaction generally high with willingness to repeat
  • Bottom line: office / local-anesthesia stenting is an effective alternative to GA in selected patients — reconstructive practices managing chronic obstruction, post-operative stricture surveillance, and stent exchanges can run these as in-office procedures at substantial cost and throughput benefit

Hydrodistension under local anesthesia for IC/BPS​

The AUA guideline places cystoscopy with hydrodistension under general or regional anesthesia;[8] local-anesthetic approaches have been studied for selected patients:

  • Aihara 2009 (n = 30) — hydrodistension 10 min after 10 mL 4% lidocaine was feasible and safe; 71% therapeutic efficacy at 1 month, median efficacy period 20 weeks, no admissions[57]
  • Electromotive drug administration (EMDA) of lidocaine (Rose 2005, n = 21) allowed more office-based distensions to completion than simple alkalinized instillation (7/11 vs 4/10) and greater bladder expansion (135% vs 70% of cystometric capacity)[58]
  • Transvaginal trigonal block with bupivacaine + xylocaine (Hoke 2017, n = 106) did not add therapeutic benefit over hydrodistension alone — both groups improved[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 — urethral and bladder mucosa absorb local anesthetics far more rapidly than intact skin; the FDA lidocaine label specifies that absorption varies with concentration, total dose, site, and duration[2]
  • Alkalinized intravesical instillation — increases both efficacy and systemic absorption[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 — highest-risk LAST population; bupivacaine is the most common culprit[33]

Maximum doses (without epinephrine):

AgentPer-dose ceiling
Lidocaine4.5 mg/kg (up to 300 mg; 600 mg in 12 h for urethral use)[2]
Bupivacaine2.5 mg/kg (≤175 mg per dose)
Ropivacaine3 mg/kg (up to 200 mg per dose; up to 770 mg over 24 h continuous infusion)[3]
Prilocaine6 mg/kg — methemoglobinemia risk, especially in infants
Levobupivacaine2.5 mg/kg

Recognition and treatment: prodrome of circumoral numbness, tinnitus, metallic taste, agitation; progression to seizures and cardiovascular collapse. Treatment is 20% lipid emulsion (intralipid rescue), supportive ACLS, and benzodiazepines for seizure control. Every office or suite where these agents are given in volume should have a LAST kit and protocol.

Clinical Positioning​

  • Lidocaine is the default in-office anesthetic — urethral jelly, periprostatic infiltration, vasectomy LIA, pelvic-floor trigger-point injection, intravesical IC/BPS therapy — all run on 1–2% lidocaine in most practices[2][8]
  • Add bupivacaine when you want hours, not minutes. Periprostatic lidocaine + bupivacaine blunts 1-hour rebound pain and extends analgesia through the week; bupivacaine is the standard for pudendal block[24][47]
  • Ropivacaine for large-volume blocks and continuous delivery — TAP blocks, wound infiltration, analgesic-eluting catheters. Higher toxicity threshold and intrinsic vasoconstriction make it the safer choice when total dose rises[5][17][55]
  • The cystoscopy experience is multimodal. Intraurethral lidocaine moves pain by ~0.2 SMD — real but small. Longer dwell time, patient-selected music, real-time visualization, and irrigation pressure each add; stacking them is the goal[11][13][14]
  • For prostate biopsy, use PPB + IRLA (EMLA) or PNB + IPLA. PNB alone is the least effective of the practical outpatient options; tramadol or bupivacaine combinations are legitimate adjuncts[20][21]
  • Intravesical lidocaine for IC/BPS is AUA Grade B. Alkalinize, consider lidocaine + heparin or lidocaine + PPS combinations, and use the trial to confirm the bladder is the pain generator before committing to chronic therapy[8][28]
  • Pediatric intraurethral lidocaine is counterproductive — it causes more pain on instillation than it prevents during catheterization in children <24 months[18]
  • Epinephrine for penile block is no longer contraindicated, but vigilance for LAST in infants is absolute — the majority of reported cases occur there[10][33]
  • UROTAP matters. For robotic urologic surgery, a well-placed wound infiltration may match a US-TAP at much lower setup cost; do not default to TAP out of habit[54]
  • Local-anesthesia retrograde stenting is an 89%-success, low-complication office procedure — a throughput and cost win for reconstructive practices doing routine stent exchanges[56]
  • Every urologic suite needs a LAST protocol with 20% lipid emulsion — mucosal application and alkalinized intravesical lidocaine deliver doses that can cross the toxicity threshold unexpectedly[2][33]

