Ultrasound-Guided Blocks for Pelvic Pain

  • Chin-Wern Chan
  • Philip W. H. Peng


Chronic pelvic pain (CPP) is defined as noncylic pain of at least 6 months duration, severe enough to cause disability or seek medical attention, occurring in locations such as the pelvis, anterior abdominal wall at or below the umbilicus, lower back, or buttocks. The pathophysiology of CPP is complex. The pain generator may include the viscera (e.g., bladder, bowel), neuromuscular system (e.g., pudendal neuralgia, piriformis syndrome), or the gynecological system (e.g., endometriosis). Pathophysiological processes, both peripherally and centrally combined with psychological factors most likely contribute to the clinical picture. Therefore, a multidisciplinary approach to management is recommended. As part of this management plan, neural blockade and injection of muscles within the pelvis play both a diagnostic and therapeutic role.


Pudendal Nerve Chronic Pelvic Pain Spermatic Cord Anterior Superior Iliac Spine Inguinal Canal 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    American College of Obstetricians and Gynecologists. Chronic pelvic pain: ACOG practice bulletin no. 51. Obstet Gynecol. 2004;103:589–605.Google Scholar
  2. 2.
    Fall M, Baranowski AP, Elniel S, et al. EAU guidelines on chronic pelvic pain. Eur Urol. 2010;57:35–48.PubMedCrossRefGoogle Scholar
  3. 3.
    Chan VWS. A Practical Guide to Ultrasound Imaging for Regional Anesthesia. 2nd ed. Toronto, ON: Toronto Printing; 2009.Google Scholar
  4. 4.
    Smith J, Hurdle M-F, Locketz AJ, Wisniewski SJ. Ultrasound-guided piriformis injection: technique description and verification. Arch Phys Med Rehabil. 2006;87(12):1664–1667.PubMedCrossRefGoogle Scholar
  5. 5.
    Peng PWH, Tumber PS. Ultrasound-guided interventional procedures for patients with chronic pelvic pain – a description of techniques and review of the literature. Pain Physician. 2008;11:215–224.PubMedGoogle Scholar
  6. 6.
    Bellingham GA, Peng PWH. Ultrasound-guided interventional procedures for chronic pelvic pain. Tech Reg Anesth Pain Manag. 2009;13:171–178.CrossRefGoogle Scholar
  7. 7.
    Rofaeel A, Peng P, Louis I, et al. Feasibility of real-time ultrasound for pudendal nerve block in patients with chronic perineal pain. Reg Anesth Pain Med. 2008;33(2):139–145.PubMedGoogle Scholar
  8. 8.
    Peng P, Narouze S. Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part I nonaxial structures. Reg Anesth Pain Med. 2009;34(5):458–474.PubMedCrossRefGoogle Scholar
  9. 9.
    Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg. 2001;108(6):1618–1623.PubMedCrossRefGoogle Scholar
  10. 10.
    Cardosi RJ, Cox CS, Hoffman MS. Postoperative neuropathies after major pelvic surgery. Obstet Gynecol. 2002;100(2):240–244.PubMedCrossRefGoogle Scholar
  11. 11.
    Luijendijk RW, Jekel J, Storm RK, et al. The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg. 1997;225(14):365–369.PubMedCrossRefGoogle Scholar
  12. 12.
    Choi PD, Nath R, Mackinnon SE. Iatrogenic injury to the ilioinguinal and iliohypogastric nerves in the groin: case report, diagnosis, and management. Ann Plast Surg. 1996;37(1):60–65.PubMedCrossRefGoogle Scholar
  13. 13.
    Sippo WC, Burghardt A, Gomez AC. Nerve entrapment after Pfannenstiel incision. Am J Obstet Gynecol. 1987;157(2):420–421.PubMedGoogle Scholar
  14. 14.
    Whiteside JL, Barber MD, Walters MD, Falcone T. Anatomy of the ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol. 2003;189(16):1574–1578.PubMedCrossRefGoogle Scholar
  15. 15.
    Grosz CR. Iliohypogastric nerve injury. Am J Surg. 1981;142(5):628.PubMedCrossRefGoogle Scholar
  16. 16.
    Lantis JC II, Schwaitzberg SD. Tack entrapment of the ilioinguinal nerve during laparoscopic hernia repair. J Laparoendosc Adv Surg Tech A. 1999;9(3):285–289.PubMedCrossRefGoogle Scholar
  17. 17.
