Presented at the 2012 AAPM Annual Meeting « Back

Technical Aspects of Inferior Hypogastric Plexus Block for Chronic Pelvic Pain: Case Report

Kai McGreevy, MD, kaimcgreevy@yahoo.com¹, Chitra Ramasubbu, MD², Kayode Williams, MD MBA³, Paul Christo, MD MBA³, (1) Southeast Spine and Rehabilitation, Kingsland, Florida, (2) Johns Hopkins Medical Center, Baltimore, Maryland, (3) Johns Hopkins University School of Medicine, Baltimore, Maryland

Introduction: Chronic pelvic pain (CPP) is one of the most challenging pain syndromes facing pain physicians. The inferior hypogastric plexus is a coalescence of nerves carrying visceral pain information from lower pelvic organs and genitalia, which can be blocked in patients with malignant or nonmalignant visceral or sympathetically mediated pelvic pain syndromes. The transsacral technique of inferior hypogastric plexus block (IHP) has been described, and provides immediate pain relief in approximately 72% of subjects. Methods: We describe a patient with endometriosis and chronic pelvic pain who failed pelvic physical therapy, medications, and superior hypogastric plexus block (SHP). Results: While refractory to multiple current treatments, our patient received excellent pain relief (>50% reduction in NRS) and functional improvement with repeat transsacral IHP injections every 3 months. Important technical considerations for the transsacral approach include proper patient positioning, fluoroscopic setup, needle selection, and troubleshooting in the foramen. Conclusion: The current case report illustrates that transsacral IHP may provide longer lasting relief of CPP than previously described, and that repeat IHP may maintain this effect, while minimizing side effects or complications. Our patient's pathology is more likely mediated by visceral afferents through the inferior, rather than superior hypogastric plexus. This is important since approximately 25% of SHP fail to provide adequate pain relief. Given the limitations of existing treatments for CPP, IHP may provide a safe and effective treatment for refractory cases. Prospective research is warranted regarding the efficacy, safety, and preferred technique of IHP for CPP disorders. References: 1)Schulz DM. Inferior Hypogastric Plexus Blockade: a Transsacral Approach. Pain Physician 2007;10:757-763

Funding: None

Conservative
      Pelvic physical therapy

Complementary and Alternative
      Meditation
      Biofeedback
      Acupuncture

Medications
      Hormonal treatments*
      Acetaminophen
      Non-steroidal anti-inflammatory drugs (NSAIDs)
      Anticonvulsants (e.g. gabapentin,pregabalin)
      Antidepressants (e.g. nortriptyline, duloxetine)
      Tramadol
      Opioids
           Hydrocodone
           Oxycodone
           Morphine sulfate
           Hydromorphone
           Oxymorphone
           Fentanyl
           Methadone
           Buprenorphine

Surgery
      Presacral neurectomy
      Hysterectomy

Interventional
      Superior hypogastric plexus block/neurolysis
      Inferior hypogastric plexus block/neurolysis
      Ganglion impar block/neurolysis
      Spinal cord stimulation
      Sacral nerve stimulation
      Intrathecal drug delivery