會陰神經介入性治療顯著改善骨盆腔鬱血症候群病人在接受骨盆曲張靜脈栓塞後的殘餘疼痛

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

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. 慢性骨盆腔疼痛是常見的問題，持續超過6個月下腹部痛，可伴隨性交疼痛、頻尿或是全身倦怠，造成社會功能失調。骨盆腔鬱血症候群是慢性骨盆腔疼痛，合併有骨盆腔靜脈曲張與功能不全。治療骨盆腔鬱血症候群方法，包括用藥物抑制卵巢，外科手術切除子宮卵巢，經血管管腔內介入性治療放置栓塞線圈或是血管支架，以及非藥物治療等；但無法保證完全治癒，且不再復發。我們提出這個41歲女性個案，慢性骨盆腔疼痛長達六年，且骨盆腔疼痛在最近一年內更趨嚴重。排除掉消化系統、泌尿道以及婦產科問題，電腦斷層血管造影發現左側卵巢靜脈功能不全與骨盆腔靜脈曲張。經血管管腔內介入性治療，將左側卵巢靜脈成功以線圈栓塞，骨盆腔疼痛立即得到改善。但是兩周後左側會陰部刺痛與殘存的下腹部疼痛困擾她，鎮痛劑治療無效，以超音波導引進行左側會陰神經介入治療，疼痛幾近消失，六個月後她對於治療效果十分滿意。本文強調介入性止痛治療在慢性骨盆腔疼痛的重要性。