See Also​

References​

1. Gordetsky J, Bendana E, O'Brien J, Rabinowitz R. "(Almost) painless surgery: a historical review of the evolution of intraurethral anesthesia in urology." Urology. 2011;77(1):12–16. doi:10.1016/j.urology.2010.03.068

2. US Food and Drug Administration. Lidocaine Hydrochloride — prescribing information. Updated 2024-08-30.

3. US Food and Drug Administration. Ropivacaine Hydrochloride — prescribing information. Updated 2024-09-05.

4. McClellan KJ, Faulds D. "Ropivacaine: an update of its use in regional anaesthesia." Drugs. 2000;60(5):1065–1093. doi:10.2165/00003495-200060050-00007

5. Zink W, Graf BM. "Benefit-risk assessment of ropivacaine in the management of postoperative pain." Drug Saf. 2004;27(14):1093–1114. doi:10.2165/00002018-200427140-00003

6. Kuthiala G, Chaudhary G. "Ropivacaine — a review of its pharmacology and clinical use." Indian J Anaesth. 2011;55(2):104–110. doi:10.4103/0019-5049.79875

7. Pehlivanoğlu M, Tavukçu HH, Akça O, et al. "Efficiency of intracavitary levobupivacaine infusion for pain management during cystoscopic procedures: a randomised study." Int J Clin Pract. 2021;75(7):e14164. doi:10.1111/ijcp.14164

8. Clemens JQ, Erickson DR, Varela NP, Lai HH. "Diagnosis and treatment of interstitial cystitis/bladder pain syndrome." J Urol. 2022;208(1):34–42. doi:10.1097/JU.0000000000002756

9. Parsons CL, Zupkas P, Proctor J, et al. "Alkalinized lidocaine and heparin provide immediate relief of pain and urgency in patients with interstitial cystitis." J Sex Med. 2012;9(1):207–212. doi:10.1111/j.1743-6109.2011.02542.x

10. Schnabl SM, Herrmann N, Wilder D, Breuninger H, Häfner HM. "Clinical results for use of local anesthesia with epinephrine in penile nerve block." J Dtsch Dermatol Ges. 2014;12(4):332–339. doi:10.1111/ddg.12287

11. Raskolnikov D, Brown B, Holt SK, et al. "Reduction of pain during flexible cystoscopy: a systematic review and meta-analysis." J Urol. 2019;202(6):1136–1142. doi:10.1097/JU.0000000000000399

12. Aaronson DS, Walsh TJ, Smith JF, et al. "Meta-analysis: does lidocaine gel before flexible cystoscopy provide pain relief?" BJU Int. 2009;104(4):506–510. doi:10.1111/j.1464-410X.2009.08417.x

13. Desai AP, Basak RS, Lotan Y, et al. "Feasibility and outcomes of interventions to reduce cystoscopy discomfort: a multi-site pilot study." BJU Int. 2025. doi:10.1111/bju.16794

14. Desai AP, Smith AB, Lotan Y. "Guidance for avoiding patient pain and discomfort during transurethral cystoscopy." Expert Rev Med Devices. 2025. doi:10.1080/17434440.2025.2579582

15. Bai W, Luo D, Wurige M, Xiao B, Li J. "Research on the use of tetracaine hydrochloride jelly surface anesthesia in combination with intravenous anesthesia for pain-free cystoscopy." Front Med. 2025;12:1653269. doi:10.3389/fmed.2025.1653269

