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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 3  |  Page : 245-247

Chronic Vulvodynia treated by Ganglion Impar block-a case report


Centre of Pain Relief and Beyond, Varma Union Hospital, Indore, Madhya Pradesh, India

Date of Submission30-Oct-2021
Date of Decision05-Nov-2021
Date of Acceptance09-Nov-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Rachna Varma
No. 15, Amitesh Nagar, Scheme No 59, Indore - 452 014, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_89_21

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  Abstract 


Vulvodynia is a condition of considerable vulvar pain and discomfort to women which affects approximately 16% of women and is mostly not diagnosed. The patients are rarely treated. The patients mostly consult gynecologist and as they do not present with any local signs are treated with antibiotics and analgesics only. The cause of vulvodynia is not known, so there is no known effective treatment available. The patients' symptoms and literature suggest it be neuropathic in origin. A ganglion impar block was used in this patient which was effective in treating the patient.

Keywords: Ganglion impar, neuropathic pain, vulvodynia


How to cite this article:
Varma R, Varma G, Chandra M, Singhal R, Singhal S. Chronic Vulvodynia treated by Ganglion Impar block-a case report. Indian J Pain 2021;35:245-7

How to cite this URL:
Varma R, Varma G, Chandra M, Singhal R, Singhal S. Chronic Vulvodynia treated by Ganglion Impar block-a case report. Indian J Pain [serial online] 2021 [cited 2022 Jan 21];35:245-7. Available from: https://www.indianjpain.org/text.asp?2021/35/3/245/334110




  Introduction Top


The International Society for the study of Vulvovaginal disease in 2015 updated the definition of vulvodynia as vulvar pain of at least 3-month duration, for which no obvious etiology could be found which may have potential associated factors.

(1) Vulvodynia may present with varied clinical symptoms and potential factors for development of vulvodynia include comorbidities and other chronic pain syndromes.

Many literatures describe vulvodynia as neuropathic in origin. Although it is still not established, but the relationship of chronic pain with peripheral and central sensitization of nervous system and also the efficacy of sympathetic nervous system (SNS) blockade in treating chronic pain is well known.

Ganglion impar is an unpaired sympathetic ganglion of the SNS when blocked has been shown to be effective in treating chronic pain of perineum, distal rectum, vulva, scrotum, distal third of vagina, and also pelvic viscera.


  Case Report Top


A 43-year-old female referred by a gynecologist presented with severe burning pain in an area which was poorly described in her private parts in and around her vulva for the past 6 months.

She had no other systemic illness. She had tried several pharmacological and nonpharmacological therapies as advised to her by different medical and nonmedical personnel.

She had taken antibiotics, antifungals, analgesics almost daily, topical steroids, and topical estrogens which gave her momentary and partial mild relief only. Her pain score never decreased to a tolerable value.

The pain described was a pain which was severe burning in character and was intermittent. It increased on touching the area and on intercourse. It had affected her psychologically and also affecting her relationship with her husband with a profound effect on her overall quality of life. Her numerical rating scale (NRS) was 8/10.

On examination, she had hyperalgesia and allodynia on her vulva. Her gynecology reports were all within normal limits. A diagnosis of vulvodynia was made.

On her first consultation, we advised her tablet gabapentin 300 mg HS, tablet paracetamol 650 mg BD, and topical lignocaine gel 5% BD for 15 days. We did not prescribe nonsteroidal anti-inflammatory drugs and opioids as she had been taking diclofenac tablet almost daily for the past 6 months, and she did not tolerate opioids. On her follow–up, she reported a negligible decrease in pain with medicines and the patient refused to take any more medicines.

A decision of Ganglion Impar block (GIB) was taken to which the patient and her husband immediately agreed. The patient was taken in the operation theater after taking a informed consent. The patient was put in prone position on the fluoroscopy table. Under all aseptic precautions, painting and draping was done.

Monitoring devices were connected. C-arm fluoroscopy machine was put in lateral position. The sacrococcygeal junction was identified, and a 22 G spinal needle was inserted after local anesthetic infiltration of skin with 1% lignocaine [Figure 1].
Figure 1: Trans sacrococcygeal approach to Ganglion Impar

Click here to view


After penetrating the skin and sacrococcygeal ligament in the midline, 0.5 ml of omnipaque (a nonionic radiocontrast dye) was injected to get a linear spread using the reverse comma sign along the Ganglion Impar under fluoroscopy.

