Paracervical local anaesthesia for cervical dilatation and uterine intervention

Design of a syringe extension device (Chloe SED®) for low-resource settings in sub-Saharan Africa: a circular economy approach

Underfunded healthcare infrastructures in low-resource settings in sub-Saharan Africa have resulted in a lack of medical devices crucial to provide healthcare for all. A representative example of this scenario is medical devices to administer paracervical blocks during gynaecological procedures. Devices needed for this procedure are usually unavailable or expensive. Without these devices, providing paracervical blocks for women in need is impossible resulting in compromising the quality of care for women requiring gynaecological procedures such as loop electrosurgical excision, treatment of miscarriage, or incomplete abortion. In that perspective, interventions that can be integrated into the healthcare system in low-resource settings to provide women needing paracervical blocks remain urgent. Based on a context-specific approach while leveraging circular economy design principles, this research catalogues the development of a new medical device called Chloe SED® that can be used to support the provision of paracervical blocks. Chloe SED®, priced at US$ 1.5 per device when produced in polypropylene, US$ 10 in polyetheretherketone, and US$ 15 in aluminium, is attached to any 10-cc syringe in low-resource settings to provide paracervical blocks. The device is designed for durability, repairability, maintainability, upgradeability, and recyclability to address environmental sustainability issues in the healthcare domain. Achieving the design of Chloe SED® from a context-specific and circular economy approach revealed correlations between the material choice to manufacture the device, the device's initial cost, product durability and reuse cycle, reprocessing method and cost, and environmental impact. These correlations can be seen as interconnected conflicting or divergent trade-offs that need to be continually assessed to deliver a medical device that provides healthcare for all with limited environmental impact. The study findings are intended to be seen as efforts to make available medical devices to support women's access to reproductive health services.

Comparison of the effects of spinal anesthesia, paracervical block and general anesthesia on pain, nausea and vomiting, and analgesic requirements in diagnostic hysteroscopy: A non-randomized clinical trial

Background

The aim of this study was to compare the effect of spinal anesthesia (SPA), paracervical block (PB), and general anesthesia (GA), on pain, the frequency of nausea and vomiting and analgesic requirements in diagnostic hysteroscopy.

Methods

This single-center, non-randomized, parallel-group, clinical trial was conducted on 66 diagnostic hysteroscopy candidates who were selected by convenience sampling at Fatemieh Hospital, in Hamadan, Iran, in 2021.

Results

The mean pain score during recovery and the need for analgesic injections was found to be significantly higher in the GA group compared to that in the SPA group (pain: 3.77 ± 2.25 vs. 0.10 ± 0.30, P < 0.001), (analgesic: 50 vs. 0%, P < 0.001) and PB group (pain: 3.77 ± 2.25 vs. 0.90 ± 1.37, P < 0.001), (analgesic 50 vs. 10%, P < 0.001), respectively. However, no statistically significant difference was observed between the mean pain score between SPA and PB groups (0.10 ± 0.30 vs. 0.90 ± 1.3, P = 0.661). In addition, there were no significant differences between groups on nausea/vomiting after operation (P = 0.382). In adjusted regression analysis (adjusting for age, weight, gravid, abortion, and cause of hysteroscopy), the odds ratio (OR) of pain score during recovery was increased in PB (OR: 4.471, 95% CI: 1.527-6.156, P = 0.018) and GA (OR: 8.406, 95% CI: 2.421-9.195, P = 0.001) groups compared with the SPA group. However, in adjusting based on times of surgery duration, anesthesia duration, recovery and return of motor function, the ORs of pain score between groups was not statistically significant.

Conclusion

Despite reduced pain during recovery in patients receiving SPA, duration of anesthesia, recovery period, and return of motor function were significantly prolonged compared to those receiving PB or GA. It seems that PB with less recovery time and faster return of motor function than SPA and also mild pain during recovery compared to GA can be a good option for hysteroscopy.

Clinical trial registration

http://www.irct.ir, identifier IRCT20120915010841N26.

