Effectiveness of Superior Hypogastric Plexus Block for Pain Control Compared to Epidural Anesthesia in Women Requiring Uterine Artery Embolization for the Treatment of Uterine Fibroids - A Retrospective Evaluation.

PURPOSE: To assess the effectiveness of pain management with superior hypogastric plexus block (SHPB) compared to epidural anesthesia (EDA) in women requiring uterine artery embolization (UAE). MATERIALS AND METHODS: In this retrospective, single-center, non-randomized trial we included 79 women with symptomatic uterine fibroids who were scheduled for percutaneous, transcatheter UAE. According to their informed decision, the women were assigned to two different approaches of pain management including either SHPB or EDA. The effectiveness outcome measure was patient reported pain using a numeric rating scale ranging from 1 to 10. The pain score was assessed at UAE, 2 hours thereafter, and at subsequent intervals of 6 hours up to 36 hours after intervention. RESULTS: Treatment groups did not differ significantly regarding age, pain score for regular menstrual cramps, uterine fibroid size, location, and symptoms of uterine fibroids. During UAE and up to 6 hours thereafter, women who received SHPB experienced stronger pain than those who received EDA (mean pain score during UAE: 3.3 vs. 1.5, p < 0.001; at 2 hours: 4.4 vs. 2.8, p = 0.012; at 6 hours: 4.4 vs. 2.6, p = 0.021). The maximum pain level was 5.8 ±â€Š2.9 with SHPB and 4.5 ±â€Š2.9 with EDA (p = 0.086). Women with a history of severe menorrhagia tended to experience worse pain than those without (regression coefficient 2.5 [95 % confidence interval -0.3 to 5.3], p = 0.076). CONCLUSION: Among women who underwent UAE, pain management including SHPB resulted in stronger pain during and after the procedure than pain treatment including EDA. KEY POINTS: · Pain control with superior hypogastric plexus block was worse than epidural anesthesia.. · Peak of pain was at 12 hours after uterine artery embolization.. · Maximum pain was independent from uterine fibroid size or location.. CITATION FORMAT: · Malouhi A, Aschenbach R, Erbe A et al. Effectiveness of Superior Hypogastric Plexus Block for Pain Control Compared to Epidural Anesthesia in Women Requiring Uterine Artery Embolization for the Treatment of Uterine Fibroids - A Retrospective Evaluation. Fortschr Röntgenstr 2021; 193: 289 - 297.

Response of hypogastric afferent fibers to bladder distention or irritation in cats.

The goal of this study in anesthetized cats was to identify silent hypogastric nerve (HGN) afferent fibers that do not respond to bladder distention but become responsive after chemical irritation of the bladder. The HGN was split into multiple filaments small enough for recording action potentials from single or multiple afferent fibers. The bladder was distended by infusion of either saline or 0.5% acetic acid (AA) through a urethral catheter while recording intravesical pressure. A total of 90 HGN filaments from 17 cats responded to bladder distention with saline or AA. Three types of HGN afferents were identified. The first type was non-nociceptive mechano-sensitive that responded to bladder distention at normal physiological pressures (10-40 cmH2O). The second type was nociceptive mechano-sensitive that only responded to high-pressure (50-80 cmH2O) bladder distention with saline but responded to low-pressure bladder distention after sensitization with AA. The third type was chemo-sensitive nociceptive that was silent even during high-pressure bladder distention but after sensitization with AA did respond to low-pressure bladder distention. These results indicate that HGN afferents as well as pelvic nerve afferents may play a role in bladder nociception. The HGN afferent fibers that are silent during bladder distention at normal physiological pressures but become responsive after chemical irritation are important for understanding the possible pathophysiological mechanism underlying bladder allodynia in painful bladder syndrome.

Effectiveness of Superior Hypogastric Plexus Neurolysis for Pelvic Cancer Pain.

