Superior Hypogastric Plexus Block for Management of Interstitial Cystitis
ICA/NIDDK International Scientific Symposium
October 30-31, 1997, Arlington, VA

Introduction
Interstitial Cystitis (IC) is characterized by urinary frequency, urgency, suprapubic pain and dyspareuria. The typical IC patient is perceived as a "difficult patient" and is frequently misdiagnosed. Exclusion criteria define diagnosis and the average IC patient will suffer for seven years prior to urological definition of disease. Table 1.

Table 1 - Exclusion Criteria 1. Bladder capacity greater than 350 cc on awake cystometry 2. Absence of an intense urge to void with the bladder filled to 150 cc of water during cystometry 3. Duration of symptoms less than 9 months 4. Absence of nocturia 5. Urinary frequency while awake of less than 8 times 6. Cystitis or prostatitis within a 3 month period 7. Acute genital herpes 8. Vaginitis 9. Age less than 18 years 10. Sterile urine and no evidence of acid-fast bacilli 11. Exclusion of neurogenic bladder

Interstitial Cystitis, once thought to be a rare disease, is actually five to ten times more common than hemophilia or cystic fibrosis. It is estimated that 500,000 cases exist in the United States, of which 90 percent are female. Most IC patients experience unnecessary surgery, multiple medical tests, and frequently require narcotic based therapy to manage their pain. Considerable overlap of visceral pain syndromes involving pelvic organs and the gastrointestinal tract has been described. Table 2. From a compassionate standpoint, relief of pain is considered the primary goal, however, from a realistic standpoint, improvement of function is many times all that can be offered.

Table 2 - Exclusion Criteria   Incidence Allergies (All causes) >50% Fibromyalgia 10% Irritable bowel syndrome >30% Migraines 20% Endometriosis 10% Autoimmune disorders (e.g. systemic lupus erythematosus) 5% Chronic fatigue syndrome 10% Premenstrual Syndrome 63% Patients % Control % Irritable bowel syndrome 22.5 6.7 Frequent upper respiratory infection 17.2 4.8 Abdominal cramping 30.7 9.0 Frequent stools 20.0 2.4 Sensitivity, allergic reactions to medications 36.0 13.2

Interstitial Cystitis shares many common features of a sympathetically maintained pain state, and has been described as a form of reflex sympathetic dystrophy. The presence of A-delta (plentiful in the bladder) and C-fibers support central sensitization at the level of the spinal cord. This central sensitization is the result of repetitive activation of peripheral receptors carried by the splanchnic and parasympathetic afferent fibers. Stimuli contacting the bladder presumably triggers visceral hyperalgesia by an unknown mechanism. Infectious, hormonal and genetic etiologies have been implicated, but specific activators have not been identified.

To obtain temporary relief, attempts have been made to identify useful treatment options to relieve pain and increase function. The urologist will commonly inject heparin or DMSO (anti-inflammatory agents), and perform bladder dilation as needed to increase capacity. The patient may self-instill bupivicaine as well. Narcotic based therapy is commonly used in moderate to high dosages. Elmiron, a recently approved adjunct, and gabapentin are improving therapeutic success in some patients.

Presacral neurectomy (removal of the superior hypogastric plexus) and bladder removal is occasionally performed to relieve the discomfort and pain of intractable cystitis. Afferent and efferent sensory impulses from the neck of the bladder and the lowest part of the ureter travel with the pelvic splanchnic nerves as well as the dorsal nerve roots. Other sensory pathways include the second through fourth sacral nerves which convey nociceptive information to the ascending fibers that synapse in the dorsal horn of the spinal cord. Injection of the superior hypogastric plexus blocks the sympathetic efferents and afferents from L1 and L2. As might be expected, not all sympathetic efferent and afferent activity is blocked with this technique, but patients commonly report increase function and decreased pain after hypogastric plexus block.

Methods
Selection of a patient group matched to the appropriate interventional procedure enhances clinical outcome. This is particularly true with IC. We assess our patients with a sophisticated assessment tool, devised in conjunction with biostatisticians, to measure the influence of pain upon the patient’s functional life events. Table 3. Ten patients were referred to the pain clinic from regional urologists for interventional management of Interstitial Cystitis. Patients selected to receive the superior hypogastric block failed conventional management and were escalating narcotic consumption.

Table 3 - Data Collection Tool VAS, Faces of Pain, and Descriptors of Pain Depression Indices Functional Assessment ADL Demographics Family and social influences

Informed consent was obtained. The risk of the procedure includes but is not limited to bowel perforation, somatic nerve irritation, intravascular injection, renal and dural violation, infection and bleeding. A protime was obtained on patients receiving Elmiron (due to anticoagulant effect). The technique utilized a bent needle fluoroscopically guided approach confirmed with multiple angular projections. Isovue 200 was injected to further confirm proper needle placement. A bupivicaine 0.5% MPF, steroid (20 mg aristicort), and nesacaine 3% MPF combination was injected to a total volume of 20 cc.

Each patient was injected in a series, spaced at intervals of two to four weeks. Most responded by the second procedure. All patients reported decreased bladder pain, urinary urgency, and frequency. No more than seven injections were performed in a 12 month period.

Results
otivated and functional patients anxious to eliminate narcotics improved usually by the second block. One patient stated that visits to the urologist for heparin instillation decreased from one every week to eleven week intervals. The most common complaint after the block was back pain (needle track) and bilateral leg pain (unknown etiology). All of the patients noted decreased analgesic usage, one eliminating narcotics completely. Eight patients reported improved function.

Summary
Interstitial Cystitis is one of the most difficult painful entities treated in the pain management department. Specific mechanisms are poorly understood, but central sensitization appears to be an important component of prolonged bladder and visceral hyperalgesia. Advances in patient function seem to be enhanced with superior hypogastric plexus block performed in series. Best patient outcome requires a supportive relationship between patient, urologist, and pain management physician.

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