SUPERIOR HYPOGASTRIC PLEXUS BLOCK

A superior hypogastric plexus block is a type of injection that is used to control pelvic pain that has been resistant to oral medications. This block can also be indicated if the patient cannot endure the side effects of the same oral medications.

The superior hypogastric plexus controls pain to and from the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon, so this block can potentially alleviate pain originating from these regions. Recent literature shows that the superior hypogastric plexus block has been used successfully to treat both malignancy-associated anal-rectal pain and nonmalignant penile pain.

The Superior Hypogastric Plexus Block can Halt Pain originating from:

• Bladder
• Urethra
• Uterus
• Vagina
• Vulva
• Perineum
• Prostate
• Penis
• Testes
• Rectum
• Descending colon

Pain secondary to:

• Cancer that metastasized to the pelvis (cervical, prostate, testicular, colorectal etc.)
• Endometriosis
• Radiation Injury

Anatomy:

The superior hypogastric plexus is a collection of nerves situated on the vertebral bodies in front of the bifurcation of the abdominal aorta. Its location allows it to innervate the vast majority of the pelvic region (including the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon).

Procedure:

The superior hypogastric plexus block is usually performed with a posterior approach. If you can lie down on your abdomen, face down without significant distress your physician will most likely use the this approach. If you cannot lie down in this position,  he or she may choose the anterior approach, or the transdiscal approach. The anterior approach can be done with fluoroscopy, computed tomography-guidance, or via ultrasound. The transdiscal approach uses fluoroscopy or ultrasound and allows you to lay down on your abdomen or your side. With this technique, your physician advances the needle through the skin and muscles of your back and the L5-S1 intervertebral disc to reach the superior hypogastric plexus.

The posterior approach remains the most common ways to perform this block and can be done under fluoroscopy or computed tomography-guidance. Fluoroscopy tends to be the preferred imaging method since there is less radiation exposure to the patient.

You will be asked to lay down on your abdomen, with a pillow under the pelvis to help flatten out the lower lumbar spines natural curvature. Your lower back will be prepped and draped in a sterile manner and anesthesia will be administered. When your skin is adequately anesthetized, two needles will be advanced under fluoroscopy guidance until correct needle placement is obtained. Their correct placement will also confirmed by administration of contrast dye, and once position is confirmed, either a diagnostic block or a therapeutic block will be performed.

A successful block is marked by profound pain relief.

Local anesthetic is usually administered for diagnostic superior hypogastric plexus block or for patients with noncancer-related pain. For patients who have a documented response to administration of local anesthetic onto the superior hypogastric plexus, a therapeutic block is preformed with administration of the neurolytic agent like phenol. Radioablation of the superior hypogastric plexus is also another treatment modality for longer-lasting pain relief.

The procedure is short, taking less than 30 minutes. Sometimes your physician will recommend intravenous sedation to make you more comfortable. Your vital signs will be monitored during, and after, the procedure.

Superior hypogastric plexus block is a short, minimally invasive procedure that is effective at treating some chronic pelvic pain, especially if it’s caused by cancer.

Risk:

This procedure has a low risk of complications. They include: Needle misplacement, bleeding, especially into your retroperitoneal space, nerve injury and/or paralysis, puncture of surrounding organs, puncture of adjacent vessels, and distal ischemia. Risks that can result from the anesthetic include: Drug allergy and seizure (if the medication is injected into a blood vessel), and the risk of infection always exists with insertion of any needle.

Outcomes:

Superior hypogastric plexus block is a well-established treatment modality for chronic pelvic pain, especially if it results from cancer. In several recent studies, it has proven more effective that continuous opioid usage (De Leon-Casasola et al). Most patients experience some paint with the initial block, but more can be performed if optimal pain relief has not been reached the first time.

If you are suffering with chronic pelvic pain or pain that you or physician believe is originating from the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon, the superior hypogastric plexus may be of great benefit for you.