BACKGROUND: The superior hypogastric plexus block has been indicated for visceral pelvic pain treatment associated with malignancy. The first international report of this technique was published by Plancarte et al, in which a posterior percutaneous approach guided by fluoroscopy was described by applying neurolytic agents. The considerable variability in the data reported gave rise to 2 clinical approaches to those who performed the blockade early and those who executed it at a later stage of cancer. OBJECTIVES: The present study aims to provide more evidence regarding the effectiveness of this procedure. STUDY DESIGN: This is a retrospective, longitudinal, descriptive study. SETTING: The study was held at the pain unit service of the National Cancer Institute, Mexico City. METHODS: A nonprobabilistic sample was selected; the data collection took place from January 2006 to December 2016 with patients diagnosed with pelvic pain, confirmed by imaging and biopsy studies. Patients who received any other type of intervention of the sympathetic axis, patients with a different approach than the classic or paravertebral technique, and patients with low survival rate were excluded. The Student t test was used to measure the significant difference between Visual Analog Scale (VAS) and morphine equivalent daily dose. The Cochran-Mantel-Haenszel test and the Gamma test were used to measure the association between the initial Karnofsky and blockade success. RESULTS: The study included a total of 180 patients. The success rate was 59.4% at 1 month, 55.5% at 3 months, and 48.8% at 6 months. There was a sustained and significant VAS reduction that was 49.55% at 3 months. A significant reduction in opioid consumption of 12.55% was found at 3 months. There was no significant statistical evidence related to either opioid consumption or the functionality of the patient before the blockade as an influential variable in the success of the procedure. LIMITATIONS: Retrospective study, developed in a single center. CONCLUSIONS: Although opioids remain the cornerstone of cancer pain treatment, they produce many deleterious side effects. The superior hypogastric plexus neurolysis represents a reproducible and effective alternative in the management of pain in this group of patients. KEY WORDS: Pelvic pain, neoplasms, chemical neurolysis, pain management, cancer pain, palliative care, analgesia, nerve block.

Pelvic plexus block to provide better anesthesia in transperineal template-guided prostate biopsy: a randomised controlled trial.

BACKGROUND: To evaluate the efficacy of pelvic plexus block (PPB) in relief pain during transperineal template-guided prostate biopsy (TTPB), compared with conventional periprostatic nerve block (PNB). METHODS: From July 2016 to August 2017, 245 patients who were performed TTPB in Clinical Medical College of Yangzhou University were recruited. The patients were randomized into three groups using a random number table. Group-1 received prostate capsule local anesthesia with 22 ml of 1% lidocaine. Group-2 additionally received PNB on the basis of Group-1. To perform PNB, 5 ml 1% lidocaine was injected into the region of prostatic neurovascular bundle situated in the angle of prostate-bladder-seminal vesicle. Group-3 received prostate capsule local anesthesia plus PPB (5 ml of 1% lidocaine injection into the pelvic plexus which located on lateral to the bilateral seminal vesicle apex). The patients' pain and satisfaction were evaluated by visual analogue scale and visual numerical scale, respectively. RESULTS: The age, total prostate volume, PSA and the number of cores were comparable among the three groups. The visual analog scale scores of group-3 were significantly lower than group-2 during biopsy (P = 0.003). Conversely, the visual numeric scale scores were higher in group-3 (P = 0.039). Both the group-2 and group-3 outperformed the group-1 in alleviating pain and had a higher quantification of satisfaction. There were no significant differences in the pain scores or the satisfaction scores at 30 min after the procedure among the three groups. CONCLUSIONS: The analgesic efficacy of PPB guided by Doppler ultrasound in TTPB was better than that of PNB and both were superior to no nerve block. TRIAL REGISTRATION: ChiCTR-IOR-17013533 , 01/06/2016.

Computed Tomography-Guided Superior Hypogastric Plexus Block for Secondary Dysmenorrhea in Perimenopausal Women.

