A Comprehensive Update of the Superior Hypogastric Block for the Management of Chronic Pelvic Pain

Ultrasound-guided erector spinae nerve block for relief of endometriosis pain in the emergency department

Endometriosis is a debilitating chronic condition often accompanied by severe pelvic pain and infertility issues. When outpatient medical management is not adequate, controlling pain can be challenging for providers in the acute setting. We report the case of a 23-year-old female with a past medical history of endometriosis who presented to a freestanding emergency department with a chief complaint of 10/10 pelvic pain on a numeric rating scale. She had tried non-steroidal inflammatory medications and heat with no success. The patient had medication intolerances to opioid analgesics and was given ketorolac intramuscularly with no relief of her pain. The emergency physician discussed and offered to perform an erector spinae plane nerve block (ESPB) for pain relief. Ultrasonography was utilized for visualization of landmarks with a curvilinear transducer; a 20-gauge Pajunk® Sonoplex needle was used to inject a total of 100 mg bupivacaine 0.25% without epinephrine along with dexamethasone 10 mg under the bilateral erector spinae fascial planes at the T9 level. Post-procedure, the patient had significant improvement in pain and rated it a 2/10. Utilizing nerve blocks for endometriosis and other chronic pelvic pain in the acute care setting can serve as an effective alternative to opioids. In patients with multiple medication intolerances and for providers navigating pain control in the setting of a nationwide opioid crisis, ESPB blocks can help alleviate acute pain or exacerbations of chronic pain. This case demonstrates the first known use of an ESPB to relieve endometriosis pain in the emergency department.

Visceral nerve interventions in interventional radiology

Chronic abdominal visceral pain management often requires multidisciplinary collaboration. Image-guided visceral nerve interventions may be critical in the management of visceral pain refractory to medical treatments. Abdominal and pelvic pain is mediated by specific nerves involving specific ganglia. The well-defined location of these ganglia provides important targets for percutaneous image-guided interventions to alleviate chronic abdominal or pelvic pain. In this review, we provide an in-depth discussion of the anatomy, indications, evidence, and technical and clinical considerations and complications for celiac plexus, superior hypogastric, inferior hypogastric, and ganglion impar block and neurolysis.

Risk factors and nomogram construction for predicting women with chronic pelvic pain:a cross-sectional population study

Background

Chronic pelvic pain (CPP) in women is a critical challenge. Due to the complex etiology and difficulties in diagnosis, it has a greatly negative impact on women's physical and mental health and the healthcare system. At present, there is still a lack of research on the related factors and predictive models of chronic pelvic pain in women. Our study aims to identify risk factors associated with chronic pelvic pain in women and develop a predictive nomogram specifically tailored to high-risk women with CPP.

Materials and methods

From May to October 2022, trained interviewers conducted face-to-face questionnaire surveys and pelvic floor surface electromyography assessments on women from community hospitals in Nanjing. We constructed a multivariate logistic regression-based predictive model using CPP-related factors to assess the risk of chronic pelvic pain and create a predictive nomogram. Both internal and external validations were conducted, affirming the model's performance through assessments of discrimination, calibration, and practical applicability using area under the curve, calibration plots, and decision curve analysis.

Results

1108 women were recruited in total (survey response rate:1108/1200), with 169 (15.3 %) being diagnosed as chronic pelvic pain. Factors contributing to CPP included weight, dysmenorrhea, sexual dysfunction, urinary incontinence, a history of pelvic inflammatory disease, and the surface electromyography value of post-baseline rest. In both the training and validation sets, the nomogram exhibited strong discrimination abilities with areas under the curve of 0.85 (95 % CI: 0.81-0.88) and 0.85 (95 % CI: 0.79-0.92), respectively. The examination of the decision curve and calibration plot showed that this model fit well and would be useful in clinical settings.

Conclusions

Weight, dysmenorrhea, sexual dysfunction, history of urinary incontinence and pelvic inflammatory disease, and surface electromyography value of post-baseline rest are independent predictors of chronic pelvic pain. The nomogram developed in this study serves as a valuable and straightforward tool for predicting chronic pelvic pain in women.

Safety and efficacy of ultrasound-guided superior hypogastric plexus block combined with conscious sedation in ambulatory patients undergoing percutaneous microwave ablation of uterine myomas: Study protocol for a single-center, double-blinded, randomized controlled trial

Background

Pain is a major challenge in performing ultrasound-guided percutaneous microwave ablation (PMWA) of uterine myomas. Inadequate analgesia by local anesthetics hinders the possibility of conducting PMWA of uterine myomas in the Ambulatory Surgery Center (ASC) of the Department of Ultrasound.

