Case Report: A Challenging Superior Hypogastric Plexus Block in a Patient with Enlarged and Bifid Transverse Processes.

ABSTRACTChronic pelvic pain (CPP) is a multifactorial condition characterized by persistent pain in the pelvic region, significantly impacting the quality of life and psychological wellbeing of affected individuals. The superior hypogastric plexus block (SHPB) has emerged as a promising interventional therapy for patients with refractory CPP. This procedure involves the targeted administration of anesthetic agents to the superior hypogastric plexus, a key neural network responsible for transmitting visceral pain from the pelvic organs. A thorough analysis of existing literature demonstrates that SHPB provides significant pain relief and improves functional outcomes in patients with CPP associated with conditions such as endometriosis, pelvic inflammatory disease, and malignancy-related pain. Moreover, SHPB has been shown to reduce the need for opioid analgesics and enhance the quality of life for many individuals. Despite its potential, the procedure is not without risks, including complications such as infection, bleeding, and transient hypotension. Therefore, careful patient selection and procedural expertise are paramount for optimizing outcomes. In conclusion, SHPB offers a viable and effective option for managing CPP, particularly in cases resistant to conventional therapies. Further research is warranted to establish standardized protocols, refine patient selection criteria, and assess long-term outcomes. As our understanding of CPP and its management evolves, SHPB is poised to play a pivotal role in comprehensively treating this challenging condition.

We aimed to investigate the effect of superior hypogastric plexus (SHP) block on pain relief and quality of life of patients with refractory endometriosis. Sixteen patients with refractory endometriosis underwent SHP block. The outcome measures included visual analogue scale (VAS) for chronic pelvic pain, VAS for dysmenorrhoea, and VAS for dyspareunia. The short-form endometriosis health profile (EHP-5) was used to measure quality of life. All the outcome measures were evaluated at weeks 0, 1, 4, 12 and 24. The mean baseline VAS scores significantly improved after the SHP block (p < .001 for all). The mean overall EHP-5 score also significantly improved from 54.3 ± 18.2 to 24.6 ± 13.3 (p < .001). The positive effects of SHP were not diminished over time. No serious adverse effect was noticed in any of the patients. Preliminary results suggest that SHP block could be used as an effective method in pain control and improvement of quality of life in refractory endometriosis. IMPACT STATEMENT What is already known on this subject? Safety and efficacy of SHP block in the treatment of CPP has been revealed in earlier investigations. However, the efficacy of SHP block for pain management in patients with refractory endometriosis has not been investigated in earlier investigations. What do the results of this study add? SHP block is an effective method for pain control and improvement of quality of life in patients with refractory endometriosis. The positive effects of this treatment did not diminish over 24-weeks follow-up of the study. No serious adverse effect was noticed in any of the patients. What are the implications of these findings for clinical practice and/or further research? Preliminary results suggest that SHP block could be used safely and effectively for controlling pain and improvement of quality of life in patients with refractory endometriosis.

The Combination of Superior Hypogastric Plexus Block and the Block of the Ganglium Impair in a Patient With Abdominal and Perineal Pain Poorly Responsive to Opioids

To evaluate the efficacy of tolperisone (calmirex) in patients with chronic nonspecific pelvic pain receiving standard therapy. In the course of clinical work, 61 patients with chronic nonspecific pelvic pain were observed. To identify the dynamics of the study, all patients were assessed for the severity of pain using a visually analogue scale (VAS), the area of pain, muscle-tonic reactions estimated by the index of muscle tension according to Khabirov. Deviations of the biomechanical parameters of the pelvic region and restoration of the musculoskeletal system statics were evaluated. According to the study protocol, the efficacy of tolperisone (calmirex) was studied in patients receiving standard therapy. Myofascial and muscle-tonic reactions play a significant role in the development and maintenance of chronic nonspecific pelvic pain. At the same time, tolperisone (calmirex) together with standard therapy of chronic nonspecific pelvic pain contributes to an effective regression of pain of myofascial and muscular-tonic origin, and creates a favorable restorative background for non-drug treatment.