BACKGROUND Refractory abdominal pain during menstruation severely affects patients' quality of life and simultaneously places enormous psychological burdens on patients and their families. Several treatments for secondary dysmenorrhea are available; however, none can permanently treat all types of secondary dysmenorrhea. Since pain is transmitted by the nerves, we hypothesized that a neurolytic block could be used as a treatment for refractory abdominal pain during menstruation. We sought to investigate the therapeutic efficacy and safety of computed tomography (CT)-guided superior hypogastric plexus block for secondary dysmenorrhea. MATERIAL AND METHODS We performed CT-guided neurolytic block of the superior hypogastric plexus by bilaterally administering 4 mL of a dehydrated alcohol solution in 25 patients from January 2014 to February 2016. The degree of pain and its impact on the patients' mood and quality of life were evaluated using the visual analogue scale, Hospital Anxiety and Depression Scale, and 36-Item Short Form Survey before and after therapy, and the data were statistically analyzed using analysis of variance and t test. RESULTS The degrees of pain were significantly (p<0.05) decreased after neurolytic block (from 7.74±1.14 to 2.96±1.55). The patients showed significantly (p<0.05) less anxiety and improved bodily pain with mental health status. CONCLUSIONS Secondary dysmenorrhea can be effectively and safely treated with a neurolytic block of the superior hypogastric plexus.

Local anesthesia for transrectal ultrasound-guided biopsy of the prostate: A meta-analysis.

A meta-analysis was performed to evaluate the efficacy of local anesthesia in alleviating pain during prostate biopsy. We searched relevant articles in PubMed and Embase. The included studies should be randomized controlled trials (RCT) using local anesthesia to alleviate pain during biopsy, which was recorded by a pain scale. Analgesic efficacy of different local anesthesia techniques were analyzed, including intrarectal local anesthesia (IRLA), periprostatic nerve block (PNB), pelvic plexus block (PPB) and intraprostatic local anesthesia (IPLA). We included 46 RCTs. PNB significantly reduced pain score compared with placebo (-1.27 [95% confidence interval [95% CI] -1.72, -0.82]) or no injection (-1.01 [95% CI -1.2, -0.82]). IRLA with prilocaine-lidocaine cream could also reduced pain (-0.45 [95% CI -0.76, -0.15]), while the IRLA with lidocaine gel was not effective (-0.1 [95% CI -0.24, 0.04]). PNB lateral to the neurovascular bundle had better analgesic effect than at prostate apex (P = 0.02). Combination use of PPB and IRLA considerably alleviated pain of patients compared with the combination of PNB and IRLA (-1.32 [95% CI -1.59, -1.06]). In conclusion, local anesthesia could alleviate patients' pain during the prostate biopsy. PNB was not so effective as PPB.

Superior Hypogastric Nerve Block to Reduce Pain After Uterine Artery Embolization: Advanced Technique and Comparison to Epidural Anesthesia.

PURPOSE: To evaluate a modified superior hypogastric nerve block (SHNB) to reduce pain after uterine artery embolization (UAE) compared to epidural anesthesia. MATERIALS AND METHODS: In this retrospective study, the amount of opiate drugs needed after UAE was compared between SHNB and epidural anesthesia. Eighty one consecutive women (mean age: 43.67 years) were in the SHNB group and 27 consecutive women (mean age: 43.48 years) treated earlier at the same institution in the epidural anesthesia group. UAE was performed from a unilateral femoral artery approach using a 4F catheter. 500-700 or 700-900 µm trisacryl gelatine microspheres were used as embolic agents. The SHNB was performed by advancing a 21G from the abdominal wall below the umbilicus to the anterior portion of the 5th vertebral body. For optimal guidance a cranio-caudal tilt of 5°-15° was used. On a lateral view the correct contrast distribution in front of the vertebral body is confirmed. Then 20 ml local anesthesia (ropivacain 0.75 %) is injected. In case of an asymmetric right-left distribution the needle was repositioned. RESULTS: All SHNB were successful without severe complications. The mean time for the SHNB was 4 min 38 s (2 min 38 s-9 min 27 s). The needle was repositioned in average 0.87 times. The opiate dose for the SHNB group was 19.33 ± 22.17 mg which was significantly lower. The average time to receive an opiate drug after SHNB was 4 h 41 min. CONCLUSION: The SHNB is a safe and minimally time-consuming way to reduce pain after UAE especially within the first 4 h.

Superior hypogastric plexus combined with ganglion impar neurolytic blocks for pelvic and/or perineal cancer pain relief.

