|Year : 2021 | Volume
| Issue : 3 | Page : 240-244
Efficacy of ganglion impar block in perineal pain of various etiologies: A case series
Pratibha Matche1, Srinivas Hebbal Thammaiah1, K Kalpana1, Devaki Kalvapudi1, Sunita Lawange2
1 Department of Anaesthesia, Critical Care and Pain Medicine, JSS Medical College, Mysore, Karnataka, India
2 Sunita Lawange, Consultant Pain Physician, Ashwini Pain Mangement centre, Nagpur, Maharashtra, India
|Date of Submission||05-Oct-2021|
|Date of Decision||16-Oct-2021|
|Date of Acceptance||31-Oct-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Srinivas Hebbal Thammaiah
Department of Anaesthesiology, J.S.S Medical College and Hospital, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
Perineal pain is a complex clinical condition causing significant functional impairment and frustration to the patient. The diversity of presentation and etiologies poses a challenge to the treating physician. Ganglion Impar is a solitary retroperitoneal structure in front of sacrococcygeal junction behind the rectum. It provides nociceptive and sympathetic supply to the perineal structures. Interventional pain management in the form of fluoroscopy guided Ganglion Impar block has been shown to benefit in patients with perineal pain. Here we describe a case series of Ganglion Impar block in four patients with various etiologies analysing its safety and efficacy. In this case series, four patients visiting the pain clinic in a tertiary care hospital with complaints of perineal pain of various etiologies were included. All the patients were given Ganglion Impar block under fluoroscopy guidance. NRS was assessed before the block, immediately after the block, and at time intervals of three months, six months, and one year post block. Any complications during the procedure and the follow up period were noted. All four patients had very good pain relief after block. The mean NRS value before the block was 8 ± 0.701. Ten minutes after the procedure, mean NRS value was 2.75 ± 0.95. NRS scores at three months, six months and one year follow-up intervals were 1.5 ± 1.29, 1.25 ± 1.25, and 1 ± 1.41 which is statistically significant. There were no complications. Fluoroscopy guided Ganglion Impar Block is a safe and effective intervention in the management of acute and chronic perineal pain of various etiologies providing good pain relief.
Keywords: Perineal Pain, Coccydynia, Ganglion Impar Block, Fluoroscopy
|How to cite this article:|
Matche P, Thammaiah SH, Kalpana K, Kalvapudi D, Lawange S. Efficacy of ganglion impar block in perineal pain of various etiologies: A case series. Indian J Pain 2021;35:240-4
|How to cite this URL:|
Matche P, Thammaiah SH, Kalpana K, Kalvapudi D, Lawange S. Efficacy of ganglion impar block in perineal pain of various etiologies: A case series. Indian J Pain [serial online] 2021 [cited 2022 Jan 28];35:240-4. Available from: https://www.indianjpain.org/text.asp?2021/35/3/240/334108
| Introduction|| |
Perineal pain is a common clinical condition having a significant impact on quality of life and function. The presentation may be acute or chronic involving either somatic or sympathetic component. Most common causes include traumatic injuries, pelvic inflammatory diseases, vulvodynia, prostatitis, interstitial cystitis, and various benign and malignant conditions of pelvic organs. Due to its complex innervation, muscular attachments, anatomical supports, and neuroanatomy, the site of pain cannot be exactly pinpointed, thereby complicating its diagnosis., Thorough clinical evaluation and necessary investigations are the mainstays in management. A blockade of nociceptive and sympathetic supply to the perineal region innervated by the ganglion impar (GI) has been proven beneficial in perineal pain.
Coccydynia refers to pain in the terminal segment of the spine due to abnormal mobility of the coccyx. Conservative management remains the mainstay of treatment which includes physiotherapy, manipulation, rehabilitation, usage of ring pillow, and oral analgesic medications for pain relief. Surgical intervention in the form of partial or total coccygectomy may be required in patients with coccydynia that is refractory to conservative management. Patients who fail to respond to conservative methods but do not require surgery can be treated with GI block.
