Phantom bladder pain

Corresponding author: Heon Keun Lee, M.D., Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 92, Chilam-dong, Jinju 660-751, Korea. Tel: 82-55-750-8137, Fax: 82-55-750-8142, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC A phantom syndrome is a pain syndrome that occurs when part of the body, such as the nose, tongue, breast, tooth, testis, penis, bladder, or anus, has been lost as the result of an accident or operation. Its frequency and etiology remain unclear [1]. Phantom bladder pain is a rare phantom syndrome that has not been reported previously in South Korea. This phantom urinary phenomenon occurs in patients with cystectomies, undergoing hemodialysis, or after spinal cord injury, in the forms of lower abdominal pain during urination, frequent urination, acute inconvenience with a full-bladder sensation, or urination with a sharp and burning pain [2]. Here, we report a patient who acquired phantom bladder pain 2 years after a cystectomy; pain was controlled successfully through a sympathetic ganglion block. A 59-year-old male patient presented with paroxysmal urgency and extreme pain accom panying bladder fullness and a bursting sensation that had started 1 month previously. He had undergone a cystectomy and prostatectomy, Miles operation, and ureteroileal conduit 2 years earlier due to rectal cancer. Defecation and urination were achieved through the connection of a colostomy and uretero-ileal conduit. A phantom sensation of the anus occurred a few months after the Miles operation, but without pain or any other inconvenience. Thus, the patient did not undergo any further treatment. Owing to celiac metastasis with leakage, an ileo-colic anas to mosis had been conducted 7 months before his visit to the pain clinic, and one month before his visit the patient had complained of bladder fullness and a bursting sensation with a desire to micturate and defecate. A spasmolytic agent, tiropramide 100 mg, was prescribed but resulted in no improve ment. A psychiatric consultation revealed that the patient had clear consciousness without depression. The pain was increasing in frequency and strength, and the patient reported a continuous burning sensation with an intermittent sharp stinging sensation in the suprapubic region about 30 times per day. He scored the continuous pain as 6 on a visual analog scale (VAS), and he scored the intermittent paroxysmal pain that lasted 20-30 min as 9-10. No aggravating or relieving factors were present, and no related symptoms were observed, except sleep disorders due to the pain. Gabapentin 1,200 mg/ d, amitriptyline 10 mg/d, oxycodone 40 mg/d, and a fentanyl patch 50 μg/h were provided with no effect. We injected 0.5% bupivacaine dextrose 6 mg into the patient’s L4/5 subarachnoid space, and required him to maintain a sitting position for 30 min to exclude a sympathetic ganglion blocking effect. The pain decreased to VAS 4 temporarily, then returned to the same level after 12 h. Then, a lumbar sympathetic ganglion block was conducted instead of a superior hypogastric plexus block. The needle was placed on the lower one-third of the L2 vertebral body using a C-arm fluoroscope, then 0.5% bupivacaine 5 ml was injected on the left, followed by confirmation of a warm sensation in the left foot. Then, the block was done on the right side, and the warm sensation was felt on the right side too. Because the VAS score diminished to 5, treatment with a neurolytic agent was advised, but lumbar sympathetic ganglion block at both the L2 and L3 levels was conducted two more times at the patient’s request. The pain decreased to VAS 1-2, without recurrence, so the patient was discharged after 2 weeks. Phantom limb pain is well-known, but other phantom pains