Objective

The superior hypogastric plexus (SHP) forms a suitable target for pain relief through the blockade, as it contains nociceptive afferent fibers from pelvic organs such as the uterus, rectum, and bladder. Superior hypogastric plexus block (SHPB) has demonstrated promise as an alternative treatment option for alleviating pelvic pain, reducing opioid consumption, and improving quality of life. This study aims to evaluate the efficacy of ultrasound-guided SHPB combined with conscious sedation as an alternative anesthesia option for ambulatory patients receiving ultrasound-guided PMWA of uterine myomas.

Methods and analysis

This randomized controlled trial (RCT) will be carried out at the Department of Ultrasound, The First Affiliated Hospital of Xiamen University. Women scheduled for ultrasound-guided PMWA of uterine myomas will be eligible. 86 patients will be recruited and randomly assigned to either the intervention or control groups in a 1:1 ratio. The intervention group will undergo ultrasound-guided superior hypogastric plexus block (SHPB) combined with conscious sedation, while the control group will receive local anesthesia combined with conscious sedation. The primary outcome is the success rate of anesthesia, secondary outcomes include vasoactive drug consumption, acetaminophen consumption, sleep quality, sonographer satisfaction score, patient satisfaction score, the detained time in hospital, and adverse events.

Discussions

This RCT represents the inaugural effort to specifically evaluate the safety and efficacy of ultrasound-guided SHPB combined with conscious sedation in patients undergoing ultrasound-guided PMWA of uterine myomas and will provide valuable evidence and insight into the analgesic management of this ambulatory surgery.

Ethics and dissemination

This study has been approved by the Ethics Committee of the First Affiliated Hospital of Xiamen University (Scientific Research Ethics Review 2023, No. 139). The results will be submitted for publication in peer-reviewed journals.

Analgesic Efficacy of Intraoperative Superior Hypogastric Plexus (SHP) Block during Abdominal Hysterectomy: A Systematic Review and Meta-Analysis of Controlled Trials

Background and Objectives: Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) and nonrandomized comparative trials (NCTs) that have surveyed the analgesic benefits and morbidity of intraoperative superior hypogastric plexus (SHP) block (intervention) compared with no SHP block (control) during abdominal hysterectomy. Materials and Methods: The Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, Web of Science, PubMed, Scopus, and Embase were searched from inception until 8 May 2022. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to evaluate the risk of bias of RCTs and NCTs, respectively. In a random effects mode, the data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Results: Five studies (four RCTs and one NCT) comprising 210 patients (SHP block = 107 and control = 103) were analyzed. The overall postsurgical pain score (n = 5 studies, MD = -1.08, 95% CI [-1.41, -0.75], p < 0.001), postsurgical opioid consumption (n = 4 studies, MD = -18.90 morphine milligram equivalent, 95% CI, [-22.19, -15.61], p < 0.001), and mean time to mobilization (n = 2 studies, MD = -1.33 h, 95% CI [-1.98, -0.68], p < 0.001) were significantly decreased in the SHP block group contrasted with the control arm. Nevertheless, there was no significant variance between both arms regarding operation time, intraoperative blood loss, postsurgical NSAID consumption, and hospital stay. There were no major side effects or sympathetic block-related aftermaths in both groups. Conclusions: During abdominal hysterectomy and receiving perioperative multimodal analgesia, the administration of intraoperative SHP block is largely safe and exhibits better analgesic effects compared to cases without administration of SHP block.

Pain specialist management of sexual pain: III-neuromodulation

INTRODUCTION

Some women with sexual pain do not respond to conservative multi-modal care modalities. Neuromodulation is a group of methods which alter nerve activity by delivering electrical energy or pharmaceutical agents directly to target neural structures. Multiple forms of neuromodulation may provide durable treatment options to fill the unmet therapeutic need of a certain population of women with chronic sexual pain.

OBJECTIVES

To provide a current review of neuromodulation treatments used for female sexual pain and introduce neuromodulation techniques which may be applied in novel ways to specific sexual pain phenotypes.

METHODS

Internet, PubMed and Cochrane Library were searched for relevant articles on female sexual pain within the clinical purview and scope of practice of pain management.

RESULTS

A thorough review of the literature was conducted to include basic science studies, clinical trials, systematic reviews, consensus statements, and case-reports. A sampling of information on real-world patient outcomes was included. The amount and quality of evidence for neuromodulation to treat female sexual pain is low-moderate. Descriptions of neuromodulation procedures for sexual pain were made and clinical studies reviewed. The effects of autonomic nervous system (ANS) dysregulation on the experience of pain were discussed with consideration of interventional procedures to facilitate restoration of ANS equilibrium.

