Current Pain and Headache Reports (2021) 25: 13

https://doi.org/10.1007/s11916-020-00933-0

CHRONIC PAIN MEDICINE (O VISWANATH, SECTION EDITOR)

A Comprehensive Update of the Superior Hypogastric Block

for the Management of Chronic Pelvic Pain
Ivan Urits 1,2 & Ruben Schwartz 3 & Jared Herman 3 & Amnon A. Berger 1 & David Lee 4 & Christopher Lee 5 &
Alec M. Zamarripa 4 & Annabel Slovek 6 & Kelly Habib 4 & Laxmaiah Manchikanti 7 & Alan D. Kaye 2 & Omar Viswanath 2,4,6,8

Accepted: 29 December 2020 / Published online: 25 February 2021

# The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021

Abstract
Purpose of Review This is a comprehensive review of the superior hypogastric block for the management of chronic pelvic pain.
It reviews the background, including etiology, epidemiology, and current treatment available for chronic pelvic pain. It then
presents the superior hypogastric block and reviews the seminal and most recent evidence about its use in chronic pelvic pain.
Recent Findings Several definitions exist for chronic pelvic pain (CPP), making the diagnosis more challenging for the clinician;
however, they commonly describe continuous pain lasting 6 months in the pelvis, with an overwhelming majority of patients
being reproductive-aged women. This pain is often one of mechanical, inflammatory, or neuropathic. It is generally
underdiagnosed and affects anywhere between 5 and 26% of women. The diagnosis of chronic pelvic pain is clinical, consisting
of mainly of a thorough history and physical and ruling out other causes. The pathophysiology is often endometriosis (70%) and
also includes PID, adhesions, adenomyosis, uterine fibroids, chronic processes of the GI and urinary tracts, as well as pelvic-
intrinsic musculoskeletal causes. Treatment includes physical therapy, cognitive behavioral therapy, and oral and parenteral
opioids. Interventional techniques provide an added tier of treatment and may help to reduce the requirement for chronic opioid
use. Superior hypogastric plexus block is one of the available interventional techniques; first described in 1990, it has been shown
to provide long-lasting relief in 50–70% of patients who underwent the procedure. Two approaches described so far, both under
fluoroscopy, have seen similar results. More recently, ultrasound and CT-guided procedures have also been described with
similar success. The injectate includes local anesthetic, steroids, and neurolytic agents such as phenol or ethanol.
Summary CPP is a common debilitating condition. It is diagnosed clinically and is underdiagnosed globally. Current treatments
can be helpful at times but may fall short of satisfactory pain relief. Interventional techniques provide an added layer of treatment
as well as reduce the requirement for opioids. Superior hypogastric plexus block provides long-lasting relief in many patients,
regardless of approach. Evidence level is limited, and further RCTs could help provide better tools for evaluation and patient
selection.

Keywords Chronic pain . Nerve block . Endometriosis . PID . Neurolysis . Injectional pain therapy