A GIB with 10 ml of Bupivicaine 0.25% and Triamcinolone 40 mg was done, [Figure 2].
Figure 2: Dye spread along the Ganglion Impar : the reverse comma sign

Click here to view


She was sent home after observation for 2 h. She was advised tablet gabapentin 300 mg HS and tablet paracetamol 650 mg SOS for 10 days. Postprocedure, she was comfortable and her vitals were stable. The need of repeat intervention if required was explained.

Her first follow-up after 10 days, she reported a markedly decreased NRS of 2/10. On examination, there was no allodynia, hyperalgesia, or tenderness.

Tablet gabapentin 300 mg was advised but refused by the patient, and she was followed up after 15 days when she reported occasional slight pain but was very comfortable. We advised her tablet gabapentin 100 mg, but she refused to take any more medicines.

In her subsequent follow-ups at 1 month, 3 months, 6 months, and then 1 year, she remains comfortable with occasional slight discomfort but not requiring any other treatment.


  Discussion Top


Vulvodynia is a diagnosis for vulvar pain with no obvious etiology and is reached by exclusion. It affects approximately 16% of women.[1]

The pain may be described by the patient as itching, burning, stinging, irritating, or stabbing. The symptoms may be localized or generalized. If it is localized to a specific area such as clitoris, it is called as clitorodynia or the vestibule of the vagina, then it is called as vestibulodynia. Sometimes, it is poorly localized. The pain may be provoked by touching, contact, or by sexual activity. It may also have a mixed pattern.[2] The pain may have a waxing or waning quality. It may also be unprovoked constant pain.

Vulvodynia can affect women of all ages and all ethnicities and race. Women with vulvodynia may not be able to articulate well about her symptoms and suffers in silence. They take multiple consultations with gynecologist, urologists, psychiatrist, dermatologist, and family doctors. Even if they are diagnosed, the proper treatment is seldom given.[3]

Cotton swab testing for eliciting mechanical allodynia and hyperalgesia is done. The type of pain and presence of allodynia and hyperalgesia strongly points toward the diagnosis of neuropathic pain. The etiology of vulvodynia is uncertain and multifactorial most probably. There is no consensus on the theory whether the pain is primarily caused by a local insult or injury or a maladaptive peripheral or central pain processing mechanism or sensitization. The initial trigger may lead to inflammation of the vulva. It results in repetitive simulation of pain receptors and ultimately receptor or nerve damage (nociceptive pain).[4],[5] The absence of such a lesion disputed the above theory.

Allergic contact dermatitis and other urogenital infections have also been proposed. Some women may also give a history of trauma, direct injury like episiotomy or indirect injury like back or hip injury to the pelvic floor. Some women also report the pain to be associated with a hormonal trigger like the birth control pill, postpartum amenorrhea, or perimenopause.

An increase in neurotransmitters and immune-mediated factors is seen at sites of chronic local inflammation. It may also result in proliferation of unmyelinated nerve fiber, chronic stimulation of afferent primary C fibers, and chronic stimulation of the dorsal horn cells in the spinal cord.[6] Such patients were often labeled as psychosomatic.

It is a very complex disorder which proves very difficult to treat. Several treatments such as vulvar care measures, psychological approaches physical therapy, topical medicines such as local anesthetics, estrogen creams, and tricycles antidepressants locally have provided relief in varying degrees.[7] Trigger point injections of steroids and bupivicaine have been successful in some patients. Oral medicines like analgesics and antineuropathic drugs have been used with varying degrees of success. Trans subcutaneous electrical nerve stimulation (TENS), laser therapy, and application of platelet-rich plasma have also been used.