16. Dong Z, Qu X, Zhang L, et al. "Efficacy and safety of oxybuprocaine hydrochloride gel in alleviating pain during male urethral catheterization: a single-center randomized controlled study." Int J Clin Pract. 2022;2022:5734387. doi:10.1155/2022/5734387

17. Jung YJ, Lee SW, Lee Y, et al. "Efficacy and safety of analgesic-eluting urethral catheter after urogynecological surgery: a prospective randomized controlled trial." Sci Rep. 2025. doi:10.1038/s41598-025-30343-4

18. Poonai N, Li J, Langford C, et al. "Intraurethral lidocaine for urethral catheterization in children: a randomized controlled trial." Pediatrics. 2015;136(4):e879–e886. doi:10.1542/peds.2015-1852

19. Özel BZ, Sun V, Pahwa A, Nelken R, Dancz CE. "Randomized controlled trial of 2% lidocaine gel versus water-based lubricant for multi-channel urodynamics." Int Urogynecol J. 2018;29(9):1297–1302. doi:10.1007/s00192-018-3576-8

20. Kim DK, Lee JY, Jung JH, et al. "What is the most effective local anesthesia for transrectal ultrasonography-guided biopsy of the prostate? A systematic review and network meta-analysis of 47 randomized clinical trials." Sci Rep. 2019;9(1):4901. doi:10.1038/s41598-019-41412-w

21. Li M, Wang Z, Li H, et al. "Local anesthesia for transrectal ultrasound-guided biopsy of the prostate: a meta-analysis." Sci Rep. 2017;7:40421. doi:10.1038/srep40421

22. Alavi AS, Soloway MS, Vaidya A, Lynne CM, Gheiler EL. "Local anesthesia for ultrasound guided prostate biopsy: a prospective randomized trial comparing 2 methods." J Urol. 2001;166(4):1343–1345.

23. Rabets JC, Jones JS, Patel AR, Zippe CD. "Bupivacaine provides rapid, effective periprostatic anaesthesia for transrectal prostate biopsy." BJU Int. 2004;93(9):1216–1217. doi:10.1111/j.1464-410X.2004.04843.x

24. Lee-Elliott CE, Dundas D, Patel U. "Randomized trial of lidocaine vs lidocaine/bupivacaine periprostatic injection on longitudinal pain scores after prostate biopsy." J Urol. 2004;171(1):247–250. doi:10.1097/01.ju.0000098688.12631.a0

25. Valdez-Flores RA, Campos-Salcedo JG, Torres-Gomez JJ, et al. "Prospective comparison among three intrarectal anesthetic treatments combined with periprostatic nerve block during transrectal ultrasonography-guided prostate biopsy." World J Urol. 2018;36(2):193–199. doi:10.1007/s00345-017-2136-z

26. Bingqian L, Peihuan L, Yudong W, Jinxing W, Zhiyong W. "Intraprostatic local anesthesia with periprostatic nerve block for transrectal ultrasound guided prostate biopsy." J Urol. 2009;182(2):479–484. doi:10.1016/j.juro.2009.04.029

27. Sen H, Seckiner I, Bayrak O, et al. "Combination of tramadol and lidocaine for pain control during transrectal ultrasound-guided prostate biopsy: a randomized double-blinded study." Urology. 2015;85(6):1247–1251. doi:10.1016/j.urology.2015.03.015

28. Henry RA, Morales A, Cahill CM. "Beyond a simple anesthetic effect: lidocaine in the diagnosis and treatment of interstitial cystitis/bladder pain syndrome." Urology. 2015;85(5):1025–1033. doi:10.1016/j.urology.2015.01.021

29. Nickel JC, Jain P, Shore N, et al. "Continuous intravesical lidocaine treatment for interstitial cystitis/bladder pain syndrome: safety and efficacy of a new drug delivery device." Sci Transl Med. 2012;4(143):143ra100. doi:10.1126/scitranslmed.3003804