This article is part of the Topical Collection on Chronic Pain Medicine

* Ruben Schwartz Annabel Slovek

rubenschwartz@yahoo.com Annabel.slovak@gmail.com

Ivan Urits Kelly Habib

ivanurits@gmail.com kellyhabib@email.arizona.edu

Amnon A. Berger Laxmaiah Manchikanti

amnon.berger@mail.huji.ac.il drlm@thepainmd.com
David Lee Alan D. Kaye
deelee26@email.arizona.edu akaye@lsuhsc.edu
Christopher Lee
ChristopherLee1@creighton.edu Omar Viswanath
viswanoy@gmail.com
Alec M. Zamarripa
aleczamarripa@email.arizona.edu Extended author information available on the last page of the article
13 Page 2 of 16
Introduction
As opposed to the definition of general chronic pain as per-
sistent or recurrent pain of at least 3 months by the
International Association for the Study of Pain (IASP), there
is currently no single definition of chronic pelvic pain (CPP)
that is universally followed [1]. The American Academy of
Family Physicians (AAFP) defines CPP pain in women as the
persistence or recurrence of pain within the pelvic anatomical
region that lasts at least 6 months and is not cyclic in nature
[2]. The American College of Obstetricians and
Gynecologists defines CPP as pain of the pelvis, anterior ab-
dominal wall, or buttocks that is non-cyclic and causes dis-
ability or requires medical care [3]. The Royal College of
Obstetricians and Gynecologists Green-top Guidelines define
CPP as intermittent or continuous lower abdominal pain for at
least 6 months that causes functional disability and is not due
to menstruation or intercourse [3]. The Society of
Gynecologists and Obstetricians of Canada defines CPP as
pain that consists of a duration of at least 6 months, refractory
to most treatments, impairs function in the work and home
setting, consists of symptoms of depression, and alters a pa-
tient’s role at home [3]. The subtle differences in the definition
of CPP make for a particular challenge for patients who may
not meet the criteria for CPP depending on the definition
followed by their healthcare provider. At the same time, the
lack of definitive guidelines also poses a challenge for
healthcare providers who diagnose based on different defini-
tions established by different medical organizations.
The pathophysiology of CCP includes pain defined as noci-
ceptive, inflammatory, or neuropathic. Nociceptive pain in the
context of pelvic pain is thought to be visceral pain due to
hemorrhage, muscle spasm, distension, inflammation, or can-
cer, which are all detected by receptors that are responsible for
the sensation of touch, pressure, or proprioception [3]. The
IASP categorizes CPP under the chronic secondary visceral
pain subdivision and also lists similar pathophysiologic causes
such as mechanical causes (e.g., obstruction), vascular explana-
tions such as ischemia or thrombosis, or general inflammation
that irritates the surrounding region [1]. Inflammatory pain con-
sists of many responsible factors that contribute to the reception
of pain, such as tumor necrosis factor-alpha, prostaglandins,
nerve growth factors, mast cell release, and interleukins [3].
Finally, neuropathic pain is due to damage in the periphery such
as in the case of diabetes or central nervous system that mani-
fests in forms such as allodynia and hyperalgesia secondary to a
phenomenon known as centralized pain, which is an exagger-
ated pain response due to various triggers [3, 4].
Epidemiology
Approximately 99% of patients with CPP are women, many
of whom are within reproductive age according to a study by
Curr Pain Headache Rep (2021) 25: 13
Tu et al., which assessed the number and age of female pa-
tients registered in the National Survey of Ambulatory
Surgery who underwent diagnostic laparoscopy for CPP [5].
The estimated prevalence of CPP has a sizeable range, possi-
bly due to different definitions used to diagnose patients with
CPP. A systematic review by Alebtekin et al. assessed all
prevalence studies from 2005 to 2012. The studies assessed
by the systematic review varied in terms of study design and
included three cross-sectional studies, a mailing questionnaire
survey, a telephone interview with computer assistance, a data
analysis survey by questionnaire, and a single prospective
study. The study found that the prevalence of CPP ranges
from 5.7 to 26.6%. Many shortcomings were determined in
this systematic review, such as a lack of a patient registry for
CPP, inconsistent criteria for CPP diagnosis, suspected under-
diagnosis of CPP given the lack of guidelines for definition,
and a lack of any sizable study that encompasses a large sam-
ple size. Further work must be done to address the educational
aspect of diagnosing CPP as well as a need for more robust
and high-quality studies to better determine the prevalence of
CPP [6]. A cross-sectional population-based study in the UK
in 2017 by Ayorinde et al. was designed to establish the prev-
alence of CPP among women who were at least ≥ 25 years of
age. Two thousand three hundred thirty-seven questionnaires
were returned with complete responses, and approximately
14.8% of responding patients had a diagnosis of CPP and
were also found to have co-existing fatigue, depression, and
somatic symptoms that were non-pain related. Furthermore,
the average age of responding patients was 53 years of age,
and a larger percentage of women were living in rural regions
vs. urban regions. This study concluded that although women
of reproductive age are thought to have the highest rate of
CPP, older women, and patients who live in regions with
limited healthcare access, such as rural regions, may also be
populations worth studying in the future to determine if there
is a similarity of the prevalence of CPP in these patient pop-
ulations compared to younger women within the reproductive
age group. Additional research should be conducted to ex-
plore the non-pain-related symptoms that were frequently
seen in this study’s older patient population, such as psycho-
logic and sociologic distress, that could potentially help future
healthcare providers identify women suffering from CPP [7].
Risk Factors
A systematic review by Pallavi et al. identified a total of 122
studies that listed over 60 risk factors that could explain or
contribute to patients with dysmenorrhea, dyspareunia, and/or
non-cyclic pelvic pain. There was evidence to suggest that any
identification of pelvic pathology, a history of abuse, or the
presence of a psychologic condition increased the likelihood
of a diagnosis of CPP. The study concluded that further stud-
ies should explore the broader consequences of these
Curr Pain Headache Rep (2021) 25: 13
identified risk factors, such as a history of abuse contributing
to the development of depression that has been linked with
CPP [8]. Another study by Sule et al. identified statistically
significant risk factors that include women who have had both
vaginal birth and cesarean sections, a family history of cancer,
previous surgical operations, urinary incontinence, urinary re-
tention, and sexual abuse or physical violence as a child. The
study acknowledges the multitude of risk factors or co-
existing conditions in patients with CPP and encouraged
healthcare providers to approach the diagnosis and treatment
of CPP with a multi-facet approach [9].
Patient Presentation
The typical clinical presentation of CPP consists of non-cyclic
pelvic pain at least 6 months in duration. Notable impairment
on daily function and co-existing mental health conditions
such as anxiety, depression, or stress may also be present.
Patients may also have complaints of urinary, bowel, or sexual
dysfunction. The physical exam should assess all relevant
anatomical locations to identify regions of pain with particular
emphasis on the abdominal, pelvic, and musculoskeletal
examination.
Diagnosis
The diagnosis of CPP is difficult as definitions and criteria
vary with no current consensus on the best guideline to follow.
Among the many definitions that currently exist for CPP, the
European Association of Urology (EAU) recommends that a
patient receive a thorough history, physical exam, and appro-
priate workup for gynecologic, urologic, gastrointestinal,
musculoskeletal, and psychosocial etiologies if they meet the
standard clinical presentation [7]. The EAU further recom-
mends that with the absence of any underlying pathology
causing the symptomatology, the diagnosis of chronic pelvic
pain syndrome (CPPS) can be made, which is thought to be a
combination of psychosocial and neuromuscular causes [10].
In addition, the EAU also classifies the existence of pain in
more than just the pelvic organ site with a negative workup on
other underlying causes as CPPS [10].
Differential Diagnosis
One of the most common gynecologic causes of CPP is en-
dometriosis. It is estimated that up to 70% of patients who