BACKGROUND: The superior hypogastric plexus (SHGP) carries afferents from the viscera of the lower abdomen and pelvis. Neurolytic block of this plexus is used for reducing pain resulting from malignancy in these organs. The ganglion impar (GI) innervats the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina. Different approaches to the ganglion impar neurolysis have been described in the literature. OBJECTIVES: To assess the feasibility, safety, and efficacy of combining the block of the SHGP through the postero-median transdiscal approach with the GI block by the trans-sacro-coccygeal approach for relief of pelvic and/or perineal pain caused by pelvic and/or perineal malignancies or any cancer related causes. METHODS: Fifteen patients who had cancer-related pelvic pain, perineal pain, or both received a combined SHGP neurolytic block through the postero-median transdiscal approach using a 20-gauge Chiba needle and injection of 10 mL of 10% phenol in saline plus a GI neurolytic block by the trans-sacro-coccygeal approach using a 22-gauge 5 cm needle and injection of 4 - 6 mL of 8% phenol in saline. Pain intensity (measured using a visual analogue scale) and oral morphine consumption pre- and post-procedure were measured. RESULTS: All patients presented with cancer-related pelvic, perineal, or pelviperineal pain. Pain scores were reduced from a mean (± SD) of 7.87 ± 1.19 pre-procedurally to 2.40 ± 2.10 one week post-procedurally (P < 0.05). In addition, the mean consumption of morphine (delivered via 30 mg sustained-release morphine tablets) was reduced from 98.00 ± 34.89 mg to 32.00 ± 28.48 mg after one week (P < 0.05). No complications or serious side effects were encountered during or after the block. LIMITATIONS: This study is limited by its small sample size and non-randomized study. CONCLUSION: A combined neurolytic SHGP block with GI block is an effective and safe technique for reducing pain in cancer patients presented with pelvic and/or perineal pain. Also, a combined SHGP block through a posteromedian transdiscal approach with a GI block through a trans-sacrococcygeal approach may be considered more effective and easier to perform than the recently invented bilateral inferior hypogastric plexus neurolysis through a transsacral approach.

Comparing the analgesic effect of caudal and ilioinguinal iliohypogastric nerve blockade using bupivacaine-clonidine in inguinal surgeries in children 2-7 years old.

BACKGROUND: We compared the analgesic effects of caudal and ilioinguinal-iliohypogastric nerve block using bupivacaine-clonidine performed in children undergoing inguinal hernia repair. The ilioinguinal-iliohypogastric nerve block provides excellent pain relief for operations on the inguinal region, including emergency procedures (e.g. strangulated inguinal hernia with intestinal obstruction). It should be preferred to caudal block for these procedures. MATERIALS AND METHODS: After local ethics committee approval and written parental consent, 67 ASA class I - II patients aged between 2-7 years old scheduled for elective inguinal hernia repair were allocated randomly into two groups after general anesthesia with same drugs in both groups. Group C received caudal block with 1 ml/kg bupivacaine 0.25% combined with 1 µg/kg clonidine, and group I received ilioinguinal- iliohypogastric nerve block with 0.3 ml /kg bupivacaine 0.25% combined with 1 µg/kg clonidine. Blood pressure and heart rate were documented every 5 minutes. Post-operative analgesia, analgesic use and side-effects were assessed during first 24 hours. RESULTS: In group C, 7 / 34 and in group I, 12/33 patients required post-operative analgesia (P = 0.174). Five patients (15.5%) in group I and one patient (2.94%) in group C had severe pain after operation. Systolic and diastolic blood pressure decreased during operation, but the differences between two groups were not significant (P = 0.176, P = 0.111). Heart rate changes between two groups were insignificant (P = 0.182). CONCLUSION: It seems that in children, caudal epidural block and ilioinguinal - iliohypogastric nerve block using bupivacaine-clonidine have comparable effects on analgesia, severity of pain and hemodynamic changes during and after surgery on inguinal region.

Efficacy of the anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in advanced gynecological cancer patients.

