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Pudendal nerve block to treat the residual pain after embolization of pelvic varicosity in a patient of pelvic congestion syndrome

  胡冠伶(Kuan-Lin Hu);鄒美勇(Mei-Yung Tsou);宋俊松(Chun-Sung Sung)

Chronic pelvic pain (CPP) is a pain of at least six months' duration that occurs below the umbilicus and can cause functional disability. The clinical presentations of CPP include dull pelvic pain which is exacerbated before or during menses, dyspareunia, urinary frequency, and/or generalized lethargy. Etiologies of CPP are diverse and often needs multi-disciplinary approaches. Pelvic congestion syndrome (PCS) is a syndrome that presents with CPP and a definite anatomical findings of pelvic vein insufficiency and pelvic varices. Venography is usually used to confirm pelvic vein reflux and pelvic varices. Among the strategies to treat PCS, endovascular embolization or stent therapy, and non-pharmacologic approach, endovascular therapy has become more popular and provided favorable clinical outcome. However, there is no promise for 100% success rate without recurrence. We present the case of a 41-year-old female with CPP that first appeared when she was 36 and her left lower abdominal pain exacerbated one year ago. Gastrointestinal, urologic, obstetric and gynecological diseases were all excluded, but computed tomography angiography showed left ovarian vein insufficiency and pelvic varices. Transcatheter coil embolization of the left gonadal vein was successfully performed with no retrograde flow immediately after embolization and symptoms improved. However, the residual pelvic and perineal pain after the endovascular embolization therapy did not respond to analgesics. She received the ultrasound-guided left pudendal nerve injection 4 monthes later, and her pain was almost completely abolished. She was delighted with the outcome at a 6-month follow-up. This case highlights the importance of interventional pain procedure in the management of pelvic pain especially when the conventional therapeutic approaches failed.