Superior Hypogastric Plexus Block
by Elizabeth Cudilo M.D, Paul Lynch M.D, and Tory McJunkin M.D
A superior hypogastric plexus block is a type of injection that is used to control pelvic pain that does not respond to oral medications. This block can also be indicated if the side effects for a pain relieving medication (excessive nausea, constipation, and sedation) are unacceptable to the patient. Since the superior hypogastric plexus contains efferent sympathetic fibers to and afferent pain fibers from the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon, this block can potentially alleviate pain originating from the above mentioned regions. The most recent literature highlights that the superior hypogastric plexus block has been used successfully to treat both malignancy-associated anal-rectal pain18 and nonmalignant penile pain14, which further adds evidence for the applications of this block.
Pain originating from:
- Descending colon
Pain secondary to:
- Cancer that metastasized to the pelvis (cervical, prostate, testicular, colorectal etc.)
- Radiation Injury
The superior hypogastric plexus is a retroperitoneal structure that extends bilaterally, just anterior to the vertebral column between the lower third of L5 and upper third of S1 vertebral bodies. It is formed by pelvis visceral afferents and efferent sympathetic nerves from branches of the aortic plexus, and fibers from the splanchnic nerves. 11 Its location allows it to innervate the vast majority of pelvic viscera (including the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon).
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.Â If you cannot lie down in this position, this position causes you too much pain, or your physician deems it too technically difficult based on your anatomy of your lower spine, he or she may choose the anterior approach or the transdiscal approach. The anterior approach can be done with fluoroscopy8, computed tomography-guidance1,9,17 or ultrasound-guidance10. The transdiscal approach is done under either under fluoroscopy6,7,15 or computed tomography-guidance5 and it allows you to be laying 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.
Nonetheless, the posterior approach remains one of the most common ways to perform this block and can be done under fluoroscopy or computed tomography-guidance16. 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 before local anesthesia is administered at the two points of entry of the needle into your skin. 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. Once position is confirmed either a diagnostic block or a therapeutic block will be preformed.
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 usually takes less than 15 minutes. Â Sometimes your physician will recommend intravenous sedation to make the procedure more comfortable. Your physician will monitor your pain and vital signs (pulse, blood pressure, temperature) 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 secondary to malignancy. Published literature also highlights that significant pain relief can also be achieved if the pain is of nonmalignant origin and is coming from one of the various organs that sends its afferent fibers to the superior hypogastric plexus.
The risk for this procedure is very low. In fact in current published literature, there is only one major complication reported. Chan, et al. (1997) describes a patient developing somatic nerve damage after a computed tomography scan-guided neurolytic block of the superior hypogastric plexus. They highlight that patients severe kyphoscoliotic lumbosacral junction deformity and the semirecumbent position of the patient may have contributed to the patient developing a complication. 2 In previous published literature no neurological complications were detected following this neurolytic block in the 200 patients that took part in the trial at the Mexican Institute of Cancer, Roswell Park Cancer Institute, and M.D. Anderson Cancer Center.12
Despite these published statistics, the theoretical risk of this procedure exists and includes: if the needle is misplaced you can experience bleeding, especially into your retroperitoneal space, nerve injury and/or paralysis, puncture of surrounding organs, puncture of adjacent vessels, and distal ischemia (if the iliac artery is penetrated and the needle dislodges an atherosclerotic plague)3. Risks secondary to the spread of the anesthetic include drug allergy and seizure (if the medication is injected into a blood vessel). Lastly with any penetration of skin and soft tissues, the risk of infection always exists.
The most common side-effect related to this procedure is lack thereof.
Superior hypogastric plexus block is a well-established treatment modality for chronic pelvic pain, especially if it’s secondary to malignancy.
Plancarte et al. (1990) showed a significant decrease in visual analog pain scale (VAPS) scores in 70% of patients who suffered from malignancy-associated chronic pelvic pain after they received the superior hypogastric plexus block. In 1993, De Leon-Casasola et al. defined that in their study, a successful superior hypogastric block would reduce opioid consumption by at least 50% in the 3 weeks following the block and that there would be a decrease in the VAPS scores as well. Despite their strict definition of success, they were able to replicate a similar significant decrease in VAPS scores (69%) after performance of the block and documented a decreased mean daily opioid use in both patients where the block was considered a success and in patients where the block was considered a failure (67% reduction compared to a 45% reduction, respectively).4 The efficacy of the superior hypogastric block only continued to be replicated by proceeding multicenter studies.12
These initial favorable results in malignancy-associated chronic pelvic pain prompted researchers to investigate if similar results could be obtained for patients with nonmalignant pelvic pain or pain from the various afferent innervations that the superior hypogastric plexus receives. In 1998, Rosenberg et al. reported in a case report that they were able to achieve more than 6 months of pain relief for a patient who was suffering from severe chronic nonmalignant penile pain after transurethral resection of the prostate.14 Another case report published in 2001, demonstrated that the superior hypogastric block in conjunction with the ganglion impar block successfully treated intractable anal pain secondary to metastatic cervical cancer.18 There have also been at least two studies looking at patients with endometriosis if they could obtain relief from the superior hypogastric block as well. In both studies the majority of patients experienced some if not complete relief from their chronic pelvic pain.8,17
The benefits of a superior hypogastric plexus block can be temporary for some people and the amount and duration of pain relief vary from person to person. Some tend to have relief for weeks where others can benefit from the block for years.Â Fortunately, the procedure is a low risk, nonsurgical treatment that if successful the first time, will most likely continue to provide pain relief with repeat treatments.
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 Arizona Pain Specialists today to see if youâ€™re a good candidate for a superior hypogastric plexus block.Â We are happy to offer this exciting treatment option to patients in Scottsdale, Glendale, and the Phoenix metro area. Call today for an appointment.
1.Â 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.Â 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.Â De Leon-Casasola O, Molloy RE, Lema M, Neurolytic visceral sympathetic blocks. In Benzon HT, Raja S,Â Molloy RE, et al (eds): Essentials of Pain Medicine and Regional Anesthesia, 2nd ed. New York, Elsevier-Churchill Livingston, 2005, pp 542-549.
4.Â 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.Â 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.Â 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.Â 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.Â 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.Â 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.Â 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.Â Plancarte-SÃ¡nchez R, Guajardo-Rosas J, Guillen-NuÃ±ez R. Superior hypogastric plexus block and ganglion impar. Techniques in Regional Anesthesia and Pain Management. 2005 April: 9(2):86-90.
12.Â 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.Â Plancarte R, Amescua C, Patt RB, Aldrete JA. Superior hypogastric plexus block for pelvic cancer pain. Anesthesiology. 1990 Aug;73(2):236-9.
14.Â 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.Â 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.Â 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.Â 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.Â 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.