Superior Hypogastric Plexus Block

Performed by Top Pain Management Doctors in San Antonio, Texas


A nerve block is a treatment option for pain, which involves injecting anesthetic medicine into a group of nerves, called a ganglion, to numb the pain. The superior hypogastric plexus is a group of nerves functioning to transmit signals to the organs of the pelvis.

A Superior Hypogastric Plexus Block may be effective in treating pain from the following areas:

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

Superior hypogastric block is also used to treat pain as a result of:

  • Endometriosis
  • Radiation Injury
  • Cancer of the pelvic region (cervical, testicular, prostate, colorectal, etc.)

Patients whose pain is unresponsive to oral medications or those who cannot tolerate the side effects of oral pain medications (nausea, vomiting, constipation, sedation) are candidates for a nerve block. Recent studies show that superior hypogastric plexus block has proven effective in treating conditions such as malignancy related anal-rectal pain and nonmalignant penile pain.

Anatomy

The bundle of nerves known as the superior hypogastric plexus resides just in the peritoneum just in front of the vertebral column, at the level of the lower third of L5 and upper third of S1 vertebral bodies. The plexus of nerves includes pelvis visceral afferents and efferent sympathetic nerves emanating from the aortic plexus and splanchnic nerve fibers. The location of the superior hypogastric plexus facilitates its ability to innervate most of the pelvic tissues, such as the urethra, bladder, vagina, vulva, uterus, perineum, penis, prostate, testes, descending colon and rectum.

Procedure

Usually, the physician will perform a temporary superior hypogastric plexus block to see if the treatment is effective in treating the patient’s pain before injecting a more permanent nerve block. Several different approaches may be taken to inject the nerve block. Usually, a posterior approach is taken, and the patient is asked to lie down on the stomach so the physician can insert the needle through the patient’s back. The area of injection is cleaned and draped to keep it sterile, and then a local anesthetic is injected into the skin to minimize discomfort during the procedure. Fluoroscopy, a technique that combines X-ray with injected dye, is implemented to help guide the route of the needles that will be used to administer the nerve block. To perform the block, two needles are inserted and once their correct placement is verified by the injection of contrast dye, the anesthetic is injected to inhibit pain signals through the superior hypogastric plexus. Profound pain relief is the result of a successful nerve block procedure. Local anesthetic is a temporary nerve block used for pain diagnostic purposes or for patients whose pain is not related to cancer. Patients who already have documented cases of pain relief from a local anesthetic superior hypogastric plexus nerve block may receive a more permanent nerve block of a neurolytic agent (such as phenol) or radio ablation of the superior hypogastric plexus.

If the patient is unable to lie down on their abdomen due to pain, the physician may opt for the anterior approach or the transdiscal approach. The anterior route is through the abdomen with the patient lying on their back and utilizes either computed tomography-guidance or ultrasound-guidance. The transdiscal approach requires the patient to maintain a side-lying position while the physician inserts the needle into the back through the L5-S1 intervertebral disc with the guidance of either fluoroscopy or computed tomography-guidance. Based on physical exam and the patient’s ability to hold position, the physician will choose which route (posterior, anterior or transdiscal) will ensure a successful superior hypogastric plexus block procedure.

The superior hypogastric plexus nerve block is a minimally invasive procedure that takes less than 15 minutes. Some patients may receive intravenous sedation to allow them to relax and be still during the procedure.

Benefits

The superior hypogastric plexus block is a quick, minimally invasive, low-risk procedure proven successful in relieving some chronic pelvic pain, most notably pain related to cancer. The literature also shows superior hypogastric plexus block effective in relieving nonmalignant pain of the organs and tissues innervated by the superior hypogastric plexus nerves.

Risks

Though the risks associated with a superior hypogastric plexus block are low, one major complication has been reported. One case of computed tomography scan-guided neurolytic block of the superior hypogastric plexus resulted in somatic nerve damage to the patient. The report attributed this complication to severe kyphoscoliotic lumbosacral junction deformity and utilizing a semi recumbent position during the procedure. However, literature published prior to this case reviewed 200 patients who received superior hypogastric plexus block and no neurological complications were found in these patients who received treatment at the Mexican Institute of Cancer, Roswell Park Cancer Institute and M.D. Anderson Cancer Center. Taking into account all this information, the procedure comes with theoretical risks. The risks of incorrect placement of the needle to administer the nerve block include:

  • Bleeding into the retroperitoneal space
  • Nerve injury or paralysis
  • Infection
  • Organ puncture
  • Blood vessel puncture
  • Distal Ischemia as a result of arterial puncture and dislodgment of atherosclerotic plaque

Outcomes

Superior hypogastric plexus block is an effective treatment for chronic pelvic pain, especially pelvic pain related to malignancy.

According to Plancarte et al. (1990), 70% of cancer patients with chronic pelvic pain demonstrated a reduction in visual analog pain scale (VAPS) scores after undergoing a superior hypogastric plexus block. De Leon-Casasola et al. reported in a 1993 study that patients who received a successful superior hypogastric block exhibited a 50% drop in opioid consumption, accompanied by a decrease in VAPS scores, within three weeks of the block. The researches carried this definition of success to another study in which they documented a superior hypogastric plexus block resulted in VAPS scores showing a dramatic decrease (69%) along with reduced mean daily opioid medication use in patients both patients whose nerve block was deemed a success, as well as patients whose nerve block reported as a failure. Multiple studies from several medical centers revealed the same findings.

These positive outcomes in treating chronic pelvic pain associated with cancer motivated researchers to investigate how effective a treatment superior hypogastric plexus block could be for nonmalignant pelvic pain. A report by Rosenberg et al. in 1998 noted a patient experiencing severe chronic nonmalignant penile pain caused by transurethral resection of the prostate achieved at least 6 months pain relief from a superior hypogastric plexus block. A report published in 2001 showed successful relief of pain caused by metastatic cervical cancer achieved by combining superior hypogastric block with ganglion impar block. Also, at least two studies document partial to complete relief of pain in patients afflicted by endometriosis who received a superior hypogastric plexus block.

Overall, relief of pain achieved by administering a superior hypogastric plexus block may be temporary, with the extent and duration of pain relief varying from patient to patient. The pain may be gone for only a few weeks or several years, but the procedure is low risk and minimally invasive, allowing for multiple treatments.

Journal Articles/Resources

Elizabeth Cudilo M.D, Paul Lynch M.D, and Tory McJunkin M.D. Superior Hypogastric Plexus Blcok. Retrieved from http://arizonapain.com/pain-center/pain-treatments/superior-hypogastric-plexus/