Chronic pelvic pain affects 2–24% of women in the reproductive period. There are various causes of chronic pelvic pain in women including gynecologic, urologic, gastrointestinal, and musculoskeletal problems. The treatment of pain is directed toward the underlying pathology. However, in some cases, no pathology can be found, and sometimes, more than one underlying pathology may be found in the same patient. Surgical denervation methods may be used in the treatment of chronic pelvic pain in women including uterosacral nerve ablation and presacral neurectomy. Uterosacral nerve ablation has been used as a treatment method for uterine causes of pelvic pain. It has been used widely in the treatment of dysmenorrhea- and endometriosis-related pain. But recent randomized studies and meta-analysis have questioned the effect of uterosacral nerve ablation in the treatment of chronic pelvic pain. Presacral neurectomy involves damage of the uterine sympathetic innervation at the level of superior hypogastric plexus. It is effective in the treatment of midline pelvic pain. It has been found to be more effective than laparoscopic uterosacral nerve ablation in a randomized study. The method, effect, and studies evaluating uterosacral nerve ablation and presacral neurectomy will be discussed in this chapter.

Aim: to assess an impact of laparoscopic superior hypogastric plexus (SHP) block combined with preemptive trocar site infiltration on postoperative pain intensity following laparoscopic myomectomy.Materials and Methods. The randomized double-blind clinical trial enrolled 198 patients undergoing laparoscopic myomectomy. Participants were randomized into three groups: the SHP block group (group 1, n = 66) received standard systemic analgesia combined with trocar site infiltration and laparoscopic SHP block; the trocar infiltration group (group 2, n = 65) received trocar site infiltration without SHP block; control group (group 3, n = 67) received standard systemic analgesia alone. The primary endpoint was presented by assessing pain intensity using the numeric rating scale (NRS) at 4 hours postoperatively. Secondary endpoints included NRS dynamics at 2, 6, 8, 12, and 24 hours postoperatively, time to first mobilization, opioid use, and pain quality assessment.Results. Pain scores were significantly lower in the SHP block group (group 1) at all time points assessed up to 12 hours postoperatively and at discharge (p &lt; 0.05). Opioid use in this group was also markedly reduced (4.5 %) compared to control group 3 (32.8 %; p = 0.001). Time to first mobilization was significantly shorter in the SHP block group compared to group 2 and group 3 (median 5 hours vs. 7 hours; p = 0.017). Deep pelvic (visceral) pain was more commonly reported in group 2 and group 3 groups than in group 1 (p = 0.021).Conclusion. Preemptive multimodal analgesia combining trocar site infiltration with laparoscopic SHP block provides effective postoperative pain control, reduces opioid intake, and accelerates postoperative mobilization following laparoscopic myomectomy. This approach offers a promising strategy for improving recovery and minimizing opioid use in fertility-preserving gynecologic surgery.

BackgroundWhile widely used for the treatment of chronic pelvic pain, limited data exists on efficacy of gabapentin, especially in the subgroup of women suffering from chronic pelvic pain without a known diagnosis, such as endometriosis.ObjectiveThis study aimed to assess the efficacy of gabapentin when administered to women with chronic pelvic pain without another diagnosis.Study DesignWe performed a Systematic Review and Meta Analysis including all controlled clinical trials addressing the use of gabapentin for the treatment of chronic pelvic pain without another diagnosis. We searched PubMed, Scopus, Web of Science, ClinicalTrials.Gov, MEDLINE, and The Cochrane Library from inception of each database to April 30, 2021. We included all the studies that fulfilled the following criteria: (1) population: women suffering from chronic pelvic pain without another identified diagnosis (such as endometriosis); (2) intervention: gabapentin (regardless of the dosage); (3) comparator:placebo; (4) outcomes: pain score (visual analog scale) after 3 months and pain score (visual analog scale) after 6 months as primary outcomes; and (5) study design: we only included randomized or controlled clinical trials. Our exclusion criteria included (1) uncontrolled clinical trials, (2) studies that did not report data or measures for any of our selected outcomes, (3) studies that included patients with surgically or clinically diagnosed endometriosis, or (4) studies with no full-text manuscript available. Risk of bias assessment was performed using the Cochrane risk of bias tool. We analyzed dichotomous outcomes as percentages and totals, whereas continuous outcomes were analyzed using mean difference, standard deviations, and relative 95% confidence intervals using the inverse variance method.ResultsWe included 4 placebo-controlled randomized controlled trials. Analysis was hindered because half of the studies (n=2) used the visual analog scale pain score and the other half (n=2) used the numerical rating scale. The analysis showed that when compared with the placebo, gabapentin significantly lowered the visual analog scale pain score at 3 months (mean difference, 0.79; 1.23 to 0.35; P=.005) and 6 months (mean difference, 1.68; 2.30 to 1.05; P=.001) and the numerical rating scale pain score at 3 months (mean difference, 0.20; 0.25 to 0.15; P=.001). However, in terms of the numerical rating scale pain score after 6 months, the 2 groups showed no significant difference (mean difference, 0.27; 0.80 to 0.26; P=.32).CONCLUSIONGabapentin may hold benefit for the management of chronic pelvic pain, with significant improvement in pain seen in both scales at 3 months when compared with the placebo, but only in the visual analog scale group at 6 months of usage. Secondary to the differences in the nature of the 2 scales, a further weighted combined analysis was not possible.