undergo a diagnostic laparoscopy for evaluation of CPP are
diagnosed with endometriosis [11]. Other common gyneco-
logic causes of CPP are pelvic inflammatory disease, adhe-
sions, adenomyosis, or uterine fibroids [12]. Further potential
causes of CPP include, but is not limited to, gastrointestinal
processes (inflammatory bowel disease, irritable bowel syn-
drome, colorectal carcinoma), urologic processes (cystitis,
Page 3 of 16 13
urethral syndrome, painful bladder syndrome), musculoskele-
tal (myofascial pain, pelvic floor tension myalgia, fibromyal-
gia, and coccygodynia), neurologic conditions (central sensi-
tization of pain), and psychosocial factors such as abuse, de-
pression, and anxiety [2, 12, 13]. There is significance in the
role of diagnostic imaging and procedures to determine the
etiology of CPP, but such workup is mostly beneficial when
CPP is addressed with a multidisciplinary approach [14].
Treatment
In 1986, the World Health Organization (WHO) developed
the analgesic ladder for the management of cancer pain [15].
Later revised in 1996, the current version of the analgesic
ladder recommends non-opioid analgesics for mild pain, weak
opioids and non-opioid analgesics for mild to moderate pain,
strong opioids and non-opioid analgesics for moderate to se-
vere pain, and lastly interventional approaches for intractable
pain, uncontrolled by the prior methods [16, 17]. Although
initially written for the treatment of cancer pain, these recom-
mendations have also governed the treatment of acute and
chronic non-cancer pain [18].
In hopes of achieving better pain control, improve quality
of life, and reduce opioid use, recent publications have advo-
cated the use of interventional approaches prior to using weak
and strong opioids in both cancer and chronic, non-cancer
pain [17, 19•]. A recent report describes a case of successful
treatment of chronic pelvic pain with a spinal cord stimulator
[20]. Interventional approaches, while can be used as mono-
therapy, demonstrated added potential in a multimodal pain
management therapy [21–25, 26••, 27, 28]. In the introduction
of the superior hypogastric plexus block by Plancarte et al., the
plexus block was able to reduce sympathetically driven, poor-
ly localized, dull visceral pain in patients with pelvic tumors
and/or radiation injuries [19•, 29]. The pain was initially re-
duced by approximately 70%, but with added strategies for
controlling somatic pain, overall pain reduction reached 90%
[29].
For the treatment of chronic pelvic pain, conventional ther-
apy includes physical therapy, cognitive behavioral therapy,
and oral and/or parenteral narcotics [30–33]. Numerous inter-
ventional approaches have been developed for the management
of chronic pelvic pain, each with its own unique benefits and
level of efficacy [34]. Interventional approaches are typically
classified into two types of techniques, neuromodulatory and
neurolytic [35]. Neuromodulation entails spinal cord stimula-
tion or neuraxial drug administration and alters the sensation of
pain. Neurolysis entails the ablation of individual nerve fibers
and plexuses [36].
In addition to interventional approaches, improvements in
the use of narcotics have also been explored for pelvic malig-
nancies. Continuous narcotic infusions with bolus capabilities
allow for better control of breakthrough pain at trough levels
13 Page 4 of 16
and avoid side effects, such as sedation, at peak levels. A non-
randomized case series of 18 patients with poorly controlled
cancer pain and/or significant intolerance to oral narcotics
showed that intravenous and subcutaneous narcotic infusions
with bolus capabilities improved pain control in all patients
without significant sedation. Three patients were able to travel
abroad with retained pain control, and one patient was even
able to return to work. Effects were, however, temporary in
some; 8 of these patients later had suboptimal control and
required rapid dose escalations, and 4 of which were in the
preterminal state at the time of escalation. Severe side effects
were rare with one account of seizures in a hospitalized pre-
terminal cancer patient following an increase in
hydromorphone infusion from 60 to 75 mg/h. Four incidents
of mechanical malfunctioning of the infusion pump were also
noted [37].
Reserved as the last line of therapy for intractable pain
following the use of oral, parenteral narcotics, and interven-
tional techniques, intrathecal medications have also demon-
strated potential, with intrathecal morphine, hydromorphone,
fentanyl, bupivacaine, ropivacaine, and clonidine being the
most studied. Often intrathecal medications are combined in
mixtures such as morphine 1 mg/mL and bupivacaine 2 to
3 mg/mL [19•]. In a case series of 46 patients who received
long-term intrathecal morphine, complications, development
of tolerance, and side effects were found to be frequent, oc-
curring in 22 (48%) of patients [33]. More randomized control
trials (RCT) are needed, however, as only 1 RCT was able to
be discussed in a 2005 Cochrane review. In the study, intra-
thecal morphine noted high rates of pain relief (85% success in
intrathecal administration compared to 71% success in oral
and transdermal routes), increased pain relief, interestingly
fewer side effects, and improved survival compared to oral
and transdermal administration of opioids [38]. Recent studies
are also focusing on intrathecal ziconotide, which has shown
good control of nociceptive and neuropathic pain in the setting
of cancer pain and chronic, non-cancer pain [39, 40].
Currently, studies, however, are limited as intrathecal
ziconotide has only been studied in the short term and mini-
mally in the context of chronic pelvic pain [34]. The current
use of intrathecal ziconotide is limited by its side effects,
which have been closely monitored in the initial dose titration
[19•, 41]. It does however, have a favorable side effect profile
in comparison to intrathecal morphine [42–46].
Limitations of Treatment Options
In recent years, multiple countries have experienced the ef-
fects of increased opioid prescriptions [47, 48]. At one point in
2004, the USA, which makes up 4.6% of the world’s popula-
tion, made up 80% of the world’s opioid use [21]. Between
1999 and 2015, the number of opioid overdoses in the USA
Curr Pain Headache Rep (2021) 25: 13
has tripled [49•]. In 2016, opioid overdoses made up 66% of
overdose cases, leading to 42,000 deaths in the USA [48, 50].
With the diagnosis and treatment of cancer improving, bet-
ter prognosis translates to more patients presenting with can-
cer pain and associated chronic non-cancer pain [51]. As opi-
oids have traditionally been recommended as the second and
third steps in the management of cancer and non-cancer pain,
this presents a dilemma to the current efforts to curb opioid use
without compromising care [17, 49•]. As short-term opioid
use is sufficient to cause addiction, abuse, and illicit drug
use, without better ways to address pain and decrease opioid
consumption, the treatment of pain will result in further mis-
use and death [50].
As interventional techniques become safer, more routine,
and better understood, recommendations have begun to sug-
gest earlier applications of interventional approaches [24,
52–54]. By using neurolytic blocks earlier, the use of opioids
can be delayed, decreasing opioid-related side effects such as
misuse, abuse, addiction, and overdose as well as opioid-
induced hyperalgesia, immune suppression, hypogonadism,
and cognitive dysfunction [21, 55, 56]. Additionally, interven-
tional techniques have been shown to decrease the amount of
opioid consumption, which is beneficial for those with con-
tinued refractory pain [52].
Anatomy
The superior hypogastric nerve plexus is a bilateral retroperi-
toneal structure located at the level of L4-S1. It positions itself
anterior to the bifurcation of the aorta, where it divides into the
common iliac vessels. It provides much of the innervation to
structures within the pelvis, including the bladder, urethra,
vagina, vulva, ovaries, prostate, penis, testicles, uterus, ureter,
pelvic floor, descending colon, and rectum [29, 34, 57–59].
The superior hypogastric plexus is a continuation of the
abdominal aortic plexus located superiorly and primarily re-
ceives sympathetic input from the lumbar splanchnic nerves
(L1-L2) of the sympathetic chain ganglion [57]. These fibers
then descend as the left and right hypogastric nerves that go on
to become the inferior hypogastric plexus that innervates the
pelvic viscera [57, 58, 60, 61]. This sympathetic input provides
functions such as ejaculation and involuntary contracture of the
internal urethral sphincter for urinary continence [62]. To a
lesser extent, the superior hypogastric plexus also contains para-