CONCLUSION

Treating female sexual pain is complex. There are considerable numbers of women who have unsatisfactory sexual pain relief despite evidence-based interdisciplinary care. These women may benefit from referral to consider neuromodulation treatment options. Neuromodulation is a relatively new capability in the arsenal of pain management and other specialists that can be considered for women with treatment refractory sexual pain.

Development of pre-procedure virtual simulation for challenging interventional procedures: an experimental study with clinical application

Background

Most pain management techniques for challenging procedures are still performed under the guidance of the C-arm fluoroscope although it is sometimes difficult for even experienced clinicians to understand the modified three-dimensional anatomy as a two-dimensional X-ray image. To overcome these difficulties, the development of a virtual simulator may be helpful. Therefore, in this study, the authors developed a virtual simulator and presented its clinical application cases.

Methods

We developed a computer program to simulate the actual environment of the procedure. Computed tomography (CT) Digital Imaging and Communications in Medicine (DICOM) data were used for the simulations. Virtual needle placement was simulated at the most appropriate position for a successful block. Using a virtual C-arm, the authors searched for the position of the C-arm at which the needle was visualized as a point. The positional relationships between the anatomy of the patient and the needle were identified.

Results

For the simulations, the CT DICOM data of patients who visited the outpatient clinic was used. When the patients revisited the clinic, images similar to the simulated images were obtained by manipulating the C-arm. Transforaminal epidural injection, which was difficult to perform due to severe spinal deformity, and the challenging procedures of the superior hypogastric plexus block and Gasserian ganglion block, were successfully performed with the help of the simulation.

Conclusions

We created a pre-procedural virtual simulation and demonstrated its successful application in patients who are expected to undergo challenging procedures.

Agents Used for Nerve Blocks and Neurolysis

The recognition of pain and the treatments used for it are vital for all practitioners. Many types of pain can be treated in a locoregional fashion, which has significant implications not just for any individual patient but for society as a whole. These treatments are most effective when performed in a minimally invasive, image-guided fashion. Interventional radiologists should play a central role in providing these lifestyle-limiting treatments. This article describes the medications most typically used for spinal and extra-axial treatments in the management of patients in pain.

Fluoroscopic-Guided Bilateral Superior Hypogastric Plexus Neurolysis in the Treatment of Intractable Neoplasm-Related Penile Pain

Intractable penile pain can be a very difficult condition to address. Studies have shown that both locally advanced and metastatic penile cancer, along with its associated management options and subsequent complications, yield a very poor prognosis, with pain being the most feared symptom. Furthermore, a lack of palliative therapy has been demonstrated in this patient population, with an emphasis on the need for implementing future options. This case depicts a 67-year-old male, with a past medical history of metastatic prostate cancer involving the penis, who presented with intractable penile pain. To the authors’ knowledge, this will be the first documented case of the successful utilization of a bilateral superior hypogastric plexus neurolysis in the management of intractable neoplasm-related penile pain attributed to both radiation-induced injury in the treatment of malignant neoplasm and penile pain secondary to metastatic prostate cancer to the penis. As a currently under-utilized treatment option in the management of intractable neoplasm-related penile pain, this case presentation acts to increase awareness of its potential use, therefore reducing the need for analgesics and the associated burdens, as well as improving patient palliation. Furthermore, this case offers evidence supporting the encouragement of its use in the general management of intractable penile pain due to other pathophysiology.

Factors associated with Successful Responses to Ganglion Impar Block: A Retrospective Study

Background: The ganglion impar (ganglion of Walther) block has been used to manage coccygeal and perineal (perianal and genital) pain due to both benign and malignant causes. However, the factors associated with successful responses to ganglion impar block are unknown. Therefore, in the present study, we aimed to identify the independent factors associated with successful responses to ganglion impar block in patients with chronic pain in coccygeal and perineal regions. Methods: From January 2008 to December 2017, we performed a retrospective review of 106 patients who underwent ganglion impar block. Patients were considered successful responders if they reported a decrease of more than 50% or 4 points on the 11-point (0 = no pain and 10 = worst possible pain) numerical rating scale 1 month after the procedure, while others were considered non-responders. Logistic regression analysis was performed to identify factors independently associated with successful responses at 1 month after the procedure. Results: Multivariable logistic regression analysis showed that cancer-related causes were significantly associated with successful responses at 1 month after ganglion impar block (odds ratio = 2.60, 95% confidence interval = 1.05 to 6.43, P = 0.038). Conclusion: Ganglion impar block may be more effective in cancer-related pain than pain due to benign causes.