    Poobalan AS, Bruce J, Smith EC, King PM, Krukowski ZH, Chambers WA. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain. 2003;19(1):48–54.PubMedCrossRefGoogle Scholar
  18. 18.
    Lim SL, Ng Sb A, Tan GM. Ilioinguinal and iliohypogastric nerve block revisited: single shot versus double shot technique for hernia repair in children. Paediatr Anaesth. 2002;12(3):255–260.PubMedCrossRefGoogle Scholar
  19. 19.
    Mandelkow H, Loeweneck H. The iliohypogastric and ilioinguinal nerves. Distribution in the abdominal wall, danger areas in surgical incisions in the inguinal and pubic regions and reflected visceral pain in their dermatomes. Surg Radiol Anat. 1988;10(2):145–149.PubMedCrossRefGoogle Scholar
  20. 20.
    Jamieson RW, Swigart LL, Anson BJ. Points of parietal perforation of the ilioinguinal and iliohypogastric nerves in relation to optimal sites for local anaesthesia. Q Bull Northwest Univ Med Sch. 1952;26(1):22–26.PubMedGoogle Scholar
  21. 21.
    Liu WC, Chen TH, Shyu JF, et al. Applied anatomy of the genital branch of the genitofemoral nerve in open inguinal herniorrhaphy. Eur J Surg. 2002;168(3):145–149.PubMedCrossRefGoogle Scholar
  22. 22.
    Ducic I, Dellon AL. Testicular pain after inguinal hernia repair: an approach to resection of the genital branch of genitofemoral nerve. J Am Coll Surg. 2004;198(2):181–184.PubMedCrossRefGoogle Scholar
  23. 23.
    Thibaut D, de la Cuadra-Fontaine JC, Bravo MP, et al. Ilioinguinal/iliohypogastric blocks: where is the anesthetic injected? Anesth Analg. 2008;107(2):728–729.PubMedCrossRefGoogle Scholar
  24. 24.
    Weintraud M, Marhofer P, Bosenberg A, et al. Ilioinguinal/iliohypogastric blocks in children: where do we administer the local anesthetic without direct visualization. Anesth Analg. 2008;106(1):89–93.PubMedCrossRefGoogle Scholar
  25. 25.
    al-Dabbagh AK. Anatomical variations of the inguinal nerves and risks of injury in 110 hernia repairs. Surg Radiol Anat. 2002;24(2):102–107.PubMedCrossRefGoogle Scholar
  26. 26.
    Brown DL. Atlas of Regional Anesthesia. Philadelphia, PA: WB Saunders; 1999.Google Scholar
  27. 27.
    Waldman SD. Atlas of Interventional Pain Management. Philadelphia, PA: Saunders; 2004.Google Scholar
  28. 28.
    Katz J. Atlas of Regional Anesthesia. Norwalk, CT: Appleton-Century-Crofts; 1985.Google Scholar
  29. 29.
    van Schoor AN, Boon JM, Bosenberg AT, Abrahams PH, Meiring JH. Anatomical considerations of the pediatric ilioinguinal/iliohypogastric nerve block. Paediatr Anaesth. 2005;15(5):371–377.PubMedCrossRefGoogle Scholar
  30. 30.
    Lipp AK, Woodcock J, Hensman B, Wilkinson K. Leg weakness is a complication of ilio-inguinal nerve block in children. Br J Anaesth. 2004;92(2):273–274.PubMedCrossRefGoogle Scholar
  31. 31.
    Johr M, Sossai R. Colonic puncture during ilioinguinal nerve block in a child. Anesth Analg. 1999;88(5):1051–1052.PubMedGoogle Scholar
  32. 32.
    Amory C, Mariscal A, Guyot E, Chauvet P, Leon A, Poli-Merol ML. Is ilioinguinal/iliohypogastric nerve block always totally safe in children? Paediatr Anaesth. 2003;13(2):164–166.PubMedCrossRefGoogle Scholar
  33. 33.
    Vaisman J. Pelvic hematoma after an ilioinguinal nerve block for orchialgia. Anesth Analg. 2001;92(4):1048–1049.PubMedCrossRefGoogle Scholar
  34. 34.
    Eichenberger U, Greher M, Kirchmair L, Curatolo M, Morigg B. Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection. Br J Anaesth. 2006;97(2):238–243.PubMedCrossRefGoogle Scholar
  35. 35.
