Pain
Jay Hyun Seo, MD
Resident
Northwell Health
Mt Kisco, New York, United States
Peter C. Lascarides, DO
Director Of Pain Management
Northwell Health
Mt Kisco, New York, United States
Jay Hyun Seo, MD
Northwell
Mt Kisco, New York, United States
A 63-year-old woman with recurrent vulvar SCC and severe lichen sclerosus presented with debilitating vulvar and perianal pain radiating to both legs. Her history included multiple vulvectomies, sentinel node dissections, pelvic radiation, and development of persistent perineal wounds from radiation ulceration, surgical breakdown, and tumor infiltration. Biopsy confirmed invasive perianal SCC without metastases. She described severe stabbing, burning pain with allodynia and hyperalgesia, impairing sleep and ambulation. Her Brief Pain Inventory (BPI) score was 8/10, and her Patient-Reported Outcomes Measurement Information System (PROMIS) physical function was below the 25th percentile. She declined opioids due to long-term sobriety. Previous treatments including tramadol, lidocaine, and gabapentin were ineffective. She was transitioned to pregabalin, nortriptyline, and topical lidocaine. Patient underwent a fluoroscopy-guided ganglion impar block with bupivacaine and triamcinolone, which provided partial relief, improving sleep and ambulation. Ongoing pain management includes bilateral pudendal nerve blocks, hyperbaric oxygen therapy for ulceration, and pelvic rehabilitation.
Discussions:
This case highlights the multifactorial nature of oncologic pelvic pain, where nociceptive, neuropathic, and radiation-induced mechanisms converge. The patient’s neuropathic features, including allodynia and hyperalgesia, are consistent with central sensitization mediated by wide dynamic range (WDR) neurons. The partial response to ganglion impar block, combined with centrally acting agents, underscores the importance of mechanism-based, multimodal pain management. Objective monitoring with BPI and PROMIS facilitated assessment of functional outcomes, which is critical in advanced cancer care.
Conclusions: Recurrent vulvar SCC with lichen sclerosus can lead to refractory pelvic pain resistant to conventional care. This case demonstrates how physiatrists can integrate interventional procedures, non-opioid pharmacotherapy, wound-directed care, and rehabilitation to improve function and survivorship in complex oncologic patients. Mechanistic insights into WDR neuron-driven central sensitization support individualized pain management strategies in this population.