Management of Adolescent Chronic Pelvic Pain from Endometriosis: A Pain Center Perspective

Botulinum toxin has proven therapeutic effects in alleviating pain in several myofascial disorders, with an expanding potential in chronic pelvic pain. The objective of this systematic review is to evaluate the efficacy and safety of botulinum toxin injection as an off-label treatment for female chronic pelvic pain. Using PRISMA guidelines, MEDLINE, EBM Reviews, PubMed, CINAHL, TRIP Database, EMBASE, Web of Science and gray literature were searched. Studies assessing the efficacy of botulinum toxin for chronic pelvic pain in adult females, with 10 or more women, published in English up to 13 January 2020, were included. All eligible studies were reviewed and data were extracted by two independent reviewers using a standardized form. Quality of evidence was graded using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Ottawa-Newcastle scale for observational studies. In all, 491 records were screened. Seventeen articles were included in the final review: 5 randomized controlled trials and 12 observational studies. The quality of evidence ranged from low to high. There was a large degree of heterogeneity in study designs, and thus a meta-analysis was not feasible. All observational studies concluded that botulinum toxin was an effective treatment for chronic pelvic pain, with the greatest change in visual analog scale from 8.69 at baseline to 3.07 at 24months post-injection. However, only one of the five randomized controlled trials found statistical significant differences favoring botulinum toxin in the reporting of the EQ-5D (botulinum 0.78 [0.69-1.00], control 0.69 [0.25-0.81], P=.03) and frequency of intercourse (botulinum 1 [1-1.75], placebo 1 [0-1], P=.025). The most common adverse effect was transient localized pain at injection site (6%-88%). No serious adverse events were reported. Although observational studies were encouraging, there is insufficient high quality evidence to recommend botulinum toxin injection for chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality in its treatment efficacy are indicated.

Introduction Botulinum toxin has proven therapeutic effects in alleviating pain in several myofascial disorders, with an expanding potential in chronic pelvic pain. The objective of this systematic review is to evaluate the efficacy and safety of botulinum toxin injection as an off-label treatment for female chronic pelvic pain. Material and methods Using PRISMA guidelines, MEDLINE, EBM Reviews, PubMed, CINAHL, TRIP Database, EMBASE, Web of Science and gray literature were searched. Studies assessing the efficacy of botulinum toxin for chronic pelvic pain in adult females, with 10 or more women, published in English up to 13 January 2020, were included. All eligible studies were reviewed and data were extracted by two independent reviewers using a standardized form. Quality of evidence was graded using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Ottawa-Newcastle scale for observational studies. Results In all, 491 records were screened. Seventeen articles were included in the final review: 5 randomized controlled trials and 12 observational studies. The quality of evidence ranged from low to high. There was a large degree of heterogeneity in study designs, and thus a meta-analysis was not feasible. All observational studies concluded that botulinum toxin was an effective treatment for chronic pelvic pain, with the greatest change in visual analog scale from 8.69 at baseline to 3.07 at 24 months post-injection. However only one of the five randomized controlled trials found statistical significant differences favoring botulinum toxin in the reporting of the EQ-5D (botulinum 0.78 [0.69-1.00], control 0.69 [0.25-0.81], P = .03) and frequency of intercourse (botulinum 1 [1-1.75], placebo 1 [0-1], P = .025). The most common adverse effect was transient localized pain at injection site (6%-88%). No serious adverse events were reported. Conclusions Although observational studies were encouraging, there is insufficient high quality evidence to recommend botulinum toxin injection for chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality in its treatment efficacy are indicated.