30. Raisin G, Dothan D, Perez D, et al. "Open label, pilot evaluation of the safety and efficacy of intravesical sustained release system of lidocaine and oxybutynin (TRG-100) for patients with interstitial cystitis/bladder pain syndrome, overactive bladder and patients with retained ureteral stents following endourological interventions." Urology. 2023;178:42–47. doi:10.1016/j.urology.2023.05.016

31. Buford K, Peters KM, Riedl C, et al. "Global consensus on interstitial cystitis/bladder pain syndrome: an update on therapeutic treatments." Neurourol Urodyn. 2025. doi:10.1002/nau.70106

32. Chou R, Gordon DB, de Leon-Casasola OA, et al. "Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council." J Pain. 2016;17(2):131–157. doi:10.1016/j.jpain.2015.12.008

33. Park M, Lee SH, Sohn JT. "Local anesthetic systemic toxicity induced by penile nerve block: a systematic review." Medicine (Baltimore). 2025;104(37):e44582. doi:10.1097/MD.0000000000044582

34. Sharlip ID, Belker AM, Honig S, et al. "Vasectomy: AUA guideline." J Urol. 2012;188(6 Suppl):2482–2491. doi:10.1016/j.juro.2012.09.080

35. Aggarwal H, Chiou RK, Siref LE, Sloan SE. "Comparative analysis of pain during anesthesia and no-scalpel vasectomy procedure among three different local anesthetic techniques." Urology. 2009;74(1):77–81. doi:10.1016/j.urology.2008.11.023

36. Shih G, Njoya M, Lessard M, Labrecque M. "Minimizing pain during vasectomy: the mini-needle anesthetic technique." J Urol. 2010;183(5):1959–1963. doi:10.1016/j.juro.2010.01.006

37. Mitsogiannis I, Dellis A, Papatsoris A, Moussa M. "An up-to-date overview of the pharmacotherapeutic options for premature ejaculation." Expert Opin Pharmacother. 2022;23(9):1043–1050. doi:10.1080/14656566.2022.2035361

38. Wyllie MG, Powell JA. "The role of local anaesthetics in premature ejaculation." BJU Int. 2012;110(11 Pt C):E943–E948. doi:10.1111/j.1464-410X.2012.11323.x

39. Cai T, Gallelli L, Verze P, Salonia A, Palmieri A. "Prilocaine/lidocaine spray for the treatment of premature ejaculation: a dose- and time-finding study for clinical practice use." Int J Impot Res. 2023;35(4):378–384. doi:10.1038/s41443-022-00554-8

40. Boeri L, Pozzi E, Fallara G, Montorsi F, Salonia A. "Real-life use of the eutectic mixture lidocaine/prilocaine spray in men with premature ejaculation." Int J Impot Res. 2022;34(3):289–294. doi:10.1038/s41443-021-00424-9

41. Atan A, Basar MM, Tuncel A, et al. "Comparison of efficacy of sildenafil-only, sildenafil plus topical EMLA cream, and topical EMLA-cream-only in treatment of premature ejaculation." Urology. 2006;67(2):388–391. doi:10.1016/j.urology.2005.09.002

42. Berkovitch M, Keresteci AG, Koren G. "Efficacy of prilocaine-lidocaine cream in the treatment of premature ejaculation." J Urol. 1995;154(4):1360–1361.