BACKGROUND AND AIMS: Pelvic cancer pain is a chronic pain related to the involvement of viscera, neural, and pelvic muscular. The study was carried out to evaluate the efficacy of anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in gynecological cancer patients. MATERIAL & METHODS: The study was conducted after approval of our Institutional Ethics Committee. A total of 50 patients diagnosed with the advanced stage of a gynecological malignancy with severe pelvic pain were enrolled and randomly divided in two groups; in Group I, patients were given oral morphine, while in Group II, patients underwent anterior ultrasonography (USG)-guided superior hypogastric neurolysis. Oral morphine was given as rescue analgesia in both the groups. The parameters recorded were pain, functional capacity, global satisfaction score, and adverse effects. RESULTS: There was a significant decrease in visual analog scale (VAS) score in the both groups, but the decline in VAS scores from baseline in Group II was significantly (P < 0.05) greater. The daily morphine consumption in Group II decreased throughout the study, and more patients in Group II improved in their functional capacity, although it was statistically insignificant. It was observed that global satisfaction scores were better in Group II during the initial first (P = 0.001) week and 1 month (P = 0.04) compared with Group I. CONCLUSION: The anterior USG-guided superior hypogastric plexus neurolysis is a useful technique in relieving pelvic pain in gynecological malignancies. However, it requires expertise to perform the block. It also avoids the radiation exposure involved with computed tomography-guided and fluoroscopy-guided superior hypogastric block.

Pelvic plexus block is more effective than periprostatic nerve block for pain control during office transrectal ultrasound guided prostate biopsy: a single center, prospective, randomized, double arm study.

PURPOSE: We compared intrarectal local anesthesia plus pelvic plexus block vs intrarectal local anesthesia plus periprostatic nerve block during transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: Patients were randomized 1:1 by a computer generated schedule into group 1-90 who received intrarectal local anesthesia (lidocaine 1.5%-nifedipine 0.3% cream) plus pelvic plexus block (2.5 ml lidocaine 1% plus naropine 0.75% injected on each side into the pelvic neurovascular plexus lateral to the seminal vesicle tip) and group 2-90 who received intrarectal local anesthesia plus periprostatic nerve block (2.5 ml of the same mixture injected on each side into the neurovascular bundles at the prostate-bladder-seminal vesicle angle) before transrectal ultrasound guided prostate biopsy. After the procedure patients were instructed to rate the level of pain/discomfort from 0 to 10 on the visual analog scale at certain time points, including during the introduction and presence of the probe in the rectum, during pelvic plexus block or periprostatic nerve block, during biopsy and 30 minutes after biopsy. RESULTS: The 2 groups were similar in age, serum prostate specific antigen and total prostate volume. There was no difference in pain perception during probe introduction and pelvic plexus or periprostatic nerve block. Pain during prostate biopsy was significantly lower in group 1 than in group 2 (p <0.001). The same trend was recorded for pain perception 30 minutes after biopsy (p = 0.001). There were no major complications. CONCLUSIONS: Pelvic plexus block under Doppler ultrasound guidance provides better analgesia than periprostatic nerve block during office based transrectal ultrasound guided prostate biopsy.

Systemic oxytocin induces a prolactin secretory rhythm via the pelvic nerve in ovariectomized rats.

We have shown previously that an intravenous injection of oxytocin (OT) in ovariectomized (OVX) rats initiates a circadian rhythm of prolactin (PRL) secretion similar to that observed after cervical stimulation (CS). In this study, we investigated the pathway through which OT triggers the PRL rhythm. We first tested whether an intracerebroventricular injection of OT could trigger the PRL secretory rhythm. As it did not, we injected OT intravenously while an OT receptor antagonist was infused intravenously. This antagonist completely abolished the PRL surges, suggesting that a peripheral target of OT is necessary for triggering the PRL rhythm. We hypothesized that OT may induce PRL release, which would be transported into the brain and trigger the rhythm. In agreement with this, OT injection increased circulating PRL by 5 min. To test whether this acute increase in PRL release would induce the PRL rhythm, we compared the effect of intravenously administered thyrotropin-releasing hormone (TRH) and OT. Although TRH injection also increased PRL to a comparable level after 5 min, only OT-injected animals expressed the PRL secretory rhythm. Motivated by prior findings that bilateral resection of the pelvic nerve blocks CS-induced pseudopregnancy and OT-induced facilitation of lordosis, we then hypothesized that the OT signal may be transmitted through the pelvic nerve. In fact, OT injection failed to induce a PRL secretory rhythm in pelvic-neurectomized animals, suggesting that the integrity of the pelvic nerve is necessary for the systemic OT induction of the PRL secretory rhythm in OVX rats.

