Chief, Pain Medicine & Palliative Care, Artemis Hospitals, Gurgaon, India
Part 9 of 12 in Advances in Chronic Pain Management
Cancer, Pelvic and Perineal Pain: Visceral Nerve Blocks and Ganglion Impar
June 8, 2025
For upper gastrointestinal cancers, gallbladder and pancreatic cancer, and chronic pancreatitis that will not heal, splanchnic nerve block or radiofrequency ablation delivers, on average, more than a year of pain relief; because the electrodes are placed along the wall of the spine rather than through the abdominal cavity, it also works for patients with ascites or multiple abdominal metastases where a coeliac plexus block cannot safely be done. For pelvic cancer and conditions like endometriosis and interstitial cystitis, superior hypogastric plexus block followed by neurolysis addresses visceral pelvic pain; Dr. Jain describes a patient treated days before this session for severe rectal pain after defecation, and a separate case, a young woman from Iraq who had been advised to undergo an ileostomy for pain so severe she had stopped going to the toilet, who recovered fully after this block instead of the planned surgery.
Below the pelvis, tailbone pain, or coccydynia, is common but almost never operated on, both because surgery is rarely indicated and because the proximity of the anal canal raises infection risk; ganglion impar block and radiofrequency ablation gives relief in 90 to 95% of patients, lasting 18 to 24 months in around 80% of cases, with the remaining 20% sometimes needing a repeat procedure. The same ganglion impar approach, along with pudendal and ilioinguinal or genitofemoral nerve blocks, treats perineal, vaginal, testicular and penile pain; Dr. Jain describes an Iraqi patient with severe penile pain who had asked to have the organ surgically removed out of frustration, treated instead with bilateral pudendal nerve pulsed radiofrequency, with pain relief confirmed on the table when sensory stimulation reproduced his usual pain in the correct location before ablation.
This guide is based on a live Jivo Masterclass — Dr. Ashu Kumar Jain taught doctors across Africa on June 8, 2025.
FROM THE LIVE Q&A
Moderator
You mentioned opioids as a line of treatment for chronic pain from avascular necrosis in sickle cell disease. Does not that class of drug carry a risk of habit-formation or addiction?
Dr. Ashu Kumar Jain
Used for chronic low back pain, knee pain or similar musculoskeletal pain, yes, opioids are habit-forming. Used for cancer pain, and for sickle cell pain, which is managed on the same principles as cancer pain, they are never habit-forming in this experience. Opioids sit near the top of the WHO analgesic ladder, are safe on organ function, and are potent enough that patients do not become dependent in this context. Countries that prescribe opioids freely for ordinary chronic non-cancer pain, as parts of the United States and Europe have, do see patients become dependent. For routine non-cancer chronic pain, that risk is real and opioids should be avoided long-term.
Book a Consultation with Dr. Ashu Kumar Jain
Book on WhatsAppOr message us on WhatsApp: +91 98182 98669
Frequently Asked Questions
The physiology of the drug and the brain's receptors are the same either way, so why is not it habit-forming in sickle cell disease and cancer the way it is elsewhere?▼
Because sickle cell pain and cancer pain are primarily visceral pain, and viscera carry opioid receptors. Back pain, knee pain, elbow pain and shoulder pain are peripheral, musculoskeletal or neuropathic pain, and that tissue does not carry the same opioid receptor expression. Visceral pain is also carried by the body's sympathetic nervous system, which does not respond to conventional painkillers, so it needs a neuropathic agent and an opioid in combination. That is the physiological difference.
Would marijuana-based therapy sit in the same class as opioids for safety?▼
Marijuana is a safer drug than a typical opioid, including for musculoskeletal as well as visceral pain, and some countries now use synthetic formulations of it. It just is not approved for medical use in India yet.
NSAIDs also carry a risk of kidney damage for musculoskeletal pain. What is the practical limit?▼
For a musculoskeletal complaint, an NSAID and a muscle relaxant should not run past seven to ten days, at most two weeks. With a new patient, the first move is not intervention: a two-week medical trial is given first, against a target of at least 50% pain relief. If that trial fails to deliver it, the next step is intervention, straight away.
Is there a list of drugs under your remit that are specialist-prescription only, and how do you manage the supply side, including the shelf life and storage of these medicines?▼
In India, opioids are scheduled drugs. Prescribing requires a competent doctor, meaning a pain specialist, anaesthesiologist or neurologist, not a general physician, general surgeon or ENT. For morphine and fentanyl specifically, the hospital needs a government licence to hold a set quantity, uses a special designated government form that gets stamped, and patients are required to bring back a consumption chart that is submitted to the drug controller. Tramadol, tapentadol and buprenorphine do not need that special licensing, but they still require a valid, stamped prescription from a competent doctor.
Given that supply and prescription control is so tight for opioids, is not it strange that some restricted painkiller combinations are still sold over the counter in India?▼
That gap exists, and it falls to drug inspectors to enforce, not to prescribing doctors. In practice it means a large number of chronic pain patients arrive in this clinic having self-medicated with over-the-counter combination painkillers for five, ten, even twenty years. This practice calls it analgesic abuse: a difficult situation created by the fact that these medicines are freely available without a prescription.
Why does splanchnic nerve block work for pelvic or abdominal cancer patients with ascites or multiple metastases, when a coeliac plexus block cannot be done?▼
Because the electrodes are placed along the wall of the spine rather than through the abdominal cavity itself, avoiding the ascites and metastatic tissue that make an intra-abdominal approach unsafe.
Is surgery an option for coccydynia (tailbone pain)?▼
Rarely. It is almost never operated on, partly because the anal canal's proximity raises infection risk. Ganglion impar block and radiofrequency ablation instead give relief in 90 to 95% of patients.
How long does relief from ganglion impar radiofrequency ablation typically last?▼
18 to 24 months in around 80% of patients. The remaining 20% may need the procedure repeated.
What nerve blocks treat perineal, testicular or penile pain?▼
Pudendal nerve block, ganglion impar block, and ilioinguinal or genitofemoral nerve block, depending on which structure the pain is arising from.
In This Series: Advances in Chronic Pain Management
- 1.Advances in Chronic Pain Management
- 2.Facial Pain: Trigeminal Neuralgia, Glossopharyngeal Neuralgia and Sphenopalatine Ganglion Block
- 3.Cervicogenic Headache and Neck Pain: Cervical Facet Radiofrequency Ablation
- 4.Cervical Radiculopathy: Epidural Injection and Why Cathlab Safety Matters
- 5.Thoracic Facetogenic Pain and T2-T3 Sympathectomy for the Upper Limb
- 6.Shoulder Pain Without Surgery: Adhesive Capsulitis and the Three-in-One Block
- 7.Failed Back Surgery, Sciatica and SI Joint Pain: Transforaminal Adhesiolysis and Facet RFA
- 8.Discogenic Low Back Pain: Biacuplasty and Intradiscal Radiofrequency Ablation
- 9.Cancer, Pelvic and Perineal Pain: Visceral Nerve Blocks and Ganglion Impar
- 10.Knee Pain Without Surgery: Cooled Radiofrequency Ablation and Regenerative Options
- 11.Spinal Cord Stimulation and Intrathecal Pumps for Pain That Doesn't Respond to Anything Else
- 12.Opioids and Sickle Cell Pain: When They Are Habit-Forming and When They Are Not