We report our experience of treating four patients with various etiologies presenting with perineal pain treated with fluoroscopy-guided GI block.
| Case Reports|| |
A 37-year-old man presented to the pain clinic with pain in the tailbone region after sustaining a fall from a motorbike onto his buttocks 1 month ago. Following the accident, the patient consulted an orthopedician who prescribed analgesics and advised bed rest for a week for which he had minimal pain relief. Hence, he was referred to the pain clinic. When he presented, he complained of pain in the tailbone region which was severe aching type of pain, aggravated on sitting for more than 15 min, and was relieved on standing up. The patient also gave a history of disturbed sleep as turning to the side was painful. The pain was severe with numerical rating scale (NRS) score of 8/10. There was no history of radiculopathy to the leg or referred pain. There was no history suggestive of bowel and bladder involvement. On examination, there was no redness or swelling at the site of injury. Tenderness was elicited on deep palpation over lower coccygeal region. No sensory or motor deficits were noted. Sacrococcygeal X-ray in lateral view showed no fractures. A diagnosis of coccydynia was made, and after ruling out the relevant red flags, the patient was considered for fluoroscopy-guided GI block.
A 14-year-old girl presented to the pain clinic with severe pain in the tailbone region for 2 months. The pain was a dull aching type which got aggravated on sitting in the chair or on the floor and was relieved on lying down. She also reported pain during defecation and straining. The pain was severe in intensity with an NRS of 7/10. She was earlier treated by an orthopedician who diagnosed an anteriorly displaced coccyx for which she was treated with conservative management and manual manipulation was attempted which aggravated her pain. Subsequently, she was referred to the pain clinic. On examination, there was severe tenderness in the coccygeal region with no signs of inflammation. There was no sensory or motor deficit. Since conservative management had failed, GI block was planned after obtaining informed consent from the parents.
A 44-year-old female patient, who was a known case of carcinoma rectum on chemotherapy, radiotherapy, and planned for debulking surgery, was referred by an oncosurgeon to the pain clinic. She presented with complaints of pain in the perianal and perineal region for 3 months. Her pain was severe in intensity with NRS of 9/10 and she described her pain to be continuous and dull aching in nature. The pain was aggravated on prolonged sitting and while passing stools and it disturbed her sleep. She was on oral morphine 20 mg fourth hourly without much relief. Since she had inadequate relief of pain, and was unable to perform her daily activities or undergo her scheduled chemotherapy and radiotherapy sessions, she was planned for GI block.
A 68-year-old female had consulted a gynecologist with a history of intractable burning pain on the left side of the vulva for 2 years. She also complained of increased frequency of micturition and was treated for urinary tract infections and atrophic vulvovaginitis. After a thorough evaluation and necessary investigations to rule out other pathologies, a diagnosis of vulvodynia was made. The patient was treated with tablet pregabalin and tablet paroxetine, followed by pudendal nerve block along with trigger point injection by the gynecologist. Despite all these measures, she had minimal pain relief, so she was referred to the pain clinic.
The patient complained of severe pain on the left side of the vulva with an NRS of 7/10. Her pain was continuous, sharp, and associated with burning sensation. It was exaggerated by sitting on a chair, bathing, and after passing urine. The pain was associated with allodynia and hyperalgesia and disturbed her sleep. Persistent pain affected her quality of life as she was unable to wear her undergarments and could not perform routine activities comfortably. There was no history of any surgery, trauma, or vaginal discharge. During the consultation, she appeared embarrassed, anxious, and irritable due to constant burning sensation and was repeatedly shifting in her seat. Since she was already treated with medications and pudendal nerve block with no significant pain relief, she was planned for a fluoroscopy-guided GI block.