Contact Arkansas Pain today to see if you’re a good candidate for a superior hypogastric plexus block. We are happy to offer this exciting treatment option to patients in Melbourne and Merritt Island, FL. Call today for an appointment.

Journal Articles:

1. Cariati M, De Martini G, Pretolesi F, Roy MT. CT-guided superior hypogastric plexus block. J Comput Assist Tomogr. 2002 May-Jun;26(3):428-31.
2. Chan WS, Peh WC, Ng KF, Tsui SL, Yang JC. Computed tomography scan-guided neurolytic superior hypogastric block complicated by somatic nerve damage in a severely kyphoscoliotic patient. Anesthesiology. 1997 Jun;86(6):1429-30.
3. De Leon-Casasola O, Molloy RE, Lema M, Neurolytic visceral sympathetic blocks. In Benzon HT, Raja S, Molloy RE, et al (eds): Essentials of Pain Medicine and Regional Anesthesia, 2nd ed. New York, Elsevier-Churchill Livingston, 2005, pp 542-549.
4. De Leon-Casasola OA, Kent E, Lema MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Pain. 1993 Aug;54(2):145-51.
5. Dooley J, Beadles C, Ho KY, Sair F, Gray-Leithe L, Huh B. Computed tomography-guided bilateral transdiscal superior hypogastric plexus neurolysis. Pain Med. 2008 Apr;9(3):345-7.
6. Erdine S, Yucel A, Celik M, Talu GK. Transdiscal approach for hypogastric plexus block. Reg Anesth Pain Med. 2003 Jul-Aug;28(4):304-8.
7. Gamal G, Helaly M, Labib YM. Superior hypogastric block: transdiscal versus classic posterior approach in pelvic cancer pain. Clin J Pain. 2006 Jul-Aug;22(6):544-7.
8. Kanazi GE, Perkins FM, Thakur R, Dotson E. New technique for superior hypogastric plexus block. Reg Anesth Pain Med. 1999 Sep-Oct;24(5):473-6.
9. Michalek P, Dutka J. Computed tomography-guided anterior approach to the superior hypogastric plexus for noncancer pelvic pain: a report of two cases. Clin J Pain. 2005 Nov-Dec;21(6):553-6.
10. Mishra S, Bhatnagar S, Gupta D, Thulkar S. Anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain. Anaesth Intensive Care. 2008 Sep;36(5):732-5.
11. Plancarte-Sanchez R, Guajardo-Rosas J, Guillen-Nuarez R. Superior hypogastric plexus block and ganglion impar. Techniques in Regional Anesthesia and Pain Management. 2005 April: 9(2):86-90.
12. Plancarte R, de Leon-Casasola OA, El-Helaly M, Allende S, Lema MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth. 1997 Nov-Dec;22(6):562-8.
13. Plancarte R, Amescua C, Patt RB, Aldrete JA. Superior hypogastric plexus block for pelvic cancer pain. Anesthesiology. 1990 Aug;73(2):236-9.
14. Rosenberg SK, Tewari R, Boswell MV, Thompson GA, Seftel AD. Superior hypogastric plexus block successfully treats severe penile pain after transurethral resection of the prostate. Reg Anesth Pain Med. 1998 Nov-Dec;23(6):618-20.
15. Turker G, Basagan-Mogol E, Gurbet A, Ozturk C, Uckunkaya N, Sahin S. A new technique for superior hypogastric plexus block: the posteromedian transdiscal approach. Tohoku J Exp Med. 2005 Jul;206(3):277-81.
16. Waldman SD, Wilson WL, Kreps RD. Superior hypogastric plexus block using a single needle and computed tomography guidance: description of a modified technique. Reg Anesth. 1991 Sep-Oct;16(5):286-7.
17. 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. July 1995 Radiology, 196, 103-106.
18. Yeo SN, Chong JL. A case report on the treatment of intractable anal pain from metastatic carcinoma of the cervix. Ann Acad Med Singapore. 2001 Nov;30(6):632-5.