Cotte166 documented the use of presacral neurectomy (PSN) or sympathectomy as a treatment for intractable dysmenorrhea in 1937. PSN has since been recommended as a surgical treatment for women with deep central pain secondary to refractory primary dysmenorrhea or endo-metriosis. Afferent innervation from the cervix, uterus, and proximal fallopian tubes (T11-L12) travels through the superior hypogastric plexus. PSN interrupts pain from these organs by transection of these nerves.

Preoperative evaluation/requirements should include:

• failure in the past to respond to medical management;

• interference with daily activities secondary to the pain;

• assessment for structural abnormalities likely contributing to the pain;

• evaluation for somatic (nonvisceral) causes of pain;

• possible trial of paracervical or fluoroscopic guided hypogastric plexus blockade to assess whether surgery may benefit;

• a discussion of the expectations/long-term relief of pain with the procedure.

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