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Superior Hypogastric Plexus Block

If you suffer from chronic pelvic pain, genital pain, or have been told you have pudendal neuralgia, you may benefit from this unique treatment option.

What is a Superior Hypogastric Plexus Block Block?

A superior hypogastric plexus block (also known as a hypogastric block) is an advanced, minimally invasive procedure used to treat pelvic and genital pain that has been so far unresponsive to oral medications and other conventional treatments. This injection is considered to be a sophisticated, and more precise version of a sympathetic block that targets a specific region of the Sympathetic Nervous System (SNS) known as the Superior Hypogastric Plexus.

Superior Hypogastric Plexus Block

The superior hypogastric plexus is a complex web of neurons and fibers responsible for transmitting subconscious sensation and signals to and from the pelvic region.  Once chronic pain develops in the pelvis, this plexus becomes a main source of sending unwanted pain signals to the brain.

Indications

The superior hypogastric plexus is a part of the sympathetic nervous system that is capable of communicating pain to the central nervous system even when there is nothing damaged or inflammed. By blocking this structure, one can relieve pain in the visceral and pelvic regions from multiple etiologies:

 Chronic Pelvic Pain
 Cancer Pain
 Pelvic Inflammatory Disease
 Endometriosis
 Prostatitis
 Interstitial Cystitis
 Dysmenorrhea and Dyspareunia
 Myofascial Pain Syndrome
 Vulvitis

 Cystitis
 Varicocele
 Sympathetically-Mediated Pain
 Pelvic Congestion
 Pelvic Fibrosis
 Pelvis Neurodystonica
 Radiation-induced Neuropathy
 Irritable Bowel Syndrome
 Pain due to adhesions resulting from multiple abdominal/GYN surgeries

What Are The Benefits?

A superior hypogastric plexus block is a minimally invasive procedure that takes just minutes to perform. It can be used to treat different types of visceral and pelvic pain that are non-responsive to oral medications and conventional therapies. The most important aspects of this procedure are its ability to treat pain from a variety of origins, and the immediate pain relief following its successful administration.

Along with spinal innervation, the structures of the pelvic region receive input from the SNS via the superior hypogastric plexus making it an appropriate target for treating pain originating from the area.

Pelvic OrgansSpinal InnervationSympathetic and Peripheral Nerves
Fallopian tubes, superior portion of uterine segment, ureters and bladder, appendix, broad ligament, proximal large bowelT9–12, L1Celiac plexus, superior hypogastric plexus
Inferior portion of uterine segment, ureters and bladder, superior vagina, distal colon, rectum, uterosacral ligamentsS2–S4Inferior hypogastric plexus, inguinal, genitofemoral
Lower vagina, vulva, perineumS2–S4Ganglion impar, superior hypogastric plexus pudendal, genitofemoral nerve, inguinal

Given the long list of structures that are innervated by the superior hypogastric plexus, one procedure can treat pain in multiple areas, all at once.

Learn More About Chronic Pelvic Pain

How Does It Work?

Futuristic MedicineThis procedure can be performed as a diagnostic block or a therapeutic block. In most cases (especially in nonmalignant pain syndromes), you physician will choose to perform a diagnostic block first.

  • Diagnostic Block – The injection will consist of a local anesthetic, like Lidocaine or Bupivacaine, to test the pain’s response to a block of the superior hypogastric plexus.
  • Therapeutic Block – In patients with a documented response to the diagnostic block (i.e. a temporary decrease in pain and symptoms), a therapeutic block will follow with the administration of a neurolytic agent such as dehydrated alcohol or phenol. This can also be performed via Radiofrequency Neurolysis.