Analgesic efficacy and safety of paracervical block versus conscious sedation in the surgical evacuation of the uterus following first-trimester incomplete miscarriages: A randomised controlled trial

Objective:

To compare the analgesic efficacy and safety of paracervical block and conscious sedation in the surgical evacuation of the uterus following a first-trimester miscarriage.

Methods:

This is an open-label, randomised control trial comparing pain relief by paracervical block versus conscious sedation during manual vacuum aspiration of first-trimester incomplete miscarriages. One-hundred and sixty-two women were equally randomised into two groups. Group A (paracervical group) received a paracervical block of 4 ml of lidocaine each at the 4 and 8 o’clock positions. Group B (conscious sedation group) received intravenous 30 mg pentazocine and 10 mg diazepam. Data obtained were presented using a frequency table, student t-test, chi-square and Mann–Whitney test and bar chart. A P-value of ⩽0.05 was taken to be statistically significant.

Results:

The mean pain score was lower in the paracervical block group compared to the conscious sedation group (P < 0.05); however, there was no significant difference in women’s satisfaction between the groups (P ⩾ 0.05). Conscious sedation had more negative side effects compared to paracervical block which was significant (P < 0.05).

Conclusion:

Paracervical block has better pain control compared with conscious sedation and has a good side effect profile.

Trial registration:

Pan African Clinical Trial Registry (registered trial no. PACTR202108841661192).

Synopsis

Paracervical block for manual vacuum aspiration (MVA) during first-trimester miscarriage is associated with less pain among women compared with conscious sedation.

A double-blind randomized trial comparing lidocaine spray and placebo spray anesthesia prior to cervical laminaria insertion

OBJECTIVE

To compare pain during laminaria insertion after lidocaine spray versus placebo spray anesthesia in women about to undergo a surgical abortion procedure.

STUDY DESIGN

A double blind, randomized, placebo-controlled trial of women at 12-24 weeks gestation one day prior to surgical uterine evacuation procedure. Participants received lidocaine 10% or placebo (saline 0.9%) spray to the endocervix and ectocervix two minutes before laminaria insertion. The primary outcome was participants' pain score immediately after initial laminaria insertion, measured using a 10 cm visual analog scale (VAS). Secondary outcomes included scores at speculum removal and 15 min after speculum insertion.

RESULTS

From 7/2016 through 8/2018, we enrolled 68 and 66 women to the lidocaine and placebo groups, respectively. Baseline characteristics were similar in both groups. The primary outcome did not differ between lidocaine and placebo groups (median VAS 2.0 vs. 2.0 respectively, p = 0.69). Reported VAS after speculum removal and 15 min from speculum insertion were similar in the lidocaine and placebo groups (median 2.0, p = 0.99; median 1.0 vs. 1.5 respectively, p = 0.32). In multivariate analyses, lidocaine use was associated with decreased VAS score at 15 min from speculum insertion [95%CI -0.96 (-1.74 to -0.18), p = 0.016]. Reported VAS ≥7 at 1st laminaria insertion did not differ between lidocaine and placebo groups (5.88% vs. 10.61% respectively, p = 0.362).

CONCLUSION

In women scheduled for laminaria insertion prior to surgical uterine evacuation at 12-24 weeks gestation, topical application of lidocaine spray to the cervix before insertion did not result in lower reported pain as compared with placebo.

IMPLICATIONS

Our results imply that physicians should not use topical application of lidocaine spray to the cervix before laminaria insertion to reduce women's pain. Continued efforts must be made to find means to relieve pain by using simple, effective analgesia or adjusting the technique, and not using a tenaculum whenever possible.

Effects of high-frequency, high-intensity transcutaneous electrical nerve stimulation versus intravenous opioids for pain relief after hysteroscopy: a randomized controlled study

OBJECTIVE

To compare the time spent in the Post-Anesthesia Care Unit (PACU) and the pain-relieving effects of treatment with high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) or intravenous (IV) opioids after hysteroscopy.

METHODS

All patients who postoperatively reported a visual analogue scale (VAS) pain score of ≥3 were included in the study. TENS treatment was given with a stimulus intensity between 40 and 60 mA for 1 minute and repeated once if there was insufficient pain relief. In the opioid group, a fractionated dose of 5 mg morphine was administered. If the patient reported insufficient pain relief after the assigned treatment, the patient was reassigned to the other treatment group.