| Materials and Methods|| |
Four patients with various etiologies of perineal pain who were planned for GI block were included [Table 1]. Their baseline NRS values were noted. Patients underwent routine blood investigations to rule out diabetes, infection, and any coagulation abnormalities. After informed consent, GI block was performed on all the patients as their NRS score was >5. The block was performed as a day-care procedure, and the patients were observed for 2 h after the procedure for any complications. The procedure was carried out with patients in a prone position with a pillow under the abdomen to overcome lumbar lordosis. Sacrococcygeal joint was identified in lateral fluoroscopic view. Under strict aseptic precautions, the skin and subcutaneous tissue was infiltrated with 1% lignocaine. An 8 cm 23G spinal needle was inserted through the sacrococcygeal ligament to reach just anterior to the sacrococcygeal joint under fluoroscopy guidance in lateral view. 0.2 ml of nonionic contrast solution (Iohexol, Omnipaque-GE) was injected. The correct needle placement was confirmed by the “reverse comma sign” in lateral view and midline spread in AP view. After confirmation of the dye spread in AP and lateral views, [Figure 1] 5 mL of preservative-free 0.25% bupivacaine and 4 mg dexamethasone were injected after negative aspiration of blood. After the procedure, anti-inflammatory medication and compression with an ice pack was prescribed to relieve local inflammation. In Case 2, the block was performed under mild sedation on the adolescent patient using a 5 cm 23 G spinal needle, and 4 mL of preservative-free 0.25% bupivacaine was injected after negative aspiration of blood. She reported significant pain relief immediately after injection. As fluoroscopic image in lateral view showed an anteriorly displaced coccyx, bimanual per-rectal reduction of the coccyx was performed by an orthopedician after the pain relief [Figure 2]. In the patient with rectal carcinoma, neurolytic GI block was performed and 5 mL of 70% alcohol was injected after negative aspiration of blood.
|Figure 1: Fluroscopic Dye Spread of Ganglion Impar Block. Left: Lateral View; Right: AP View|
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After the procedure, all the patients were prescribed oral anti-inflammatory medication for 3 days. In the patient with rectal carcinoma, the dose of oral morphine was reduced to 10 mg CR twice daily with adequate pain relief. The patient with vulvodynia was asked to continue her neuropathic medication with reduced dose which was tapered and stopped over a period of 6 months as she had sustained pain relief.
In all patients, the intensity of pain was assessed using NRS before the administration of GI block, immediately after the block, at 3 months, 6 months, and at 1 year post procedure.
| Results|| |
All the patients reported immediate pain relief within 10 min after GI block. The patients had preprocedure NRS scores ranging from 7 to 10, which reduced following GI block and at subsequent follow-up visits at 3, 6, and 12 months [Figure 3]. The mean NRS score before the block was 8 ± 0.701, which was reduced to 2.75 ± 0.95 10 min after the block. NRS scores at 3 months, 6 months, and 1 year follow-up were 1.5 ± 1.29, 1.25 ± 1.25, and 1 ± 1.41, respectively, which was statistically significant [Table 2]. No complications were noted immediately after the procedure and during the follow-up period.
|Figure 3: Comparision of NRS Scores Pre and Post GI Block at Various Intervals|
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|Table 2: Mean numerical rating scale scores before and after ganglion impar block|
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Analysis was carried out using SPSS Version 23.0. Armonk, NY: IBM, (licensed to the institution). Mean and standard deviation were used to represent quantitative data. Inferential statistics such as t-test were applied to test pre and post-block NRS scores. P < 0.05 was considered statistically significant.
| Discussion|| |
The GI, or the ganglion of Walther, is a part of the sympathetic chain that resides in the pelvis, just in front of the sacrococcygeal junction behind the rectum. It is often used to block pain that is refractory to conservative management. GI block can be offered as a treatment modality for patients with perineal pain of various etiologies such as coccydynia of traumatic or nontraumatic causes, perineal or pelvic pain syndromes, and anorectal and vulval cancer pain. GI can be blocked by either injecting local anesthetic with steroids, neurolytic solution such as alcohol or phenol, or using radiofrequency ablation. Complications including rectal perforation, hemorrhage, and local infection can be avoided with the use of fluoroscopy or ultrasound guidance.
