Prolonged relief of chronic pelvic pain by pulsed radiofrequency ablation of superior hypogastric plexus performed under ultrasound guidance: A case report

Chronic prostatitis/chronic pelvic pain syndrome (CPPS) is a debilitating syndrome commonly seen in men under the age of 50 years, which greatly impacts the quality of life. The treatment is challenging, which often requires a multimodal management approach. The superior hypogastric plexus is located anterior to L5 and S1 vertebral bodies in the retroperitoneal space and contains afferent pain fibers from most of the pelvic structures. Performing a superior hypogastric plexus block (SHPB) can potentially alleviate pain originating from various pelvic regions and structures. It is currently a viable therapy for many syndromes including endometriosis, interstitial cystitis, irritable bowel syndrome, and pain after pelvic surgery. In this case report, we present a patient who had chronic pelvic pain with a poor response to conservative management. Initially, attempts at an SHPB from the classic posterolateral approach were unsuccessful. This technique for performing this block can prove difficult due to vasculature variability or anatomic barriers, such as the iliac crest and transverse process of the fifth lumbar vertebrae. Thus, a left S1 transforaminal approach was used to block the plexus. This provided the patient with one month of near 100% pain relief, with gradual return to baseline thereafter. CPPS poses unique treatment challenges. Although often treated conservatively, SHPB is a valid treatment option for those who fail to respond adequately to other modalities. An S1 transforaminal approach is a novel and valuable alternative technique for SHPB in patients with compromising anatomy. Key words: Chronic prostatitis, chronic pelvic pain, superior hypogastric plexus, superior hypogastric plexus block, pelvic trauma, pelvic pain in men

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Superior hypogastric plexus block for chronic pelvic pain in the presence of endometriosis: CT techniques and results.

Radiology ◽

10.1148/radiology.196.1.7784552 ◽

1995 ◽

Vol 196 (1) ◽

pp. 103-106 ◽

Cited By ~ 45

Author(s):

R J Wechsler ◽

P M Maurer ◽

E J Halpern ◽

E D Frank

Keyword(s):

Pelvic Pain ◽

Chronic Pelvic Pain ◽

Hypogastric Plexus ◽

Superior Hypogastric Plexus ◽

Plexus Block

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Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer

Pain ◽

10.1016/0304-3959(93)90202-z ◽

1993 ◽

Vol 54 (2) ◽

pp. 145-151 ◽

Cited By ~ 108

Author(s):

Oscar A. de Leon-Casasola ◽

Edward Kent ◽

Mark J. Lema

Keyword(s):

Pelvic Pain ◽

Chronic Pelvic Pain ◽

Hypogastric Plexus ◽

Superior Hypogastric Plexus ◽

Plexus Block

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RETROGRADE EJACULATION FOLLOWING LUMBOPELVIC SYMPATHETIC NEUROLYSIS – A CASE SERIES

Pain Management Case Reports ◽

10.36076/pmcr.2017/1/133 ◽

2017 ◽

pp. 133-142

Author(s):

Ajax Yang

Keyword(s):

Pelvic Pain ◽

Chronic Pelvic Pain ◽

Case Series ◽

Retrograde Ejaculation ◽

Potential Consequence ◽

Careful Evaluation ◽

Hypogastric Plexus ◽

Superior Hypogastric Plexus ◽

Male Patients ◽

Ganglion Impar

Background: Sympathetic neurolysis, or sympathectomy, is an established modality for the treatment of chronic pain. In cases of chronic pelvic pain (CPP), the ganglion of impar (GI) and the superior hypogastric plexus (SHP) are widely accepted targets for such therapy. Objective: While diagnostic injections typically predate any neurolysis for the purpose of ascertaining any potential effi cacy for interrupting a particular pathway, careful attention is equally paid to evaluate for possible adverse events - in the case of lumbopelvic neurolysis, retrograde ejaculation (RE) is one such possibility. Study Design: A case series. Setting: An outpatient pain management clinic. Methods: We present 3 male patients with CPP treated who underwent neurolytic procedures targeting the GI and SHP. Results: The fi rst patient developed RE after undergoing a simultaneous neurolysis of both the SHP and GI, in the same sitting. The second and third patients both experienced temporary RE immediately after diagnostic blockades of the SHP, following GI neurolysis that was performed several weeks prior. Limitations: Cause-effect conclusions cannot be drawn from the results of a case series. Conclusions: RE is a potential consequence of combined or serial SHP and GI neurolysis. While neurolysis of either the GI or SHP individually have not been known to cause RE in men, this case series demonstrates the potential risk in causing it when both structures are simultaneously incapacitated in some form; as such, the authors recommend against both structures being ablated or disabled concurrently without careful evaluation with temporary blockades fi rst. In an effort to avoid such a complication or evaluate for the possibility in a particular individual, we recommend that an individual with CPP, who has already been treated with a neurolysis, undergoes diagnostic blocks fi rst on whichever of the 2 structures has not yet been ablated to carefully evaluate if RE will occur. Key words: Retrograde ejaculation, superior hypogastric plexus, ganglion impar; neurolysis, chronic pelvic pain, male infertility, diagnostic block