    Gofeld M, Christakis M. Sonographically guided ilioinguinal nerve block. J Ultrasound Med. 2006;25(12):1571–1575.PubMedGoogle Scholar
  36. 36.
    Hu P, Harmon D, Frizelle H. Ultrasound-guided blocks of the ilioinguinal/iliohypogastric nerve block: a pilot study. Ir J Med Sci. 2007;176(2):111–115.PubMedCrossRefGoogle Scholar
  37. 37.
    Ford S, Dosani M, Robinson AJ, et al. Defining the reliability of sonoanatomy identification by novices in ultrasound-guided pediatric ilioinguinal and iliohypogastric nerve blockade. Anesth Analg. 2009;109(6):1793–1798.PubMedCrossRefGoogle Scholar
  38. 38.
    Broadman L. Ilioinguinal, iliohypogastric, and genitofemoral nerves. In: Gay SG, ed. Regional Anesthesia. An Atlas of Anatomy and Techniques. St Louis, MA: Mosby; 1996:247–254.Google Scholar
  39. 39.
    Conn D, Nicholls B. Regional anaesthesia. In: Wilson IH, Allman KG, eds. Oxford Handbook of Anaesthesia. 2nd ed. New York: Oxford University Press; 2006:1055–1104.Google Scholar
  40. 40.
    NYSORA. Genitofemoral Nerve Block. <>; 2009. Accessed 11.12.09.
  41. 41.
    Parziale JR, Hudgins TH, Fishman LM. The piriformis syndrome. Am J Orthop. 1996;25(12):819–893.PubMedGoogle Scholar
  42. 42.
    Barton PM. Piriformis syndrome: a rational approach to management. Pain. 1991;47(3):345–352.PubMedCrossRefGoogle Scholar
  43. 43.
    Durrani Z, Winnie AP. Piriformis muscle syndrome: an underdiagnosed cause of sciatica. J Pain Symptom Manage. 1991;6(6):374–379.PubMedCrossRefGoogle Scholar
  44. 44.
    Hallin RP. Sciatic pain and the piriformis muscle. Postgrad Med. 1983;74(2):69–72.PubMedGoogle Scholar
  45. 45.
    Benzon HT, Katz JA, Enzon HA, Iqbal MS. Piriformis syndrome anatomic considerations, a new injection technique, and a review of the literature. Anesthesiology. 2003;98(6):1442–1448.PubMedCrossRefGoogle Scholar
  46. 46.
    Robinson D. Piriformis syndrome in relations to sciatic pain. Am J Surg. 1947;73:335–358.CrossRefGoogle Scholar
  47. 47.
    Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004;35(1):65–71.PubMedCrossRefGoogle Scholar
  48. 48.
    Benson ER, Schutzer SF. Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. J Bone Joint Surg Am. 1999;81(7):941–949.PubMedGoogle Scholar
  49. 49.
    Fishman S, Caneris O, Bandman T, Audette J, Borsook D. Injection of the piriformis muscle by fluoroscopic and electromyographic guidance. Reg Anesth Pain Med. 1998;23(6):554–559.PubMedGoogle Scholar
  50. 50.
    Lang AM. Botulinum toxin type B in piriformis syndrome. Am J Phys Med Rehabil. 2004;83(3):198–202.PubMedCrossRefGoogle Scholar
  51. 51.
    Fishman L, Konnoth C, Rozner B. Botulinum neurotoxin type B and physical therapy in the treatment of piriformis syndrome: a dose finding study. Am J Phys Med Rehabil. 2004;83(1):42–50.PubMedCrossRefGoogle Scholar
  52. 52.
    Pecina M. Contribution to the etiological explanation of the piriformis syndrome. Acta Anat. 1979;105(2):181–187.PubMedCrossRefGoogle Scholar
  53. 53.
    Beason LE, Anson BJ. The relation of the sciatic nerve and its subdivisions to the piriformis muscle. Anat Rec. 1937;70:1–5.Google Scholar
  54. 54.
    Fanucci E, Masala S, Sodani G, et al. CT-guided injection of botulinic toxin for percutaneous therapy of piriformis muscle syndrome with preliminary MRI results about denervative process. Eur Radiol. 2001;11(12):2543–2548.PubMedCrossRefGoogle Scholar
  55. 55.
    Filler A, Haynes J, Jordan S, et al. Sciatic pain of non-disc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome of resulting treatment. J Neurosurg Spine. 2005;2(2):99–115.PubMedCrossRefGoogle Scholar
  56. 56.