43. Abu El-Hamd M. "Effectiveness and tolerability of lidocaine 5% spray in the treatment of lifelong premature ejaculation patients: a randomized single-blind placebo-controlled clinical trial." Int J Impot Res. 2021;33(1):96–101. doi:10.1038/s41443-019-0225-9

44. Zolnoun DA, Hartmann KE, Steege JF. "Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis." Obstet Gynecol. 2003;102(1):84–87. doi:10.1016/s0029-7844(03)00368-5

45. American College of Obstetricians and Gynecologists. "Treatment of urogenital symptoms in individuals with a history of estrogen-dependent breast cancer: clinical consensus." Obstet Gynecol. 2021;138(6):950–960. doi:10.1097/AOG.0000000000004601

46. Carey ET, Geller EJ, Rapkin A, et al. "Rationale and design of a multicenter randomized clinical trial of vestibulodynia: understanding pathophysiology and determining appropriate treatments (Vestibulodynia: UPDATe)." Ann Med. 2022;54(1):2885–2897. doi:10.1080/07853890.2022.2132531

47. Antolak S, Antolak C, Lendway L. "Measuring the quality of pudendal nerve perineural injections." Pain Physician. 2016;19(4):299–306.

48. Levin D, Van Florcke D, Schmitt M, et al. "Fluoroscopy-guided transgluteal pudendal nerve block for pudendal neuralgia: a retrospective case series." J Clin Med. 2024;13(9):2636. doi:10.3390/jcm13092636

49. Ly J, Scott K, Xi Y, Ashikyan O, Chhabra A. "Role of 3 Tesla MR neurography and CT-guided injections for pudendal neuralgia: analysis of pain response." Pain Physician. 2019;22(4):E333–E344.

50. American College of Obstetricians and Gynecologists. "Chronic pelvic pain: ACOG Practice Bulletin, Number 218." Obstet Gynecol. 2020;135(3):e98–e109. doi:10.1097/AOG.0000000000003716

51. Hui J, Seko K, Shrikhande G, et al. "A novel, nonopioid-based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound-guided nerve hydrodissection and pelvic floor musculature trigger point injections." Neurourol Urodyn. 2020;39(2):658–664. doi:10.1002/nau.24242

52. Zayed M, Allers K, Hoffmann F, Bantel C. "Transversus abdominis plane block in urological procedures: a systematic review and meta-analysis." Eur J Anaesthesiol. 2021;38(7):758–767. doi:10.1097/EJA.0000000000001453

53. Zako J, Kevorkov A, Jeffries SD, et al. "Transversus abdominis plane block for postoperative pain management and opioid sparing: a systematic review and meta-analysis of randomised controlled trials." Br J Anaesth. 2025. doi:10.1016/j.bja.2025.10.033

54. Rosen DC, Winoker JS, Mullen G, et al. "Robot-assisted vs ultrasonography-guided transversus abdominis plane (TAP) block vs local anaesthesia in urology: results of the UROTAP randomized trial." BJU Int. 2022;130(6):815–822. doi:10.1111/bju.15833

55. Cacciamani GE, Menestrina N, Pirozzi M, et al. "Impact of combination of local anesthetic wounds infiltration and ultrasound transversus abdominal plane block in patients undergoing robot-assisted radical prostatectomy: perioperative results of a double-blind randomized controlled trial." J Endourol. 2019;33(4):295–301. doi:10.1089/end.2018.0761

56. Pischetola A, Jahrreiss V, Traxer O, et al. "Indications and outcomes of local anesthetic retrograde ureteral stent insertion: a systematic review from EAU Endourology." J Endourol. 2025. doi:10.1089/end.2024.0772

57. Aihara K, Hirayama A, Tanaka N, et al. "Hydrodistension under local anesthesia for patients with suspected painful bladder syndrome/interstitial cystitis: safety, diagnostic potential and therapeutic efficacy." Int J Urol. 2009;16(12):947–952. doi:10.1111/j.1442-2042.2009.02396.x

58. Rose AE, Payne CK, Azevedo K. "Pilot study of the feasibility of in-office bladder distention using electromotive drug administration (EMDA)." Neurourol Urodyn. 2005;24(3):254–260. doi:10.1002/nau.20106

59. Hoke TP, Goldstein H, Saks EK, Vakili B. "Hydrodistention of the bladder for the treatment of bladder pain syndrome/interstitial cystitis (BPS/IC)." Neurourol Urodyn. 2017;36(3):784–786. doi:10.1002/nau.23024