Anatomical tracer injections into the lower urinary tract may compromise cystometry and external urethral sphincter electromyography in female rats.

Physiological and anatomical investigations are commonly combined in experimental models. When studying the lower urinary tract (LUT), it is often of interest to perform both urodynamic studies and retrogradely labeled neurons innervating the peripheral target organs. However, it is not known whether the use of anatomical tracers for the labeling of, e.g. spinal cord neurons may interfere with the interpretation of the physiological studies on micturition reflexes. We performed cystometry and external urethral sphincter (EUS) electromyography (EMG) under urethane anesthesia in adult female rats at 5-7 days after injection of a 5% fluorogold (FG) solution or vehicle into the major pelvic ganglia (MPG) or the EUS. FG and vehicle injections into the MPG and EUS resulted in decreased voiding efficiency. MPG injections increased the duration of both bladder contractions and the inter-contractile intervals. EUS injections decreased EUS EMG bursting activity during voiding as well as increased both the duration of bladder contractions and the maximum intravesical pressure. In addition, the bladder weight and size were increased after either MPG or EUS injections in both the FG and vehicle groups. We conclude that the injection of anatomical tracers into the MPG and EUS may compromise the interpretation of subsequent urodynamic studies and suggest investigators to consider experimental designs, which allow for physiological assessments to precede the administration of anatomical tracers into the LUT.

Mechanisms of adaptive supersensitivity in vas deferens.

Adaptive supersensitivity is a phenomenon characteristic of excitable tissues and discloses as a compensatory adjustment of tissue's response to unrelated stimulatory endogenous and exogenous substances after chronic interruption of excitatory neurotransmission. The mechanisms underlying such higher postjunctional sensitivity have been postulated for a variety of cell types. In smooth muscles, especially the vas deferens with its rich sympathetic innervation, the mechanisms responsible for supersensitivity are partly understood and appear to be different from one species to another. The present review provides a general understanding of adaptive supersensitivity and emphasizes early and recent information about the putative mechanisms involved in this phenomenon in rodent vas deferens.

omega-Conotoxin-GVIA-sensitive calcium channels on preganglionic nerve terminals in mouse pelvic and celiac ganglia.

Release of acetylcholine (ACh) from preganglionic nerve terminals requires calcium entry through voltage-gated calcium channels. The calcium channel subtype required for ACh release varies depending on the particular ganglionic synapse. I have investigated the functional role of calcium channels in transmitter release from parasympathetic and sympathetic preganglionic terminals in pelvic and celiac ganglia of female mice. Single electrode voltage clamp was used to measure EPSC amplitude in the absence and presence of selective calcium channel antagonists. In pelvic ganglia omega- conotoxin GVIA, a selective N-type calcium channel antagonist, reduced the amplitude of EPSCs evoked by pelvic nerve stimulation by 46+/-5% (n=8, P=0.015). In contrast, in the celiac ganglion, omega- conotoxin GVIA had no effect on the amplitude of EPSCs evoked by splanchnic nerve stimulation (P=0.09, n=7). EPSCs in both pelvic and celiac ganglia were resistant to the P-type calcium channel antagonist agatoxin (50 nM, n=5 for both ganglia) and the R-type calcium channel antagonist SNX482 (100 nM, n=4 for both ganglia). These results indicate that in female mice, release of ACh in sympathetic pathways to prevertebral ganglia does not require calcium entry from N-type calcium channels. However, release of ACh from sacral parasympathetic preganglionic neurons requires calcium entry from both N-type and toxin-resistant calcium channels.