    Fishman LM, Dombi GW, Michaelson C, et al. Piriformis syndrome: diagnosis, treatment, and outcome – a 10 year study. Arch Phys Med Rehabil. 2002;83(3):295–301.PubMedCrossRefGoogle Scholar
  57. 57.
    Fishman LM, Andersen C, Rosner B. Botox and physical therapy in the treatment of piriformis syndrome. Am J Phys Med Rehabil. 2002;81(12):936–942.PubMedCrossRefGoogle Scholar
  58. 58.
    Finoff JT, Hurdle MFB, Smith J. Accuracy of ultrasound-guided versus fluoroscopically guided contrast controlled piriformis injections. A cadaveric study. J Ultrasound Med. 2008;27(8):1157–1163.Google Scholar
  59. 59.
    Koski JM. Ultrasound-guided injections in rheumatology. J Rheumatol. 2000;27(9):2131–2138.PubMedGoogle Scholar
  60. 60.
    Broadhurst NA, Simmons ND, Bond MJ. Piriformis syndrome: correlation of muscle morphology with symptoms and signs. Arch Phys Med Rehabil. 2004;85(12):2036–2039.PubMedCrossRefGoogle Scholar
  61. 61.
    Huerto AP, Yeo SN, Ho KY. Piriformis muscle injection using ultrasonography and motor stimulation – report of a technique. Pain Physician. 2007;10(5):687–690.PubMedGoogle Scholar
  62. 62.
    Robert R, Prat-Pradal D, Labat JJ, et al. Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat. 1998;20(2):93–98.PubMedCrossRefGoogle Scholar
  63. 63.
    Benson JT, Griffis K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol. 2005;192(5):1663–1668.PubMedCrossRefGoogle Scholar
  64. 64.
    Amarenco G, Kerdraon J, Bouju P, et al. Treatments of perineal neuralgia caused by involvement of the pudendal nerve. Rev Neurol. 1997;153(5):331–334.PubMedGoogle Scholar
  65. 65.
    Peng PWH, Antolak SJ Jr, Gordon AS. Pudendal neuralgia. In: Pukall C, Goldstein GI, Goldstein A, eds. Female Sexual Pain Disorders. 1st ed. Hoboken, NJ: Wiley-Blackwell; 2009:112–118.CrossRefGoogle Scholar
  66. 66.
    Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306–310.PubMedCrossRefGoogle Scholar
  67. 67.
    Leibovitch I, Mor Y. The vicious cycling: bicycling related urogenital disorders. Eur Urol. 2005;47(3):277–287.PubMedCrossRefGoogle Scholar
  68. 68.
    Allen RE, Hosker GL, Smith AR, Warrell DW. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol. 1990;97(9):770–779.PubMedCrossRefGoogle Scholar
  69. 69.
    Lien KC, Morgan DM, Delancey JO, Ashton-Miller JA. Pudendal nerve stretch during vaginal birth: a 3D computer simulation. Am J Obstet Gynecol. 2005;192(5):1669–1676.PubMedCrossRefGoogle Scholar
  70. 70.
    Soulie M, Vazzoler N, Seguin P, Chiron P, Plante P. Urological consequences of pudendal nerve trauma during orthopedic surgery: review and practical advice. Prog Urol. 2002;12(3):504–509.PubMedGoogle Scholar
  71. 71.
    Amarenco G, Ismael SS, Bayle B, Denys P, Kerdraon J. Electrophysiological analysis of pudendal neuropathy following traction. Muscle Nerve. 2001;24(1):116–119.PubMedCrossRefGoogle Scholar
  72. 72.
    Antolak S, Hough D, Pawlina W, Spinner RJ. Anatomical basis of chronic pelvic pain syndrome: the ischial spine and pudendal nerve entrapment. Med Hypotheses. 2002;59(3):349–353.PubMedCrossRefGoogle Scholar
  73. 73.
    Labat JJ, Robert R, Bensignor M, Buzelin JM. Neuralgia of the pudendal nerve. Anatomo-clinical considerations and therapeutical approach. J Urol (Paris). 1990;96(5):329–344.Google Scholar
  74. 74.
    Amarenco G, Lancoe Y, Ghnassia RT, Goudal H, Pernigot M. Alcock’s canal syndrome and perineal neuralgia. Rev Neurol (Paris). 1988;144(8–9):523–526.Google Scholar
  75. 75.