RESULTS

Seventy-four women were randomized to TENS (n=38) or IV opioids (n=36) for treatment. Both groups reported significant pain relief after discharge from the PACU, with a decrease of VAS scores from 5.6 to 1.4 in the TENS group (P<0.001) and 5.1 to 1.3 in the opioid group (P<0.001). There were no significant differences between the groups. When only the responders in both groups, i.e., patients with VAS scores of <3 on respectively assigned treatments, were compared, the TENS responders (n=22) were found to have spent a significantly shorter time in the PACU (91 vs. 69 minutes, P=0.013) compared to the opioid responders (n=20).

CONCLUSION

Using TENS as first line of pain relief may reduce the need for postoperative opioids. In addition, TENS appears preferable as the first line of treatment due to its association with a shorter time spent in the PACU if the patient responds to the treatment.

TRIAL REGISTRATION

Västra Götalandsregionen Identifier: 211261.

Office hysteroscopy in the management of women with postmenopausal bleeding

Postmenopausal bleeding (PMB) is a relevant aspect for health-care providers in clinical practice: the first objective is to rule out potential gynecological cancer. The purpose of this narrative review is to evaluate the role of office hysteroscopy in the management of PMB. Office hysteroscopy is a minimally invasive procedure allowing direct visualization of uterine pathology without the need for general anesthesia and the use of an operating room, generating cost savings and greater compliance among patients. Here, we focus on major intrauterine diseases (polyps, submucosal myomas, endometrial hyperplasia, and cancer) as causes of PMB. Office hysteroscopy appears to be safe and feasible, and could allow accurate diagnosis of intrauterine pathologies, especially that with a focal growth pattern, otherwise misdiagnosed with blinded procedures. However, studies focusing exclusively on postmenopausal women are still few, so further research, especially randomized controlled trials, is needed.

Deep Sedation or Paracervical Block for Daycare Gynecological Procedures: A Prospective, Comparative Study

Context:

Many minor gynecological procedures are done for diagnostic and therapeutic reasons. A balance has to be struck between ability to discharge a patient at the earliest with minimum procedure-related discomfort to ensure patient safety as well as satisfaction.

Aim:

This prospective randomized study was designed to compare deep sedation versus paracervical block for minor gynecological surgeries comparing the time to discharge readiness, pain after the procedure, and overall patient satisfaction.

Setting and Design:

This prospective randomized comparative study was conducted at a tertiary level hospital after institutional ethics committee approval and registry of trial at CTRI (India).

Methods:

Seventy young women underwent minor gynecological procedures under these two modes of anesthesia. Time to discharge readiness from hospital to home was assessed using modified postanesthesia discharge score system (PADSS). Pain after procedure as well as patient satisfaction was evaluated. Patients were also asked whether they would recommend the same anesthetic technique for the procedure in the future. Answers were noted on a Likert scale.

Results:

Patients were ready to be discharged faster in deep sedation group compared to paracervical block group based upon modified PADSS score (1 h 9.6 min vs. 1 h 18 min) (P = 0.005). Pain in the perioperative period was analyzed using repeated-measures ANOVA and found to be significantly lesser in deep sedation group when considered till 80 min after surgery. The mean satisfaction score in patients who underwent deep sedation was 91.24 (standard deviation [SD] 2.8) compared to patients given paracervical block which was low at 64.67 (SD 15.8). All patients given deep sedation were ready to recommend the anesthesia technique as compared to only 53.3% of patients who were given paracervical block.

Conclusions:

Deep sedation may be preferred over paracervical block for daycare minor gynecological procedures.

Perioperative pain management strategies among women having reproductive surgeries

This review presents opioid-sparing strategies for perioperative pain management among women undergoing reproductive surgeries and procedures. Recommendations are provided regarding the use of nonsteroidal anti-inflammatory drugs, acetaminophen, other adjunctive medications, and regional anesthetic blocks. Additional considerations for chronic opioid users or patients using opioid replacement or antagonist therapy are discussed.

