Background & Aims

Penile cancer is a rare case, with 36.068 new cases in GLOBOCAN 2020, and HIV is one of the predisposing factors for this malignancy. The pain caused by penile cancer can be devastating, frequently intractable, challenging to manage, and reducing the quality of life for both patient and family. Management of penile cancer pain should aim to enhance patients’ quality of life. When conventional pharmacological therapy cannot achieve a satisfying result, pain intervention with neurolysis superior hypogastric plexus can be considered as a modality to reduce the pain to the level that is acceptable for the patient. Previous studies reported the use of a superior hypogastric plexus block to reduce pain in penile pain due to metastatic prostate cancer. Still, limited articles reported its use in penile cancer pain. We aim this case as a reference for neurolysis of the superior hypogastric plexus as a modality in pain management for patients with penile cancer.

Methods

Male, 42 years old, with HIV since 2005, and in 2020, had been diagnosed with Penile Squamous Cell Carcinoma staging T4N1M0, unresectable. Later, in 2022, he came to pain clinic with a chief complaint of penile pain NRS 8-9 with burn sensation, itch after urination, and an open wound and pus around his genitalia, which was not relieved by NSAIDs. History and physical examination, we assessed the patient as mixed cancer pain. At first, he obtained a fentanyl patch of 25 mcg and oral Morphine Intermediate Release (MIR) 10 mg for breakthrough pain. Within 3 months of evaluation, the fentanyl patch increased to 62,5 mcg. Pain persisted with frequent breakthroughs; took MIR 3-4 times every day. After risk-benefit discussion with the patient and family, bilateral neurolysis of superior hypogastric with the posterior approach under fluoroscopic guide was conducted with the regimen of Bupivacaine 0,5% 2 ml and Dexamethasone 5 ml, followed by Alcohol 90% 5 ml for neurolysis.

Results

The procedure was uneventful, in our limitations of choices in needle type and fluoroscopy projection can only be PA/AP view. The immediate post-intervention evaluation showed no complications. The patient reported no muscle weakness or paresthesia and could sit and stand independently. The pain level was down to NRS 3-4, which was acceptable for the patient. On one day follow-up, the patient felt better, could sleep well, reported one breakthrough pain within 24 hours, and consumed only one MIR tablet. After two weeks of the procedure, the pain was still NRS 3-4 but felt much better; sometimes, breakthrough pain came but was tolerable for him, and MIR consumed only two tablets in a week. The patient was planning to start the radiotherapy the following week.

Conclusions

Neurolysis of autonomic nerve can be considered in cancer pain when pharmacological therapy fails to give satisfactory pain relief and causes unacceptable side effects. Despite this, superior and inferior hypogastric plexus and ganglion impar block are choices for pelvic pain and genito-urinaria. Bilateral neurolysis of the superior hypogastric plexus was chosen to control pain relating to penile cancer pain at a level that can be acceptable to the patient. The balance of potential risks-benefits as we considered this technique are patient conditions and the device’s limitations. The patient’s condition with a vast mass around the genitalia made it uncomfortable lying prone for prolonged procedures, and lesions on the anococcygeal area made a higher risk of infection in ganglion impar block. The limitation of choice in needle type and fluoroscopy projection made the patient change position from prone to lateral decubitus, more challenging to do inferior hypogastric or ganglion impar.

References

1. Griffiths R, Norman J, Fai K. Blocks of the autonomic nervous system. In: Hester J, Sykes N, Peat S, editors. Interventional Pain Control in Cancer Pain Management. New York: Oxford University Press; 2012. p. 191-97.
2. Fisher K, Daoud J, Gonzalez C, Reyes J, Lopez D, Desyatnikov O. Fluoroscopic-Guided Bilateral Superior Hypogastric Plexus Neurolysis in the Treatment of Intractable Neoplasm-Related Penile Pain. Cureus. 2021;13(11):e19991.
3. Fu L, Tian T, Yao K, Chen XF, Luo G, Gao Y, et al. Global Pattern and Trends in Penile Cancer Incidence: Population-Based Study. JMIR Public Health Surveill. 2022 Jul 6;8(7):e34874.
4. Urits I, Schwartz R, Siddaiah HB, Kikkeri S, Chernobylsky D, Charipova K, et al. Inferior Hypogastric Block for the Treatment of Chronic Pelvic Pain. Anesth Pain Med. 2021 Feb 16;11(1):e112225.
5. Stogicza A. Superior and inferior hypogastric plexus blocks. In: Diwan S, Staats PS, editors. Atlas of Pain Medicine Procedure. New York: Mc Graw Hill; 2015. p. 381-91.
6. Margulis I, Gulati A. Genito-urinary cancer pain syndromes. In: Gulati A, Puttaniah V, Bruel BM, Rosenberg WS, Hung JC, editors. Essentials of Interventional Cancer Pain Management. New York: Springer; 2019. p. 107-12.
7. WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents, 2018.

Presenting Author

Annisa

Poster Authors

Annisa Annisa

MD

Faculty of Medicine University of Indonesia

Lead Author

Yuddi Gumara

MD

Dharmais National Cancer Center, Jakarta, Indonesia

Lead Author

Pryambodho dr

Sp.An-KAR

Rumah Sakit Cipto Mangunkusumo

Lead Author

Astrid Pratidina Susilo

Faculty of Medicine Universitas Surabaya

Lead Author

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Cancer Pain & Palliative Care