Superior hypogastric plexus block is the common treatment for tailbone or pelvic pain. The superior hypogastric plexus is a retroperitoneal structure located bilaterally at the level of the lower 3rd of the fifth lumbar and upper third of the first sacral promontory and in proximity to the bifurcation of the common iliac vessel. In addition, these plexus emerge from the visceral afferent nerves and the sympathetic nerves from the aortic plexus. The organs innervated by the superior hypogastric plexus include the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testis, rectum and descending colon. During the growth of malignancies and degenerative conditions of any of these visceral organs can cause severe progressively enervating pain and highly advisable if patients have taken pain relievers that were ineffective. In such cases, this technique is helpful by preventing pain signals reaching the plexus.
Anatomy of Hypogastric Plexus
The superior hypogastric plexus is a retroperitoneal structure located bilaterally at the level of the lower third of the fifth lumbar vertebral body and upper third of the first sacral vertebral body at the sacral promontory and in proximity to the bifurcation of the common iliac vessels. This plexus (sometimes referred to as the presacral nerve) originates from the confluence of the lumbar sympathetic chains and branches of the aortic plexus that contains fibres that have traversed the celiac and inferior mesenteric plexuses. In addition, it usually contains parasympathetic fibres that originate in the ventral roots of S2-4 and travel as the slender nerve erigentes (pelvic splanchnic nerves) through the inferior hypogastric plexus to the superior hypogastric plexus.
The superior hypogastric plexus divides into the right and left hypogastric nerves that descend laterally to the sigmoid colon and rectosigmoid junction to reach the two inferior hypogastric plexuses. The superior plexus gives off branches to the ureteric and testicular (or ovarian) plexuses, the sigmoid colon, and the plexus that surrounds the common and internal iliac arteries. The inferior hypogastric plexus is a bilateral structure that settles on either side of the rectum, lower part of the bladder, and (in the male) prostate and seminal vesicles or (in the female) the uterine cervix and vaginal fornices. In contrast to the superior hypogastric plexus, the configuration of the inferior hypogastric plexus is more in traverse orientation, extending posteroanterior and parallel to the pelvic floor. Because of its location and configuration, the inferior hypogastric plexus does not lend itself to surgical or chemical extirpation.
Hypogastric Plexus Indications
Chronic intractable lower abdominal or pelvic pain is the indications for superior hypogastric plexus block. Indications include:
- Non-malignant pelvic pain
- Pelvic inflammatory disease
- Testicular pain
- Ilioinguinal neuralgia or post-herniorrhaphy pain
- Neoplastic pelvic pain
Prior to the procedure, the area where the needle is inserted will be numbed with local anesthetic and prepped with an antiseptic solution such as Povidone iodine or chlorhexidine. The surrounding areas of the injection site will be draped with surgical linen for a sterile field. When performing a superior hypogastric plexus block, the physician will use an X-ray or a fluoroscope as a guide to insert the needle and catheter before the anesthetic is administered.
Superior Hypogastric Procedure
This procedure is a hypogastric nerve block and can be done in an outpatient procedure room or X-ray table under local anesthesia. The most common approach is the posterior and transdiscal approaches. However, In the posterior approach, prone is the most appropriate position with one or two pillows under the lower abdomen to reduce lumbar lordosis. And if this approach is stressful to the patient or not feasible with the physician due to technical difficulties then the transdiscal or anterior technique with fluoroscopy or ultrasound guidance is the appropriate method. A contrast dye will be used to confirm the placement of the needles. Once the needles are placed, either a diagnostic block to determine whether the pain originates from that site or therapeutic block to offer pain relief and pain will be relieved significantly.
Benefits of Superior Hypogastric Plexus
This treatment is a well-established procedure for the treatment of chronic pelvic pain particularly related secondary to malignancies. It is minimally invasive and does not require surgery. 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 fibres to the superior hypogastric plexus.
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 procedure for years. Above all, the procedure is a low-risk, non-surgical treatment that if successful the first time, will most likely continue to provide pain relief with repeat treatments.
If you are suffering from chronic pain or pelvic 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.
Dr Ronak Patel, a pain management doctor in Plainsboro NJ and Princeton NJ, is happy to offer this exciting treatment option. To schedule an appointment today, call (609) 269-4451.