sympathetic fibers from the pelvic splanchnic nerves (S2-S4)
that ascend from the inferior hypogastric plexus [57, 63].
Because the afferent nerve fibers innervating the pelvic
organs travel with the sympathetic fibers that pass through
the superior and inferior hypogastric plexuses, these nerve
bundles serve as good potential targets of blockade for the
management of chronic pelvic pain [19•, 29]. Because the
inferior hypogastric plexus sits within the pelvis, parallel to
the pelvic floor, oriented in a posteroanterior manner, the
Curr Pain Headache Rep (2021) 25: 13
plexus is not as readily accessible to interventions as the su-
perior hypogastric plexus [29, 58]. Block of the inferior hypo-
gastric plexus, while not impossible, is relatively newer and
requires more RCTs to evaluate its safety and efficacy [36]. In
contrast, blockade of the superior hypogastric plexus was
done as early as 1990 and has shown to be effective at con-
trolling sympathetically mediated chronic pelvic pain in neo-
plastic and non-neoplastic cases, including cervical, prostate,
testicular cancer, and radiation injury, with minimal side ef-
fects and complications [29].
Indications for Superior Hypogastric Plexus Block
The superior hypogastric plexus block is used for the diagno-
sis and treatment of intractable visceral pelvic pain [58, 64].
Most commonly, this is in the setting of malignancy (gyneco-
logic, colorectal, and genitourinary), endometriosis, pelvic in-
flammatory disease, and adhesions [58, 65]. The uses for su-
perior hypogastric plexus blocks are numerous and are not
limited to these. They are also effective in the relief of intrac-
table pain secondary to upper abdominal cancer as an adjunct
to celiac plexus blocks [66]. On individual accounts, these
blocks have also brought complete relief to tenesmus second-
ary to rectal cancer and chronic nonmalignant penile pain
secondary to complications of transurethral resection of the
prostate [67, 68]. There are also ongoing studies to evaluate
its potential as an alternative to epidurals for postoperative
pain control following hysterectomies [64]. According to the
modified World Health Organization’s analgesic ladder, the
superior hypogastric plexus block is typically reserved as the
fourth step in the management of pain, following the use of
opioids and non-opioid analgesics [19•]. However, recent rec-
ommendations are considering the use of interventional ap-
proaches at an earlier time, prior to the use of weak and strong
opioids for cancer pain and chronic non-cancer pain [17, 19•].
Etiologically, cancer pain is multifactorial and stems from
compression of nerves, occlusion of blood vessels, infiltration
of nerves and blood vessels, obstruction of viscera, inflamma-
tion, necrosis, infection, and/or swelling [69]. These etiologies
are classified into two categories of pain, nociceptive and neu-
ropathic. Nociceptive pain occurs secondary to injury of so-
matic and visceral structures, while neuropathic pain origi-
nates from abnormal nerve sensitivity following prior nerve
injury [70••, 71]. From patient to patient, the degree of noci-
ceptive and neuropathic pain varies. Some patients experience
pure neuropathic pain or pure nociceptive pain, while others
experience a mixture of the two [70••]. Based on the location
and nature of the pain, different types of blocks can be utilized.
Sympathetic nerve blocks have to lead to great relief of overall
cancer pain in the setting of advanced malignant disease of
various origins [69, 72]. Traditionally, intercostal blocks have
been used for pain secondary to malignant chest wall tumors,
Page 5 of 16 13
while celiac plexus and splanchnic nerve blocks have been
used for upper abdominal tumors [36].
Superior Hypogastric Plexus Block Techniques
Anatomically, the superior hypogastric plexus (SHGP) is a
retroperitoneal structure lying anteriorly to the L5 and S1 ver-
tebral discs—it is typically located at the lower third of the L5
vertebral body and the upper third of the S1 vertebral body
[73•]. Other landmarks include the psoas muscle and bifurca-
tion of the iliac vessels with the SHGP found anteromedially
and caudally, respectively. The SHGP contains visceral sym-
pathetic nerve fibers formed by multiple unmyelinated
branches of the aortic plexus and lumbar splanchnic
nerves—it ultimately branches into smaller nerve bundles to
supply pelvic viscera (except ovaries) with sympathetic effer-
ent innervation [73•]. When SHGP block was first described
in 1990 by Plancarte et al., it was theorized that lower abdom-
inal pain secondary to pelvic/abdominal malignancies could
be reduced/managed with analgesic block and/or neurolysis of
the plexus [73•]. Several modified techniques have been de-
scribed by Plancarte et al., and the safety and efficacy must be
analyzed for each.
Classic Approach
The classic approach to SHGP block/neurolysis is a fluoros-
copy-guided, posterior, and two-needle technique. The patient
is first placed in the prone position on a fluoroscopy table.
Then, the anterior portion of the L5 vertebral body is targeted
using a 17-cm, 22-gauge, beveled needle [29]. During needle
penetration, as the fascia of the ipsilateral psoas muscle is
crossed, loss of resistance is felt by the provider. The correct
placement of the needle in the paramedian region is confirmed
using an injection of 3–4 mL of contrast medium before com-
pleting the same process again on the other side [73•].
Plancarte et al. were the first to describe the procedure in
1990 when they completed a prospective patient series with
28 patients. They used injectate consisting of 6–8 mL of 10%
aqueous phenol resulting in mean pain reduction of 70% [29].
The study concluded that the SHGP block is a viable alterna-
tive treatment method for the management of intractable pel-
vic pain secondary to malignancy [29]. In 2020, Rocha et al.
conducted a retrospective, longitudinal, descriptive study, fur-
ther evaluating the safety and efficacy of the classic approach
to the SHGP block. The study ultimately resulted in > 50%
pain reduction in 59.4% of patients at 1 month, 55.5% at
3 months, and 48.8% at 6 months—it was concluded that
the procedure is a safe and effective adjunct for the manage-
ment of cancer pain [74]. Other results are summarized in the
table.
13 Page 6 of 16
Transdiscal Approach
The transdiscal approach to the SHGP block is a fluoroscopy-
guided, single-needle technique. The patient is placed in either
a lateral or prone position. Using the anterior border of the L5/
S1 disc space as the preferred target, a 15-cm, 20-gauge,
beveled needle is inserted perpendicularly into the skin. The
needle is carefully advanced under lateral fluoroscopic control
until the thecal sac is penetrated. Correct placement is con-
firmed using contrast medium in both lateral and
anteroposterior views [73•, 75].
Erdine et al. described the technique in 2003 when they
conducted a prospective patient series with 20 patients [76].
The transdiscal approach was developed to avoid potential
anatomical barriers to needle advancement, such as the iliac
crest. Out of the 20 patients who underwent SHGP block
using the transdiscal approach, 12 patients (60%; p < 0.05)
reported significant pain reduction, 15 patients (75%;
p < 0.05) demonstrated a significant reduction in analgesic
requirements, and five patients (25%) reported no pain relief
at all [76]. The study concluded that the transdical approach
appears to be safe and effective.
In 2006, Gamal and colleagues conducted a randomized-
controlled trial to compare the classic approach with the
transdiscal approach. The study found that there is no signif-
icant difference in VAS pain score reduction between the
groups with both groups demonstrating significant pain reduc-
tion at 24 h, 1 week, 1 month, and 2 months (p < 0.05) follow-
up [77••]. The study also found that the transdiscal approach is
completed significantly faster (25.4 ± 5.6 min) when com-
pared to the classic approach (57.9 ± 9.8 min) (p < 0.05), a
factor that should be considered [77••]. Overall, the transdiscal
approach appears to be safer and faster than the classic
approach.
Ultrasound-Guided Approach
The ultrasound-guided approach has become popular through-
out the last decade—some advantages include real-time adjust-
able imaging and the absence of radiation. In this method, a
patient is positioned supine in a slight Trendelenburg. Using a
curvilinear transducer, sagittal long-axis mapping of the L5/S1
vertebral bodies and disc is completed [73•]. After ensuring that
only abdominal wall structures are found between the transduc-
er and center of the L5/S1 disc, a needle is introduced targeting
the anterior aspect of the disc [73•]. After observing the needle
tip at the desired location, analgesic or neurolytic is injected.
