non-pathologic pelvic pain

[deleted131481]

Occasionally I get referrals for a female 20s-40s with chronic pelvic pain. Negative imaging and workup, failed pelvic floor therapy/PT. Is superior hypogastric plexus block worth it or should I stick with SNRIs?

Occasionally I've considered offering the procedure when they are headed toward the diagnostic laparascopy or hysterectomy route to try to avoid a surgery, but I wonder if I'm just tacking on another procedure without benefit. I only did it once for this indication, the patient said they improved substantially, and they still decided to get the hysterectomy.

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[willabeast]

Occasionally I get referrals for a female 20s-40s with chronic pelvic pain. Negative imaging and workup, failed pelvic floor therapy/PT. Is superior hypogastric plexus block worth it or should I stick with SNRIs?

Occasionally I've considered offering the procedure when they are headed toward the diagnostic laparascopy or hysterectomy route to try to avoid a surgery, but I wonder if I'm just tacking on another procedure without benefit. I only did it once for this indication, the patient said they improved substantially, and they still decided to get the hysterectomy.

I would avoid this diagnosis unless you are in a tertiary setting. In any setting always have a chaperone present.

 

[lobelsteve]

Occasionally I get referrals for a female 20s-40s with chronic pelvic pain. Negative imaging and workup, failed pelvic floor therapy/PT. Is superior hypogastric plexus block worth it or should I stick with SNRIs?

Occasionally I've considered offering the procedure when they are headed toward the diagnostic laparascopy or hysterectomy route to try to avoid a surgery, but I wonder if I'm just tacking on another procedure without benefit. I only did it once for this indication, the patient said they improved substantially, and they still decided to get the hysterectomy.

Putting needles in places without an explanation as to why, other than a subjective complaint does not seem like a really good idea.

 

[Orin]

I think a block provides data/validation for a surgeon to consider visceral vs non-visceral structures, but these are diagnostic and not curative blocks. I provide II/IH/GF, pudendal, hypogastric, impars, etc but the consideration for the next step after that require more discussion.

 

[lobelsteve]

I think a block provides data/validation for a surgeon to consider visceral vs non-visceral structures, but these are diagnostic and not curative blocks. I provide II/IH/GF, pudendal, hypogastric, impars, etc but the consideration for the next step after that require more discussion.

Got any data on the Sn/Sp of any of these blocks as diagnostic for anything? Could lead to unnecessary surgery and beyond.

 

[GlowInTheDark]

We would do differential epidural blocks where I trained.

Lumbar epidural, catheter to like L1-T10 range, dose them up until about a T8 dermatome level. If they still have abdominal pain then they’re told we’ve got nothing to offer. If their pain was essentially zero then we’d consider other blocks.

Some of our more adept Gyn surgeons would send the patients to us before operating on them. Others wouldn’t and then when their pain was no better after a whatever-ectomy they’d try to tell us it was our problem now.

 

[Orin]

Got any data on the Sn/Sp of any of these blocks as diagnostic for anything? Could lead to unnecessary surgery and beyond.

Sure, would love to define those numbers, but have you got a gold standard for a definite diagnosis of chronic pelvic pain?

The problem we're working around is a circular definition and a pathology with significant somatic involvement + suffering. Pelvic and facial pain seem to be the worst.

For me, if it responds to a sympathetic block, it's a visceral generator. If it responds to a somatic nerve block, it's a somatic issue. If it responds to neither, surgery isn't a good idea. If it responds to both, then we've got some questioning to do.

I don't disagree that it's a problematic issue, but I'm not sure we've got better options for helping patients/colleagues narrow down a generator. I'd much rather do these blocks early to help validate the need for more, rather than let incidentalomas drive interventional work.

Much like anything else though, doesn't have to be your circus, but it helps to know who to send to when you don't want to be the ring master.

 

[jqueb29]

Bilateral L1 and S2 DRG

 

[MitchLevi]

Bilateral L1 and S2 DRG

Ha

 

[lobelsteve]

Sure, would love to define those numbers, but have you got a gold standard for a definite diagnosis of chronic pelvic pain?

The problem we're working around is a circular definition and a pathology with significant somatic involvement + suffering. Pelvic and facial pain seem to be the worst.

For me, if it responds to a sympathetic block, it's a visceral generator. If it responds to a somatic nerve block, it's a somatic issue. If it responds to neither, surgery isn't a good idea. If it responds to both, then we've got some questioning to do.

I don't disagree that it's a problematic issue, but I'm not sure we've got better options for helping patients/colleagues narrow down a generator. I'd much rather do these blocks early to help validate the need for more, rather than let incidentalomas drive interventional work.

Much like anything else though, doesn't have to be your circus, but it helps to know who to send to when you don't want to be the ring master.

Gynofibro.
Dont go chasing waterfalls.

 

[Doctodd]

i think a negative workup is rare....they almost always have endometriosis or large ovarian cysts or chronic salpingitis from multiple ectopics or other things. Endometriosis is probably what i see most, and i have 1 patient on 1 vicodin per day.

 

[drrosenrosen]

I just saw a pt, recently moved from out of state, 30 y/o with chronic endometriosis, s/p all the usual treatments and gyn surgeries, has been on Perc 10/325 q4h for 6 years

I agreed to see her as a favor to a PCP friend, with the caveat that I do not endorse and will not take over the opioid regimen. Pt seems very reasonable, and wanted to try SHP block, which I am going to do.

 

[Orin]

I just saw a pt, recently moved from out of state, 30 y/o with chronic endometriosis, s/p all the usual treatments and gyn surgeries, has been on Perc 10/325 q4h for 6 years

I agreed to see her as a favor to a PCP friend, with the caveat that I do not endorse and will not take over the opioid regimen. Pt seems very reasonable, and wanted to try SHP block, which I am going to do.

Superior hypogastric plexus block as an effective treatment method for endometriosis-related chronic pelvic pain: an open-label pilot clinical trial - PubMed

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...

pubmed.ncbi.nlm.nih.gov

Anatomically makes sense.
Data is suggestive of benefit.

Insurance will likely not cover

 

[Ligament]

Superior hypogastric plexus block as an effective treatment method for endometriosis-related chronic pelvic pain: an open-label pilot clinical trial - PubMed

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...

pubmed.ncbi.nlm.nih.gov

Anatomically makes sense.
Data is suggestive of benefit.

Insurance will likely not cover

A good endo surgeon can do a presacral neurectomy if patient has good anesthetic phase response to Sup. Hypogastric plexus blocks.

 

[DrMDAware]

Never needle a nut.

I agree with the sentiment.

What do you tell patients who come to you looking for pain relief? Is it some thing of a silent denial where you just prescribe pelvic floor PT and Cymbalta? Or is it something more direct? Honest questions.

When I offer these types of blocks I make sure the patient knows that they are unlikely to work and we will never likely find the clear underlying diagnosis. In addition, I stress of the psychological and non-intervention approaches as being key pillars. I make no guarantees.