    Juenemann K-P, Lue TF, Scmidt RA, Tanagho EA. Clinical significance of sacral and pudendal nerve anatomy. J Urol. 1988;139(1):74–80.PubMedGoogle Scholar
  76. 76.
    Gruber H, Kovacs P, Piegger J, Brenner E. New, simple, ultrasound-guided infiltration of the pudendal nerve: topographic basics. Dis Colon Rectum. 2001;44(9):1376–1380.PubMedCrossRefGoogle Scholar
  77. 77.
    Mahakkanukrauh P, Surin P, Vaidhayakarn P. Anatomical study of the pudendal nerve adjacent to the sacrospinous ligament. Clin Anat. 2005;18(3):200–205.PubMedCrossRefGoogle Scholar
  78. 78.
    Shafik A, Doss SH. Pudendal canal: surgical anatomy and clinical implications. Am Surg. 1999;65(2):176–180.PubMedGoogle Scholar
  79. 79.
    O’Bichere A, Green C, Phillips RK. New, simple approach for maximal pudendal nerve exposure: anomalies and prospects for functional reconstruction. Dis Colon Rectum. 2000;43(7):956–960.PubMedCrossRefGoogle Scholar
  80. 80.
    Thompson JR, Gibbs S, Genadry R, Burros L, Lambrou N, Buller JL. Anatomy of pelvic arteries adjacent to the sacrospinous ligament: importance of the coccygeal branch of the inferior gluteal artery. Obstet Gynecol. 1999;94(6):973–977.PubMedCrossRefGoogle Scholar
  81. 81.
    Shafik A, el-Sherif M, Youssef A, Olfat ES. Surgical anatomy of the pudendal nerve and its clinical implications. Clin Anat. 1995;8(2):110–115.PubMedCrossRefGoogle Scholar
  82. 82.
    Schraffordt SE, Tjandra JJ, Eizenberg N, Dwyer PL. Anatomy of the pudendal nerve and its terminal branches: a cadaver study. ANZ J Surg. 2004;74(1–2):23–26.PubMedCrossRefGoogle Scholar
  83. 83.
    Sedy J, Nanka O, Belisova M, Walro JM, Jarolim L. Sulcus nervi dorsalis penis/clitoridis: anatomic structure and clinical significance. Eur Urol. 2006;50(5):1079–1085.PubMedCrossRefGoogle Scholar
  84. 84.
    Bowes WA. Clinical aspects of normal and abnormal labour. In: Resnick R, Creasy RK, eds. Maternal-Fetal Medicine: Principles and Practice. 2nd ed. Philadelphia, PA: WB Saunders; 1989:510–546.Google Scholar
  85. 85.
    Naja Z, Ziade MF, Lonnqvist PA. Nerve stimulator-guided pudendal nerve block decreases ­posthemorrhoidectomy pain. Can J Anaesth. 2005;52(1):62–68.PubMedCrossRefGoogle Scholar
  86. 86.
    Imbelloni LE, Viera EM, Gouveia MA, Netinho JG, Spirandelli LD, Cordeiro JA. Pudendal block with bupivacaine for postoperative pain relief. Dis Colon Rectum. 2007;50(10):1656–1661.PubMedCrossRefGoogle Scholar
  87. 87.
    Prat-Pradal D, Metge L, Gagnard-Landra C, Mares P, Dauzat M, Godlewski G. Anatomical basis of transgluteal pudendal nerve block. Surg Radiol Anat. 2009;31(4):289–293.PubMedCrossRefGoogle Scholar
  88. 88.
    Choi SS, Lee PB, Kim YC, Kim HJ, Lee SC. C-arm guided pudendal nerve block: a new technique. Int J Clin Pract. 2006;60(5):553–556.PubMedCrossRefGoogle Scholar
  89. 89.
    Kovacs P, Gruber H, Piegger J, Bodner G. New, simple, ultrasound-guided infiltration of the pudendal nerve: ultrasonographic technique. Dis Colon Rectum. 2001;44(9):1381–1385.PubMedCrossRefGoogle Scholar
  90. 90.
    Hough DM, Wittenberg KH, Pawlina W, et al. Chronic perineal pain caused by pudendal nerve entrapment: anatomy and CT-guided perineural injection technique. AJR Am J Roentgenol. 2003;181(2):561–567.PubMedGoogle Scholar

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Authors and Affiliations

  1. 1.Department of AnesthesiaUniversity of Toronto, Toronto Western HospitalTorontoCanada

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