Bhatnagar et al. published a prospective patient series in
2012, evaluating the US-guided approach. Their findings are
summarized in the table—they concluded that the US-guided
SHGP block is both safe and effective [53]. The following
year, Mishra and colleagues published a randomized-
controlled pilot study comparing oral morphine (group I) to
Curr Pain Headache Rep (2021) 25: 13
US-guided SHGP block (group II). Results showed that both
groups demonstrated a significant decrease in VAS pain
scores (p < 0.05) from baseline, but group II showed greater
improvement [78]. No significant difference was observed
between groups at 3 months (p = 0.586), and changes in func-
tional capacity between the groups were only statistically sig-
nificant at 1 week (p = 0.002): group I score 2.0 (0–3, N = 25),
and group II score 1.0 (0–2, N = 25) [78]. The study conclud-
ed that the US-guided technique is both a safe and effective
modality [78].
CT-Guided Approach
The CT-guided approach was described as early as 1995 by
Wechsler and colleagues [79]. The technique can be per-
formed either anteriorly or posteriorly. Patients are positioned,
and a CT scan is utilized to confirm the location of L5 and S1
disc spaces [80]. Boundaries are identified—anterolateral
margin of the L5 vertebral body is the left boundary, and
anterior margin of psoas major is the right boundary. Using
a CT ruler, ideal puncture angle and depth are calculated. The
needle is inserted under CT guidance, and following injection,
repeat CT confirms the distribution of injectate [80].
Ghoneim et al. conducted a randomized control trial with
30 patients, half underwent the classic approach, and the other
half underwent a CT-guided anterior approach. They discov-
ered that both groups demonstrated significant pain reduction
throughout the 2-month follow-up period [81]. Important to
note is that the CT-guided approach took nearly half the
amount of time to complete—the CT-guided approach was
completed in an average 29.6 ± 6.3 min compared to the clas-
sic approach’s average of 56.4 ± 7.9 min [81]. The study con-
cluded that the CT-guided approach has several advantages,
including improved safety and speed [81].
Finally, in 2018, Yang and colleagues published a prospec-
tive patient series with 25 patients. The findings of their study
are summarized in the table. Pre-op VAS pain scores were
7.74 ± 1.14, with any score > 7 being classified as severe pain.
After the procedures, VAS scores dropped to 2.96 ± 1.55 (p =
0.045), 2.94 ± 2.02 (p = 0.023), 3.60 ± 2.02 (p = 0.003), and
4.58 ± 1.99 (p = 0.017) at 1 month, 3 months, 6 months, and
12 months, respectively [80]. Overall, CT-guided SHGP
block is safe and effective, but further studies are required to
determine safety and efficacy in other pain syndromes [80].
Injectate
When performing a superior hypogastric block, the character-
istic of the injectate used must be considered. Physicians
should try to maximize the analgesic effect of the injectate
selected while also minimizing the side effects experienced
by patients [82]. Typical neurolytic blocking agents cause a
Wallerian degeneration of the nerve axon, causing
Curr Pain Headache Rep (2021) 25: 13
degeneration of the nerve axon distal to the destructive lesion
that can last 3 to 6 months [83]. The typical agents used are
steroids, the anesthetic bupivacaine, and the chemical agents,
phenol (5–10%) and ethanol (50–100%) [83]. This section
will explore the effectiveness and safety profiles of each agent
listed above.
Steroids
The use of corticosteroid’s anti-inflammatory effect in a supe-
rior hypogastric block has been studied for chronic pelvic pain
management. There are no current randomized studies com-
paring the effectiveness of a steroid-based block in a superior
hypogastric block compared with other types of injectate, but
some case studies have shown promising preliminary results.
A case study of a patient with chronic nonmalignant penile
pain after transurethral resection of the prostate showed that
treatment with a superior hypogastric block composed of
0.25% bupivacaine and 20 mg of methylprednisolone acetate
resolved the pain completely, both immediately after the pro-
cedure and during follow-up appointments up to 6 months
later [68]. The efficacy of this block with 0.25% bupivacaine
and 20 mg methylprednisolone has not been studied further
beyond a case report and needs further testing in a randomized
control trial for more validity.
The literature currently does not have more studies on ste-
roid use in a neurolytic superior hypogastric block, but other
studies have researched the effectiveness of a steroid block in
other anatomic locations. A randomized clinical trial studying
60 patients undergoing laparoscopic cholecystectomy studied
the effectiveness of dexamethasone in a transversus
abdominis plane (TAP) block, dividing patients randomly into
a control group, a TAP group, and a TAP with perineural
dexamethasone group. There was no difference between the
first-time requirement of additional analgesia or pain scores in
the TAP group and group that received TAP and dexametha-
sone (P < 0.01) [84]. Further studies are required to test the
effectiveness of steroid use in a superior hypogastric block.
Bupivacaine
Bupivacaine is typically used as an anesthetic before the in-
jection of alcohol in a superior hypogastric block because of
the severe pain it can produce. It is often recommended to
inject 5–10 mL of 0.25% bupivacaine 5 min before using an
alcohol-based block or diluting the alcohol to 50% with
0.25% bupivacaine [82]. Using bupivacaine as the sole agent
in a superior hypogastric plexus block has also been studied.
One milliliter of diatrizoate meglumine mixed with 6–8 mL of
0.25 bupivacaine hydrochloride superior hypogastric plexus
block was injected in 5 patients with chronic pelvic pain due to
endometriosis. The procedure resulted in pain relief in all pa-
tients but one due to the anesthetic being injected into the
Page 7 of 16 13
peritoneal cavity. The researchers concluded that a superior
hypogastric plexus block could be used as a treatment for
chronic pelvic pain, but did not compare the advantages or
disadvantages of the bupivacaine solution to other types of
anesthetic [79]. Further studies with a larger sample size need
to be conducted as well.
Phenol
Phenol is a commonly used agent in peripheral neurolysis due
to the fact that it is less water-soluble than alcohol, and the
safety profile is greater than alcohol [83]. Alcohol injection is
highly painful and works by denaturing proteins, which dam-
ages the nerve cells and results in Wallerian degeneration [83].
Phenol acts as a neurolytic agent at higher concentrations and
also denatures proteins causing Wallerian degeneration but
does not affect the dorsal root ganglion [83]. Unlike alcohol,
phenol is not painful upon injection and has a lower risk factor
of neuritis [85]. The effectiveness of a phenol blockade was
studied in 227 patients with gynecological, colorectal, or gen-
itourinary cancer with pelvic pain. A bilateral superior hypo-
gastric plexus block of 10% phenol was performed 1 day fol-
lowing a block with 0.25% bupivacaine. Not only were pain
scores on the Visual Analog Scale (VAS) reduced from pre-
phenol block to after phenol block by 72% (95% CI of 65–
79%) but also the morphine therapy required after the block
was reduced by 40% (58 ± 43 to 35 ± 19 mg/day) 3 weeks
after the block [86].
More recently, a retrospective study regarding the effec-
tiveness of the superior hypogastric plexus block using phenol
10% in 180 patients in pelvic cancer pain was reviewed. Their
results confirmed the effectiveness of a phenol block in the
superior hypogastric plexus for pelvic pain. They found that
there was a significant reduction in VAS scores by 49.55% in
3 months as well as a 12.55% reduction in opioid use in
3 months [74].
Ethanol
The use of alcohol as a neurolytic block has also been studied.
In a study by Amr et al., 109 patients with abdominal or pelvic
cancer and visceral pain were divided into two cohorts: a
superior hypogastric plexus block was performed before opi-
oids were given or vice versa if the strong opioids did not
control the pain adequately. A neurolytic block was performed
with 12 mL of 70% alcohol and 3 mL of 2% lidocaine. Results
showed that those who received the block before the opioids
had significantly reduced pain levels (P < 0.0001) and reduced
opioid consumption (P < 0.0001) during the first 12 months
[87]. Further studies have confirmed the effectiveness of al-
cohol as a neurolytic superior hypogastric block as a pain-
reducing agent: A randomized clinical trial by Huang et al.
demonstrated that 30 ± 5 mL of alcohol used in a combined
Table 1 Comparison of superior hypogastric plexus block techniques

