Clinical Background
A 70-year-old male, a known case of non-metastatic carcinoma prostate, had undergone radical prostatectomy with bilateral orchidectomy eight years earlier. He presented to us with non-specific dull aching lower abdominal pain of six months’ duration.
His serum PSA had remained below 2 ng/mL throughout, and both CT and MRI imaging showed no evidence of disease recurrence.
A trial of conservative management with neuropathic medications did not provide adequate relief, leaving the patient with persistent discomfort affecting his daily quality of life.
Diagnosis
In the absence of any structural or oncological cause on imaging, the pain was attributed to a component of chronic pelvic neuropathic/visceral pain—a recognized long-term sequela following radical pelvic surgery, where surgical disruption and fibrosis around the pelvic autonomic plexus can generate persistent pain independent of cancer recurrence.
Intervention
Given the failure of pharmacological management, the patient was planned for superior hypogastric plexus (SHP) neurolysis—an interventional technique targeting the sympathetic plexus responsible for transmitting nociceptive signals from pelvic viscera.
The procedure was performed under fluoroscopic guidance, with bilateral needle trajectories advanced to the anterolateral aspect of the L5–S1 vertebral junction.
Contrast dye was injected under live fluoroscopy to confirm accurate needle tip placement and appropriate spread anterior to the vertebral body, avoiding vascular or visceral structures, before proceeding with the neurolytic step.
Outcome
The patient tolerated the procedure well with no immediate complications.
On follow-up, he reported greater than 90% relief in his pelvic pain, with significant improvement in daily function and quality of life.
Discussion
Superior hypogastric plexus neurolysis is a well-established interventional pain procedure, particularly valuable in patients with pelvic pain of oncological or post-surgical origin who have not responded to conservative treatment.
It offers a minimally invasive, image-guided option that can provide substantial and durable pain relief, reducing dependence on systemic neuropathic medications and their associated side effects.
This case highlights the importance of considering targeted interventional techniques in patients with chronic pelvic pain even in the absence of active disease, and reinforces the role of fluoroscopy-guided plexus blocks in comprehensive pain management.