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Pulsed Radiofrequency of the Sacral Roots Improves the Success Rate of Superior Hypogastric Plexus Neurolysis in Controlling Pelvic and Perineal Cancer Pain. Randomized Trial

January 2018 - Pain Physician ◽

10.36076/ppj.2020/23/149 ◽

2020 ◽

Vol 2;23 (4;2) ◽

pp. 149-157

Author(s):

Diab Fuad Hetta

Keyword(s):

Cancer Pain ◽

Pain Score ◽

Pelvic Pain ◽

Mean Difference ◽

Perineal Pain ◽

Pulsed Radiofrequency ◽

Post Procedure ◽

Hypogastric Plexus ◽

Pelvic Cancer ◽

Superior Hypogastric Plexus

Background: Superior hypogastric plexus neurolytic (SHP-N) block is the mainstay management for pelvic cancer pain of visceral origin when oral opioids fail due to inefficacy or intolerance to side effects. Unfortunately, SHP-N has the potential to control pelvic pain in 62%-72% of patients at best, because chronic pelvic pain may assume additional characteristics other than visceral. Objective: Combining SHP-N with pulsed radiofrequency (PRF) of the sacral roots might block most of the pain characteristics emanating from the pelvic structures and improve the success rate of SHP-N in controlling pelvic and perineal cancer pain. Study Design: This study was a prospective randomized controlled clinical trial. Settings: The research took place in the interventional pain unit of a tertiary center in the university hospital. Methods: Fifty-eight patients complaining of cancer-related chronic pelvic and perineal pain were randomized to either the PRF + SHP group (n = 29), which received SHP-N combined with PRF of the sacral roots S2-4, or the SHP group (n = 29), which received SHP-N alone. The outcome variables were the percentage of patients who showed a > 50% reduction in their Visual Analog Scale (VAS) pain score, the VAS pain score, and global perceived effect evaluated during a 3-month follow-up period. Results: The percentage of patients who showed a > 50% reduction in their VAS pain score was significantly higher in the SHP + PRF group compared to the SHP group when assessed at one month (92.9% [n = 26] vs 57.7% [n = 15]; P = .003) and 3 months (85.7% [n = 24) vs 53.8% [n = 14]; P = .01) post procedure, respectively. However, no significant difference was observed between the 2 groups at the 6-month evaluation (SHP + PRF [57.1% (n = 16)] vs SHP [50% (n = 13)]; P = .59). There was a statistically significant reduction of VAS in the SHP + PRF group in comparison to the SHP group at one month (2.8 ± 0.9 vs 3.5 ± 1.2 [mean difference, -0.7 (95% confidence interval [CI], -1.29 to -0.1), P = .01]), 2 months (2.8 ± 0.9 vs 3.5 ± 1.2 [mean difference, -0.64 (95% CI, -1.23 to -0.05), P = .03]), and 3 months (2.7 ± 1 vs 3.4 ± 1.2 [mean difference, -0.67 (95% CI, -1.29 to -0.05)], P = .03]) post procedure, respectively; however, the 2 groups did not significantly differ at 2 weeks, 4, 5, and 6 months post procedure. Regarding postprocedural analgesic consumption, there were trends towards reduced opioid consumption at all postprocedural measured time points in the SHP+PRF group compared to the SHP group; these differences reached statistical significance at 2 months (median, 30 [interquartile range (IQR), 0.00-30] vs median, 45 [IQR, 30-90]; P = .046) and 3 months (median, 0.00 [IQR, 0.00-30] vs median, 30 [IQR, 0.00-67.5]; P = .016) post procedure, respectively. Limitations: The study follow-up period is limited to 6 months only. Conclusions: SHP-N combined with PRF of the sacral roots (S2, 3, 4) provided a better analgesic effect than SHP-N alone for patients with chronic pelvic and perineal pain related to pelvic cancer. Trial Registry: ClinicalTrials.gov. NCT03228316. Key words: Pelvic pain, pulsed radiofrequency, sacral roots, superior hypogastric plexus

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