Technique Description Author Study design Intervention Results Conclusion

Classic approach Fluoroscopy-guided, posterior, two-needle Plancarte et al. Prospective patient Classic approach with injectate - Mean pain reduction of A viable alternative method for
13 Page 8 of 16

technique. The patient is placed in the prone (1990) [29] series (n=28) consisting of 6–8 mL of 70% management of intractable
position on the fluoroscopy table. The anterior 10% aqueous phenol - No significant adverse chronic pelvic pain secondary to
portion of the L5 vertebral body is targeted events reported malignancy
using a 7-in., 22-gauge, beveled needle. When Choi et al. Retrospective chart CT scans utilized to estimate - Axial angle 32° [28–34] in Significant differences in entry
the needle crosses the fascia of the ipsilateral (2018) [91] review (n=268) target angles and points and males, 35° [29–38] in angles and distances between
psoas muscle, loss of resistance is felt. The entry points and distances females (p=0.003) males and females must be
correct placement of the needle in the - Right oblique angle 14° considered when performing
paramedian region is confirmed using an [12–17] in males, 19° classic approach
injection of 3–4 mL of contrast medium. The [16–18, 19•, 20–23] in
process is completed bilaterally [73•] females (p<0.001)
- Left oblique angle 15°
[13–18] in males, 20°
[16–18, 19•, 20–23] in
females (p<0.001)
- Right entry distance 4.9 cm
(4.4–5.2) in males, 5.0 cm
(4.5–5.7) in females (p=
0.080)
- Left entry distance 4.7 cm
(4.4–5.2) in males, 5.0 cm
(4.5–5.7) in females (p=
0.006)
Rocha et al. Retrospective, Classic approach with injectate - 1-month follow-up: 59.4% Safe and effective adjunct method
(2020) [74] longitudinal, consisting of 8–10 mL of reported >50% pain in the management of cancer
descriptive study (n= 10% aqueous phenol reduction pain
180) - 3-month follow-up: 55.5%
reported >50% pain
reduction
- 6-month follow-up: 48.8%
reported >50% pain
reduction
Mean VAS pain score:
- Baseline: 5.7 (moderate)
- 24 h post-op: 0.9
(78.97–88.04%; p =0.00)
- 7 days post-op: 2.1
(56.12–68.65%; p=0.00)
- 1 month post-op: 2.7
(45.13–56.48%; p=0.00)
- 3 months post-op: 2.9
(42.87–53.06%; p=0.00)
- 6 months post-op: 3.0
(38.9–52.16%; p =0.00)
Transdiscal Fluoroscopy-guided, single-needle technique. Erdine et al. Prospective patient Transdiscal approach with - Post-op follow-ups at 24 h Method appears to be safe and
approach The patient is placed in the lateral or prone (2003) [76] series (n=20) injectate consisting of 5 mL and monthly for 3 months effective
position. A 15-cm, 20-gauge, beveled needle of 10% aqueous phenol
Curr Pain Headache Rep (2021) 25: 13
Table 1 (continued)

Technique Description Author Study design Intervention Results Conclusion

is inserted perpendicularly to the skin at the - 12 patients (60%; p<0.05)

center of the L5-S1 interlaminar space. The with significant pain
needle penetrates the thecal sac using lateral reduction
fluoroscopic control. The correct placement of - 15 patients (75%; p<0.05)
the needle is confirmed using contrast with significant reduction
medium in both lateral and anteroposterior in analgesic requirements
views [73•, 75] - 5 patients (25%) reported
no pain relief
Curr Pain Headache Rep (2021) 25: 13

Turker et al. Prospective patient Transdiscal approach with - All 3 patients reported > A safe and effective technique
(2005) [75] series (n=3) injectate consisting of 8 mL 50% pain reduction
of 10% aqueous phenol lasting 6–12 months
- Case 1: Baseline VAS pain
score decreased from 9/10
on average to 2/10
- Case 2: Baseline VAS pain
score decreased from 7/10
on average to complete
resolution. Pain recurred
at 12-month follow-up
- Case 3: Baseline VAS pain
score decreased from 7/10
on average to 2/10
Gamal et al. Randomized-controlled - Classic approach injectate: - No significant difference in Safe and effective method.
(2006) trial (n=30) 8 mL of 10% aqueous VAS scores between Findings suggest it is safer, more
[77••] phenol groups effective, and faster than the
- Transdiscal approach - Both groups demonstrated classic approach
injectate: 10 mL of 10% significant pain reduction
aqueous phenol at 24 h, 1 week, 1 month,
and 2 months (p<0.05)
- VAS score at 3 months was
not significantly different
from baseline
- Transdiscal approach
significantly faster (25.4±
5.6 min) when compared
to the classic approach
(57.9±9.8 min) (p<0.05)
Choi et al. Retrospective chart CT scans utilized to estimate - Right oblique angle 21° Significant differences in entry
(2018) [91] review (n=268) target angles and points and [18, 19•, 20–25] in males, angles and distances between
entry points and distances 28° [24, 25, 26••, 27–31] males and females must be
in females (p<0.001) considered when performing
- Left oblique angle 20° [17, transdiscal approach
18, 19•, 20–24] in males,
26° [23–25, 26••, 27–30]
in females (p<0.001)
- Right entry distance 5.1 cm
(4.7–5.7) in males, 6.1 cm
Page 9 of 16 13
Table 1 (continued)