Evaluation of Paracervical Block and IV Sedation for Pain Management during Hysteroscopic Polypectomy: A Randomized Clinical Trial

BACKGROUND

The aim of this study was to compare the effectiveness of paracervical block (PB) and IV sedation (IVS) on women's pain perception during operative hysteroscopy.

METHODS

A total of 84 patients with uterine polyps were randomized to either PB or IV sedation or general anesthesia (GA) as control group. In PB group, the patients received oral diazepam 10 mg and 100 mg diclofenac Na suppository 60 min before surgery and 10 cc of 2% buffered lidocaine was injected at cervix. Conscious sedation was performed with the IV administration of 2-3 mg/kg/h propofol 1% and midazolam 0.02 mg/kg and fentanyl (1-2 μg/kg) with o2 4-5 lit/min via face mask.

RESULTS

There were no significant differences between groups on VAS score at 3 hours after operation (PB: 1.22 ± (1.31), IVS: 1.10 ± (1.68), GA: 1.29 ± (2.03), P = 0.671) and during recovery (PB: 0.85 ± (1.06), IVS: 0.68 ± (1.33), GA: 1.21 ± (2.04), P = 0.458). There was no difference between PB (3.33 ± (2.81)) and IVS (2.31 ± (2.63)) groups at hysteroscopy (P = 0.182). Patients undergoing IVS reported lower VAS score than PB group at dilation and curettage, although the difference was not statistically significant (PB: 2.59 ± (1.78), IVS: 1.72 ± (2.34), P = 0.051). Moreover, patients undergoing IVS obtained lower VAS score than PB group at polypectomy, while the difference was not statistically significant (PB: 1.81 ± (1.52), IVS: 1.10 ± (1.32), P = 0.073).

CONCLUSION

The finding of the present study revealed that IVS and PB showed the same effect in reducing pain during and after gynecological surgical procedures. The study was registered in Iranian Registry of Clinical Trial with the number IRCT2016031426855N3, on April 28, 2016.

Lidocaine for pain control during intrauterine device insertion

AIM

The aim of this study was to compare the effects of topical lidocaine spray, cream and injection on pain perception during intrauterine device (IUD) insertion.

METHODS

Multiparous women of reproductive age were randomized into control, lidocaine cream, spray and injection groups. A 10 cm visual analog scale was used for all patients to evaluate pain during the three steps of the IUD insertion procedure. Baseline pain assessment was made immediately after the administration of analgesics, the second pain assessment was performed immediately after use of the tenaculum, and the third pain assessment was performed after IUD insertion.

RESULTS

Two hundred patients were enrolled in the study. The groups were similar in terms of demographic characteristics. The lidocaine injection group exhibited higher baseline pain scores (P < 0.001). Pain associated with tenaculum use was lower in the lidocaine spray group. Pain related to IUD insertion was lower in the lidocaine spray and injection groups (P < 0.001); however, lidocaine spray was superior to injection for the reduction of IUD insertion related pain (P = 0.001).

CONCLUSION

Lidocaine spray is a good option for reducing the pain experienced during insertion of an IUD. It reduces pain related to both tenaculum use and IUD insertion. Spray application is both easy and rapid. Paracervical lidocaine injection also reduces pain during IUD insertion, but has no effect on tenaculum-related pain; moreover, the injection itself is painful. Therefore, this option is not a plausible method for reducing pain during IUD insertion.

Effectiveness of paracervical block for pain relief in women undergoing hysterosalpingography

OBJECTIVES

To evaluate the potential benefit, in terms of pain relief, of the paracervical block with 2% lignocaine in women undergoing hysterosalpingography (HSG).

STUDY DESIGN

This study was a prospective randomized controlled study.

SETTINGS

This study was conducted in infertility clinic of a tertiary care center.

MATERIALS AND METHODS

Four hundred and six patients undergoing HSG as a part of infertility evaluation were included in the study. These women were randomized into two groups: Group I received paracervical block with 2% lignocaine at the time of HSG (n = 53) and Group II (n = 53) served as control. Hyoscine (10 mg) oral tablet was given to all the patients 30 min before the procedure. Pain perception during the procedure was analyzed by the patient between 0 and 10 on a numeric rating scale, immediately after HSG.