Learn More About Radiofrequency Ablation

More Details - Superior Hypogastric Plexus

SNS diagramThe superior hypogastric plexus is a collection of nerves located in the retroperitoneal space at the bifurcation of the aorta and lies directly in front of the L5/S1 intervertebral disc. It contains afferent and efferent fibers from the SNS, and to a lesser extent carries parasympathetic information to the structures of the pelvis as well.[1]  Overall, it provides innervation to most, if not all, structures of the pelvic region:

  • Bladder
  • Urethra
  • Vagina
  • Vulva
  • Prostate
  • Uterus
  • Ureter
  • Pelvic Floor (Perineum)
  • Ovaries
  • Penis
  • Testicles
  • Descending Colon and Rectum

In 1990 Plancarte first described this procedure when it was used to treat patients with pelvic pain due to cancer.[2]  In just a few years time, other physicians have adopted this treatment for lower abdominal and visceral pain in the pelvis due to a variety of causes.

How Many Treatments Will I Need?

The diagnostic portion of the procedure is typically performed twice to make certain the Superior Hypogastric Plexus is indeed a source of pain.  Once this has been confirmed, the neurolysis is a one time procedure that will offer pain relief for several months at a time.

When Will I Feel Better?

woman walking on beachThe relief from a positive diagnostic block is almost immediate, as the effects of the local anesthetic should typically be felt before the patient even leaves the office.  The medication will wear off in just a few hours and the pain will return – THIS IS NORMAL.  This will enable your doctor to verify the Superior Hypogastric Plexus is transmitting pain, making it a good target for the therapeutic procedure.

The relief from the therapeutic procedure make take up to a few days to reach maximum effect.

 

Learn More About the Sympathetic Nervous System

Is a Superior Hypogastric Plexus Block Right for Me?

If you suffer from chronic pelvic pain or even pudendal neuralgia that has failed to resolve with medications, physical therapy and other conservative therapies, this procedure may be an option for you.  A superior hypogastric plexus block should be performed under the strict supervision of a board-certified pain management specialist.

Contact the Ainsworth Institute to set up an initial evaluation to find out if you are a candidate.

Procedure - Patient Details

A superior hypogastric plexus block is an outpatient procedure generally performed under local anesthetic. Intravenous sedation or other anesthesia can be provided for comfort, and may be necessary in certain instances when patients are unable to lie prone.

There are a number of approaches described in textbooks and literature when performing this procedure:

•  Anterior[3]
•  Posterior[1]
•  Transdiscal[4]

Superior Hypogastric Plexus BlockThe procedure is most commonly performed under fluoroscopy, although authors have reported success with computed tomography (CT) scan[5],[6] and ultrasound guidance.[7] The most common technique for performing a superior hypogastric plexus block is the posterior approach and the preferred method for guidance is fluoroscopy due to the lack of radiation compared to CT, and improved control compared to ultrasound.

Before starting, you will be hooked up to monitors to track your vital signs. Next, your skin will be cleaned with sterile soap to minimize the risk of infection. The skin and underlying tissue are then anesthetized for comfort. Once everything is numb, two thin needles are inserted. The target for the procedure is to advance the tips of the needles directly in front of the L5/S1 intervertebral disc. Once the tips are in the proper position, a small amount of contrast dye will be injected to verify the needles are in the correct spot and safely situated adjacent to the superior hypogasric plexus (one needle on either side of it).

At this point, a small amount of local anesthetic (with the possible addition of a neurolytic agent) will be injected and the procedure is complete. After a successful block, you will begin to feel profound pain relief in a matter of minutes to hours.

The entire procedure takes less than 15 minutes. Once the injection is complete, two small dressings will be placed and you will be transferred to the recovery area and monitored to see what effect the procedure had.

Risk Factors

The superior hypogastric plexus block is considered to be a safe procedure with a low risk profile. In 200 cases performed at one institute, there was not a single reported case of neurological complication.[8] As with any procedure, bleeding and infection are a rare, but potential complication.  Retroperitoneal hematoma is another uncommon but conceivable complication. Finally, there is the theoretical complication of an atherosclerotic plague becoming dislodged from the iliac vessels, should there be one present.