Technique Description Author Study design Intervention Results Conclusion

(5.5–6.8) in females (p<

13 Page 10 of 16

0.001)
- Left entry distance 5.2 cm
(4.6–5.6) in males, 6.0 cm
(5.3–6.5) in females (p <
0.001)
Ultrasound-guided The patient is positioned supine in slight Bhatnagar Prospective patient US-guided approach with - Baseline VAS=8.5±0.86 Safe and effective technique.
approach Trendelenburg. A curvilinear transducer is et al. (2012) series (n=18) injectate consisting of - Day 2 VAS=1.11±1.02 Consider early application in
used for sagittal long-axis mapping of the [53] 10 mL of 50% ethanol in - Week 1 VAS=1.28±1.02 patients with incurable pain
L5/S1 disc. After ensuring only abdominal 0.25% bupivacaine - Month 1 VAS=1.72±1.13
wall structures are positioned between - Month 2 VAS=2.33±1.53
transducer and center of L5/S1 disc, the - (p<0.001)
needle is introduced targeting the anterior - No adverse events
surface of the disc. After observing needle tip Mishra et al. Randomized-controlled, Group I: oral morphine sulfate - Both groups demonstrated A safe and effective technique for
in the middle of the disc, analgesic or (2013) [78] single-blind pilot according to the WHO significant (p<0.05) pain reducing pain when compared to
neurolytic is injected [73•] study (n=50) analgesic ladder reduction, but group II to a morphine alone
Group II: US-guided approach greater extent
- No significant difference at
3 months (p=0.586)
- Global satisfaction scores
for group II: 1 week (76%
satisfied, p=0.0), 1 month
(88%, p=0.04)
- Most common adverse
events included nausea,
vomiting, diarrhea, and
back pain
Gofeld et al. Feasibility cadaveric Anterior US-guided approach - Technique modified for 6/8 The described modified technique
(2017) [92] experiment (n=8) with fluoroscopy procedures should be a considered approach
confirmation. Injections of - Fluoroscopy confirmation to the superior hypogastric
5 mL iohexol performed demonstrated similar plexus block. Further trials to
using C6 curvilinear spread pattern to validate efficacy are required
transducer transdiscal approach
Srivastava Case report (3 US-guided approach with - Complete pain relief for at A safe and effective technique for
et al. (2019) treatments) injectate consisting of least 3 months following management of acute pelvic
[93] 20 mL of 0.2% ropivacaine 3rd and final procedure pain in patients with MRKH
and 30 μg of clonidine - No reported adverse events syndrome
CT-guided Patients are placed in the prone position. CT scan Wechsler et al. Prospective patient CT-guided approach with - Mild pain relief classified as Safe and easily performed. Has
approach is used to confirm the location of target L5 and (1995) [79] series (n=5) (7 injectate consisting of 1 mL <50% reduction; both diagnostic and prognostic
S1 disc spaces. The anterolateral margin of L5 procedures) diatrizoate meglumine considerable pain relief implications. Recommend
vertebral body is used as the left boundary, mixed with 6–8 mL of classified as >50% performing prior to permanent
and the anterior margin of the psoas major is 0.25% bupivacaine reduction superior hypogastric plexus lysis
used as the right boundary. CT ruler is used to hydrochloride - 1 procedure resulted in mild
measure ideal puncture angle and depth before relief
inserting the needle with CT guidance. - 3 procedures resulted in
Analgesic or neurolytic is injected, followed considerable relief
Curr Pain Headache Rep (2021) 25: 13
Table 1 (continued)

Technique Description Author Study design Intervention Results Conclusion

by repeat CT to observe the distribution of - 2 procedures resulted in

injectate [80] complete relief
- 1 procedure terminated due
to incorrect injection
location
Ghoneim et al. Randomized-controlled - 15 patients underwent a - Significant pain reduction Several advantages to CT-guided
(2014) [81] trial (n=30) classic approach with 8 mL in both groups throughout approach—more effective,
of 10% aqueous phenol the 2-month follow-up faster, less adverse events
Curr Pain Headache Rep (2021) 25: 13