Coccydynia is more common in adolescents and adults, with a higher incidence in females and obese patients. The etiologies of coccydynia are varied; however, in most patients, it is usually followed by an external or internal trauma due to direct injury to the sacrococcygeal region with or without coccyx fracture. In the present case series, the first patient (Case 1), a 37-year-old male who sustained trauma following a fall from a bike onto his buttocks presented with severe pain on sitting. Gunduz et al. and Sagir et al. noted that trauma, especially after a backward fall, was the cause of coccydynia in 50% of patients, similar to this case presenting with traumatic coccydynia., As this patient had minimal relief after 2 weeks of conservative management, she was considered for GI Block. The patient had an NRS of 8/10 before the block, with a significant reduction in the NRS during subsequent follow-up visits at 3, 6, and 12 months. Gonnade et al. and Sagir et al. reported a significant decrease in pain in 31 patients following GI block in a 1-year follow-up study similar to our patient.,
Coccydynia in adolescents can be due to anatomical predispositions like anterior subluxation of the coccyx and less stability which are all sources of anatomical weakness. Nontraumatic coccydynia can result from hypermobility or hypomobility of the sacrococcygeal joint, obesity, infection, and variants of coccygeal morphology. It is also important to rule out other nonorganic causes, such as somatization disorder and other psychological disorders in patients of chronic recalcitrant coccydynia. Ellinas et al. have observed that although well described in adults, the diagnosis and treatment of idiopathic coccydynia in children are less frequently reported. Kalstad et al. found a strong preponderance of females in the studies involving adolescents with coccydynia. This reason for the sex ratio of 5:1 favoring females may be due to anatomical differences in the shape of the pelvis. Woon found that female coccyges were shorter and straighter and may be more prone to retroversion. The second patient (Case 2), a 14-year-old girl, presented with coccydynia of idiopathic etiology with an NRS of 7/10. The patient underwent manipulation, after which her pain was aggravated. Postmanipulation fluoroscopy image showed anteriorly displaced coccyx, which might be the pain generator. She underwent GI Block and had immediate and complete pain relief. In Maigne et al.' study, in their patient cohort, 32 of 53 adolescents (60%) were reported as totally or almost pain free following the block, which is similar to our findings.
Pelvic pain and perineal pain are common in patients with malignancy of pelvic organs due to neoplastic infiltration which requires high doses of medication and often results in inadequate pain relief. GI block is an effective technique in management of intractable pelvic pain, with a degree of evidence I C., The third patient (Case 3) in the present case series was a known case of carcinoma rectum presented with severe pain with NRS of 9/10. After neurolytic GI block, she had significant pain relief similar to the findings of Laksono in his case report. Correia et al. reported that after neurolytic GI block, 93% of patients had pain relief, with a significant reduction in oral morphine consumption. Our patient also had a reduced requirement for oral morphine following neurolytic GI block with significant pain relief which was comparable to the observations of Correia et al.
Vulvodynia is a common chronic neuropathic pain condition. Due to its multifactorial etiology, it is often difficult to diagnose and treat. Although vulvodynia is more common in younger women, it can present even in postmenopausal women. It is characterized by mechanical allodynia and hyperalgesia localized in the vulvovaginal area. The fourth patient (Case 4) in the present case series had chronic vulvodynia which affected her quality of life and had no relief despite taking long-term treatment with analgesics, neuropathic medications, and landmark-guided pudendal nerve block. This patient received GI block under fluoroscopy guidance which gave her significant pain relief. There was no recurrence of pain even at 1 year follow-up. The pain relief in Case 4 was comparable to that of Hong et al. in their case series of four patients presenting with vulvodynia who were effectively managed with GI block with pain relief lasting more than a year.
In the present case series, we assessed the efficacy of GI block in perineal pain of various etiologies with good results. The limitation of this study is the small sample size. Randomized control trials with a larger sample size are required to substantiate our findings.
| Conclusion|| |
Fluoroscopy-guided GI block is a safe and effective intervention in the management of acute and chronic perineal pain of various etiologies providing good pain relief. Larger studies with randomized control groups will be helpful to validate the findings in this study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]