Chronic pelvic pain (CPP) is defined as pain of at least 6 months' duration that occurs in the lower abdomen or below the umbilicus and has resulted in functional or psychological disability or required intervention and treatment. Therapeutic interventions center around the treatment of CPP as a diagnosis in and of itself, and treatment of specific disorders that may be related to CPP. A multidisciplinary approach for diagnosis and treatment seems to be most effective for symptomatic relief. This paper reviews the evidence for such interventions as psychological treatments including the use of complementary and alternative medicine techniques for CPP in women. Unfortunately, finding the best evidence in this setting is difficult as only very few randomized controlled trials are available. A combination of treatments is usually required over time for the treatment of refractory CPP. The multifactorial nature of CPP needs to be discussed with the patient and a good rapport as well as a partnership needs to be developed to plan a management program with regular followup. Promotion of a multidisciplinary approach which includes complementary and alternative medicine techniques in managing CPP in women seems to yield the best results.

Expectations and patient satisfaction with transvaginal ultrasound results in women with chronic pelvic pain

Some pelvic pain syndromes are very resistant to medical treatment. Several studies have demonstrated that sacral neuromodulation, which has been successfully used for the treatment of bladder dysfunction, incontinence, urinary retention and urinary frequency [1]-[3], can be successfully used for the treatment of chronic pelvic pain [4]-[7]. Several studies have also demonstrated significant involvement of dorsal column pathways in the transmission of visceral pelvic pain [8] and the successful use of spinal cord stimulation for the treatment of chronic pelvic pain [9]. We report three cases of severe chronic pelvic pain that failed conservative treatment modalities. Placement of a combined sacral nerve roots stimulator and a low thoracic spinal cord stimulator resulted in a significant pain relief and improvement in daily life activities. We believe that this combination may help patients suffering from chronic pelvic pain resistant to medical management.

Objective To study the short-term (at the end of 6-month of treatment) and long-term (at the end of 1-year of treatment) overall curative effects of laparoscopy combined with continuous epidural block in treatment of chronic pelvic pain (CPP). Methods From April 2012 to April 2014, a total of 80 cases CPP patients who were treated in Yibin First People′s Hospital, and in accordance with the inclusion and exclusion criteria of CPP patients in this research were selected as the research subjects. According to the age of CPP patients, they were divided into ≤35-year old group (n=14), >35-45-year old group (n=21), >45-55-year old group (n=38), >55-year old group (n=7). At the same time, according to the different pathological types of laparoscopic examination results, they were divided into normal pelvic group (n=10), chronic pelvic inflammation group(n=16), pelvic adhesions group(n=26) and pelvic congestion group(n=28). If the above pathological types were crossed in one patient, the patient was enrolled into the serious degree pathological type group. By statistical method to analyze the short-term and long-term overall curative effects of laparoscopy combined with continuous epidural block in treatment of CPP. Results Short-term and long-term overall curative effects of laparoscopy combined with continuous epidural block in treatment of CPP in different pathological types groups, and different age groups were 96.3% (77/80) and 92.5%(74/80), 93.8% (75/80) and 91.3% (73/80), respectively, all the overall efficacies were over 91%. There were no significant differences of overall efficacies of long-term and short-term in different pathological types groups and in different age groups (P>0.05), respectively. Conclusions CPP is caused by multiple factors, the clinical syndromes are complicated, and its treatment method is still uncertain currently. Both the short-term and long-term curative effects of laparoscopy combined with continuous epidural block in treatment of CPP are good. Key words: Laparoscopes; Pelvic pain chronic; Analgesia, eidural; Female

Chronic Pelvic Pain