Third, four subjects having successful blocks had laparoscopic presacral neurectomy, yielding one durable success, two transient remissions, and one nonresponse. We investigated open dissection instead. Six patients with disabling pain (including two who failed laparoscopic procedures) underwent complete pelvic sympathectomy (superior hypogastric plexus and lateral chains). Five have no vulvar pain and one has a bizarre but generally transient pain (sympathalgia).58 Fourth, since the peripheral sympathetic nerve fibers are primarily an efferent system, it has been postulated that the afferent limb of this reflex arc is provided by "sensitization" of otherwise silent somatic C fibers that travel in the adventitia of musculocutaneous blood vessels .58, 71 Sensitization means that the polymodal nociceptors (pain receptors) on these C fibers can be fired by noradrenalin, rather than acetylcholine, hence producing a pain loop maintained by activity within the adjacent sympathetic efferents. Preliminary experience with a quantitative thermal testing machine in vulvodynia patients has shown microneurographic patterns of chronic C fiber inflammation.
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