- 15 patients underwent - CT-guided approach

CT-guided anterior completed in 29.6±
approach with 10 mL of 6.3 min
10% aqueous phenol - Classic approach completed
in 56.4±7.9 min
Yang et al. Prospective patient CT-guided approach with VAS pain scores: Safe and effective method for
(2018) [80] series (n=25) 4 mL dehydrated alcohol - Pre-op=7.74±1.14 treatment of secondary
injectate containing 3% - 1 month post-op=2.96± dysmenorrhea. Further studies
iohexol 1.55 (p=0.045) required to determine safety and
- 3 months post-op=2.94± efficacy in other pain syndromes
2.02 (p=0.023)
- 6 months post-op=3.60±
2.02 (p=0.003)
- 12 months post-op=4.58±
1.99 (p=0.017)
Page 11 of 16 13
13 Page 12 of 16
Table 2 Characteristics of injectates used in superior hypogastric block
Injectate Article Groups studied and intervention
type
Steroid Rosenberg Case study of a patient with chronic
(1998) nonmalignant penile pain after
transurethral resection of the prostate
treated with a hypogastric block
composed of 0.25% bupivacaine and
20 mg of methylprednisolone acetate
Huang (2016) A randomized clinical trial, studying 60
patients undergoing laparoscopic
cholecystectomy using a transversus
abdominis plane (TAP) block. Patients
were divided randomly into a control
group, a TAP group, and a TAP with
perineural dexamethasone group
Bupivacaine Wechsler A case series of 7 patients with chronic
(1995) pelvic pain due to endometriosis were
treated with a superior hypogastric
block composed of 1 mL of diatrizoate
meglumine mixed with 6–8 mL of 0.25
bupivacaine hydrochloride
Phenol Plancarte Prospective cohort trial with 227 patients
(1997) with gynecological, colorectal, or
genitourinary cancer with pelvic pain
taking oral opioids. A bilateral superior
hypogastric plexus block of 10%
phenol was performed 1 day following
a block with 0.25% bupivacaine
Rocha (2020) A retrospective analysis of 180 patients
with chronic pelvic cancer pain treated
with the classic or paravertebral
technique of a superior hypogastric
plexus neurolysis with phenol 10%
Koyyalagunta Retrospective chart review of 93 patients There was no difference found in the
(2016) comparing using alcohol (50–100%)
with phenol (5–10%) for splanchnic
nerve neurolysis
Ethanol Amr (2014) Prospective cohort of 109 patients with
abdominal or pelvic cancer and visceral
pain were divided into two groups: a
superior hypogastric plexus block was
performed before strong opioids were
given or strong opioids were given
first, and then a superior hypogastric
block was performed. A neurolytic
block was performed with 12 mL of
70% alcohol and 3 mL of 2% lidocaine
Huang (2016) A randomized clinical trial of 52 patients A 30±5 mL of alcohol used in a combined A combined neurolytic block of the celiac
with upper abdominal malignancies
and cancer pain was divided into two
groups: a celiac plexus block alone or a
combined neurolytic block of the celiac
and superior hypogastric blocks
Curr Pain Headache Rep (2021) 25: 13
Results and findings Conclusions
The pain completely resolved after the A superior hypogastric plexus block with
procedure and during follow-up anesthetic and a steroid successfully
appointments up to 6 months later treated the pain of transurethral
resection of the prostate
There was no difference between the Perineural dexamethasone has no
first-time requirement of additional additional analgesic effect in a TAP
analgesia or pain scores in the TAP procedure
group and group that received TAP and
dexamethasone
All patients experienced pain relief of A superior hypogastric block of 1 mL of
varying degrees except for one patient diatrizoate meglumine mixed with
due to the anesthetic being injected into 6–8 mL of 0.25 bupivacaine
the peritoneal cavity hydrochloride is an effective and
promising treatment for chronic pelvic
pain in this case series
Reduction of visual analog score pain in The phenol-based superior hypogastric
72% (95% CI 65–79%) of patients and block was effective in 72% of patients
reduction in oral opioid therapy in reducing pain and lessening the
number of opioids required for pain
relief
There was a significant reduction in VAS The superior hypogastric plexus
scores by 49.55% in 3 months as well neurolysis is an effective treatment for
as a 12.55% reduction in opioid use of chronic pelvic cancer pain and should
in 3 months be considered in order to reduce the
potential damaging effects of opioid
treatment
A phenol-based block is just as effective
1-month post-procedure pain scores or as an alcohol-based block for
side effects between the alcohol or splanchnic nerve neurolysis
phenol solutions. The only difference
between the two agents found was the
amount of volume required with 24.73±
8.89 mL of alcohol used compared to
20.24±5.95 mL used for phenol
Those who received the block before the Before proceeding with step 2 on the
opioids had significantly reduced pain WHO ladder (give strong opioids),
levels and reduced opioid consumption performing an alcohol-based block can
reduce the number of opioids needed
neurolytic block of the celiac and and superior hypogastric plexus
superior hypogastric plexus is more composed of 30±5 mL of alcohol
effective at treating upper abdominal reduced abdominal cancer pain than a
cancer pain than using 21±3 mL of celiac plexus block alone
alcohol in a celiac plexus block alone.
The group treated with both the celiac
and superior hypogastric plexus block
had reduced morphine use afterwards
as well
Curr Pain Headache Rep (2021) 25: 13
neurolytic block of the celiac and superior hypogastric plexus
is more effective at treating upper abdominal cancer pain than
using 21 ± 3 mL of alcohol in a celiac plexus block alone [66].
Furthermore, the group treated with both the celiac and supe-
rior hypogastric plexus block had reduced morphine use after-
ward as well (P < 0.05) [66].
The use of both ethanol and phenol in the superior hypo-
gastric block has proven to have effective analgesic effects for
chronic pelvic pain. The effectiveness of alcohol (50–100%)
compared with phenol (5–10%) for splanchnic nerve
neurolysis was analyzed in a retrospective chart review of 93
patients [88]. Both agents were found to reduce pain scores
and the frequency of opioids required. There was no differ-
ence found in the 1-month post-procedure pain scores or side
effects between the alcohol or phenol solutions [88]. The only
difference between the two agents found was the amount of
volume required with 24.73 ± 8.89 mL of alcohol used com-
pared to 20.24 ± 5.95 mL used for phenol [88]. A more recent
study compared alcohol (70%) with phenol (30%) in a supe-
rior hypogastric plexus block for treatment of cancer-related
pelvic pain in 46 patients and found that there was also no
difference in VAS pain reduction in the type of neurolytic
agent at 1 month. They suggested that more studies are needed
comparing the two and the long-term follow-up pain scores
since patients with higher VAS scores at the beginning had
more significant reductions [89].
Volume of Injectate
Lastly, the volume of the injectate must be carefully consid-
ered when selecting a superior hypogastric block for use.
Using a bilateral 6- or 7-in., 22-gauge beveled needle, a 6 to
8 mL bilateral injection of 0.25% bupivacaine followed by 6
to 8 mL of 10% aqueous phenol is the recommended treat-
ment modality [90]. Other studies have recommended an in-
creased volume of phenol with 8 to 10 mL of 10% phenol
injected bilaterally, although the volume selected depends on
the specific patient [74].
Conclusion
In conclusion, CPP is a broadly defined condition that is
thought to primarily affect women of reproductive age. The
non-cyclic pain and dysfunction of daily activities in CPP
significantly impact the quality of life in many patients.
There are currently no guidelines that are universally followed
in the recognition, diagnosis, and treatment of CPP. As a re-
sult, it is important to obtain a thorough history and physical
examination to identify any potential underlying pathology
that includes gynecologic, urologic, gastrointestinal, muscu-
loskeletal, psychosocial, neurologic, malignant, or idiopathic
processes. Pelvic pathology, such as endometriosis, or
Page 13 of 16 13
underlying psychosocial issues, such as depression, anxiety,
or a history of physical, mental, or sexual abuse, are signifi-
cant risk factors that should be considered when evaluating for
CPP. Diagnostic imaging and procedures should be coordi-
nated in a multidisciplinary manner to ensure the appropriate
use of imaging and when procedures such as a diagnostic
laparoscopy are indicated. There continue to be growing con-
cerns in the use of narcotics in the setting of CPP, especially
for patients who do not have cancer-related pains. Among the
treatments that have been proposed for CPP, the superior hy-
pogastric plexus block has evidence that demonstrates its util-
ity in treating CPP, especially pain in the setting of cancer.
When pain is secondary to cancer, superior hypogastric plexus
blocks have been shown to act as both a diagnostic and ther-
apeutic procedure. The efficacy and safety of superior hypo-
gastric plexus blocks also highlight its potential role in reduc-
ing the reliance of opioids for pain. Additional methods of
delivering superior hypogastric plexus blocks, such as CT-
guided blocks, promote safety with block administration.
Superior hypogastric plexus blocks have also demonstrated
utility in managing pain that occurs acutely and chronically
after invasive procedures. There is much potential and prom-
ise in the use of superior hypogastric plexus that warrants
further exploration of its role in pain of diverse etiologies
(Tables 1 and 2).
Compliance with Ethical Standards
Conflict of Interest Ivan Urits, Ruben Schwartz, Jared Herman, Amnon
A. Berger, David Lee, Alec M Zamarripa, Annabel Slovek, Laxmaiah
Manchikanti, and Omar Viswanath declare no conflict of interest. Alan
Kaye is a Section Editor for Current Headache and Pain Reports. He has
not been involved in the editorial handling of this manuscript. Dr. Kaye is
also a speaker for Merck.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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Affiliations
Ivan Urits 1,2 & Ruben Schwartz 3 & Jared Herman 3 & Amnon A. Berger 1 & David Lee 4 & Christopher Lee 5 &
Alec M. Zamarripa 4 & Annabel Slovek 6 & Kelly Habib 4 & Laxmaiah Manchikanti 7 & Alan D. Kaye 2 & Omar Viswanath 2,4,6,8
1
Beth Israel Deaconess Medical Center, Department of
Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical
School, Boston, MA, USA
2
Department of Anesthesiology, Louisiana State University
Shreveport, Shreveport, LA, USA
3
Department of Anesthesiology, Mount Sinai Medical Center, Miami
Beach, FL, USA
4
Department of Anesthesiology, University of Arizona College of
Medicine – Phoenix, Phoenix, AZ, USA
Curr Pain Headache Rep (2021) 25: 13
90. Nagpal AS, Moody EL. Interventional management for pelvic pain.
Phys Med Rehabil Clin N Am. 2017;28(3):621–46.
91. Choi JW, Kim WH, Lee CJ, Sim WS, Park S, Chae HB. The
optimal approach for a superior hypogastric plexus block. Pain
Pract. 2018;18(3):314–21.
92. Gofeld M, Lee C-W. Ultrasound-guided superior hypogastric plex-
us block: a cadaveric feasibility study with fluoroscopic confirma-
tion. Pain Pract. 2017;17(2):192–6.
93. Srivastava M, Punj J. Management of cyclical pelvic pain by mul-
tiple ultrasound-guided superior hypogastric plexus blocks in a rare
case of Mayer-Rokitansky-Küster-Hauser syndrome - a case series
of three blocks in a patient. Intractable Rare Dis Res. 2019;8(4):
271–4.
Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
5
Creighton University School of Medicine – Phoenix Regional
Campus, Phoenix, AZ, USA
6
Valley Pain Consultants – Envision Physician Services,
Phoenix, AZ, USA
7
Pain Management Centers of America, Paducah, KY, USA
8
Department of Anesthesiology, Creighton University School of
Medicine, Omaha, NE, USA