Evidence of Performance

Pain management doctors consider superior hypogastric blocks to be the procedure of choice for many types of pelvic pain. The effectiveness of this procedure is unquestioned and there are a number of studies that support its place in the treatment algorithm of pain.

In 1990, Plancarte and colleagues published the first study on the use of superior hypogastric plexus blocks for the treatment of pelvic pain. In this study, patients suffered from pelvic pain associated with cancer.[2]  The authors reported 70% of patients had a significant decrease in pain. In a subsequent study, thre were similar reports with 69% of patients reporting a decrease in pain.[9] More importantly, the author also described patients had a 67% reduction in morphine use. In a more recent study, 159 patients with pelvic pain associated with cancer were enrolled. Of the total patients, 115 (72%) reported adequate pain control with superior hypogastric plexus neurolysis.[10]  Patients in this study also reported a 49% decrease in medication consumption.

The successes echoed in these publications are two-fold. The first being the ability to decrease pain scores in something as hard to treat as cancer; second, is the decrease in medication consumption.

Given the ability for superior hypogastric plexus blocks to treat pain associated with cancer, it should come as no surprise this treatment is equally effective in treating nonmalignant pain. Rosenberg et al published a study on the efficacy of this procedure on penile and prostate pain.[11] The pain relief in this case lasted for more than 6 months. In a study published in 1999, authors studied the use of superior hypogastric plexus blocks on the treatment of endometriosis.[3]  Patients reported their pain was reduced and even eliminated. A similar report was also published with comparable results; the only difference was the use of CT scan in the approach.[6]

If you are suffering from chronic pelvic pain that has failed to respond to conventional treatments, you may be a candidate for a superior hypogastric plexus block. If your pain is originating from the uterus, prostate, bladder, urethra, vagina, vulva, prostate, penis, perineum/pelvic floor, testicles, colon or rectum, then you may benefit from this highly advanced treatment modality.

The Ainsworth Institute is Here to Help

Contact the Ainsworth Institute of Pain Management and schedule an appointment with one our board certified pain management specialists to learn more about this life changing treatment option. You could be one phone call away from getting your life back.

References

[1] Benzon, Honorio. Essentials of Pain Medicine. Philadelphia: Saunders Elsevier, 2011. Print.

[2] Plancarte R, Amescua C, Patt RB, et al.: Superior hypogastric plexus block for pelvic cancer pain. Anesthesiology. 1990; 73:236-239.

[3] Kanazi GE, Perkins FM, Thakur R, Dotson E. New technique for superior hypogastric plexus block. Reg Anesth Pain Med. 1999; 24:473-6.

[4] Gamal G, Helaly M, Labib YM: Superior hypogastric block. transdiscal versus classic posterior approach in pelvic cancer pain Clin J Pain. 2006; 22:544-547.

[5] Cariati M, De Martini G, Pretolesi F, Roy MT. CT-guided superior hypogastric plexus block. J Comput Assist Tomogr. 2002; 26:428-31.

[6] Wechsler RJ, Maurer PM, Halpern EJ, Frank ED. Superior hypogastric plexus block for chronic pelvic pain in the presence of endometriosis: CT techniques and results. Radiology, 1995; 196, 103-106.

[7] Mishra S, Bhatnagar S, Gupta D, Thulkar S. Anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain. Anaesth Intensive Care. 2008; 36:732-5.

[8] Plancarte R, de Leon-Casasola OA, El-Helealy M, et al.: Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth. 1997; 22:562-568.

[9] deLeon-Casasola OA, Kent E, Lema MJ: Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Pain. 1993; 54:145-151.

[10] Plancarte R, de Leon-Casasola OA, El-Helealy M, et al.: Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth. 1997; 22:562-568.

[11] Rosenberg SK, Tewari R, Boswell MV, et al.: Superior hypogastric plexus block successfully treats severe penile pain after transurethral resection of the prostate. Reg Anesth Pain Med. 1998; 23:618-620.

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