Complementary and alternative therapies such as alterations in diet, use of alternate medicine, physical therapy, reduction of smoking and alcohol, and ice fomentation have all been tried.[8]

Chronic pain and the sensitization of SNS have been studied and well established. Sympathetic nerve blocks have been often used to treat various chronic neuropathic pain conditions.[9],[10]

Ganglion impar also known as Walters ganglion is the only unpaired ganglion of the SNS at the Sacrococcygeal junction.[11] It conveys sympathetic efferent to and nociceptive afferent from the perineum, distal rectum, perianal, distal urethra and vulva/scrotum, and the distal third of vagina and supplies sympathetic innervation of the pelvic viscera.

GIB was first described in 1990 by Plancarte et al. to treat sympathetic pain of malignant origin.[12]

There are four different techniques described for GIB.

  1. Transsacrococcygeal
  2. Anococcygeal
  3. Itercoccygeal
  4. Paracoccygeal.[13]


We used trans-sacrococcygeal approach. It is essential to locate the ganglion accurately. It is done by injection of nonionic radiocontrast dye and see the vertical spread called as the reverse comma sign along the ganglion in a lateral view.[14],[15]


  Conclusion Top


GIB proved effective in treating this patient of Vulvodynia. The need for the day is better understanding of this painful and distressing chronic pain in different fields of medicine for a multidisciplinary and multimodal treatment to treat this condition effectively.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bornstein J, Goldstein AT, Stockdale CK, Bergeron S, Pukall C, Zolnoun D, et al. 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent Vulvar pain and vulvodynia. Obstet Gynecol 2016;127:745-51.  Back to cited text no. 1
    
2.
Haefner HK. Report of the international society for the study of Vulvovaginal disease: Terminology and classification of vulvodynia. J Low Genit Tract Dis 2007;11:48-9.  Back to cited text no. 2
    
3.
Sadownik LA. Etiology, diagnosis, and clinical management of vulvodynia. Int J Womens Health 2014;6:437-49.  Back to cited text no. 3
    
4.
Danby CS, Margesson LJ. Approach to the diagnosis and treatment of vulvar pain. Dermatol Ther 2010;23:485-504.  Back to cited text no. 4
    
5.
Thornton AM, Drummond C. Current concepts in vulvodynia with a focus on pathogenesis and pain mechanisms. Australas J Dermatol 2016;57:253-63.  Back to cited text no. 5
    
6.
Schlereth T, Birklein F. The sympathetic nervous system and pain. Neuromolecular Med 2008;10:141-7.  Back to cited text no. 6
    
7.
Vasileva P, Strashilov SA, Yordanov AD. Aetiology, diagnosis and clinical management of vulvodynia. Menopause Rev 2020;19:44-8.  Back to cited text no. 7
    
8.
Haefner HK, Collins ME, Davis GD, Edwards L, Foster DC, Hartmann ED, et al. The vulvodynia guideline. J Low Genit Tract Dis 2005;9:40-51.  Back to cited text no. 8
    
9.
Wu CL, Marsh A, Dworkin RH. The role of sympathetic nerve blocks in herpes zoster and postherpetic neuralgia. Pain 2000;87:121-9.  Back to cited text no. 9
    
10.
Day M. Sympathetic blocks: The evidence. Pain Pract 2008;8:98-109.  Back to cited text no. 10
    
11.
Gunduz OH, Kenis-Coskun O. Ganglion blocks as a treatment of pain: Current perspectives. J Pain Res 2017;10:2815-26.  Back to cited text no. 11
    
12.
Plancarte R, Amescua C, Patt RB, Allen- de S: Presacral neurectomy of the gan- glion impar (Ganglion of Walther). An- esthesiology 1990; 73:A751.  Back to cited text no. 12
    
13.
Sencan S, Kenis-Coskun O, Demir FG, Cuce I, Ercalık T, Gunduz OH. Ganglion impar block improves neuropathic pain in coccygodynia: A preliminary report. Neurol Neurochir Pol 2018;52:612-7.  Back to cited text no. 13
    
14.
Scott-Warren JT, Hill V, Rajasekaran A. Ganglion impar blockade: A review. Curr Pain Headache Rep 2013;17:306.  Back to cited text no. 14
    
15.
Hong DG, Hwang SM, Park JM. Efficacy of ganglion impar block on vulvodynia: Case series and results of mid and long-term follow-up. Medicine (Baltimore) 2021;100:e26799.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]



 

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