RESULTS

The baseline demographic characteristics of participants in two groups were similar. Mean pain score immediately after HSG in the study group and control group was 4.84 ± 2.56 and 5.21 ± 1.89, respectively (P = 0.21).

CONCLUSIONS

There is no benefit of paracervical block with 2% lignocaine, in terms of pain relief, in women undergoing HSG.

Comparison of four different pain relief methods during hysterosalpingography: a randomized controlled study

BACKGROUND

Hysterosalpingography (HSG) is the most commonly used method for evaluating the anatomy and patency of the uterine cavity and fallopian tubes, and is an important tool in the evaluation of infertility. The most frequent side effect is the pain associated with the procedure.

OBJECTIVES

To evaluate four analgesic methods to determine the most useful method for reducing discomfort associated with HSG.

METHODS

In the present prospective study, 75 patients undergoing HSG for evaluation of infertility were randomly assigned to four groups: 550 mg of a nonsteroidal anti-inflammatory drug (NSAID) (group 1); 550 mg NSAID + paracervical block (group 2); 550 mg NSAID + paracervical analgesic cream (group 3); or 550 mg NSAID + intrauterine analgesic instillation (group 4). A visual analogue scale was used to assess the pain perception at five predefined steps.

RESULTS

Instillation of the liquids used for HSG was found to be the most painful step of HSG, and this step was where the only significant difference among groups was observed. When comparing visual analogue scale scores, group 2 and group 3 reported significantly less pain than the other groups. Group 1 reported significantly higher mean (± SD) scores (7.2 ± 1.6) compared with groups 2 and 3 (4.7 ± 2.5 and 3.8 ± 2.4, respectively) (P<0.001). In addition, group 2 reported significantly less pain than group 4 (4. 7 ± 2.5 versus 6.7 ± 1.8, respectively) (P<0.02).

CONCLUSIONS

For effective pain relief during HSG, in addition to 550 mg NSAID, local application of lidocaine cream to the posterior fornix of the cervix uteri and paracervical lidocaine injection into the cervix uteri appear to be the most effective methods.

Randomized comparative trial of cervical block protocols for pain management during hysteroscopic removal of polyps and myomas

Purpose

To evaluate the efficacy of two cervical block protocols for pain management during hysteroscopic removal of intrauterine polyps and myomas using the MyoSure^® device.

Patients and methods

This was a randomized, comparative treatment trial conducted by five private Obstetrics and Gynecology practices in the USA. Forty premenopausal women aged 18 years and older were randomized to receive either a combination para/intracervical block protocol of 37 cc local anesthetic administered at six injections sites in association with the application of topic 1% lidocaine gel, or an intracervical block protocol of 22 cc local anesthetic administered at three injections sites without topical anesthetic, for pain management during hysteroscopic removal of intrauterine polyps and/or a single type 0 or type 1 submucosal myoma ≤3 cm. The main outcomes were a composite measure of procedure-related pain and pain during the postoperative recovery period, assessed by the Wong-Baker Faces Rating Scale (0= no pain to 10= maximum pain). The lesion characteristics, procedure time, and adverse events were summarized.

Results

A total of 17 polyps and eight myomas were removed in the para/intracervical block group, with diameters of 1.3±0.5 cm and 1.8±0.8 cm, respectively. In the intracervical block group, 25 polyps with a mean diameter of 1.2±0.7 cm and 7 myomas with a mean diameter of 1.9±0.9 cm were removed. The mean tissue resection time was 1.2±2.0 minutes and 1.2±1.4 minutes for the para/intracervical and intracervical block groups, respectively. The mean composite procedure-related pain score was low for both cervical block protocols, 1.3±1.4 in the para/intracervical block group vs 2.1±1.5 in the intracervical block group. During the postoperative recovery period, the mean pain scores were 0.3±0.7 vs 1.2±1.7 for the para/intracervical and intracervical block groups, respectively. There were no serious adverse events.

Conclusion

The MyoSure procedure for removal of polyps and myomas was well tolerated, with low pain scores reported for both the para/intracervical and intracervical block protocols.

MRI-assisted cervix cancer brachytherapy pre-planning, based on application in paracervical anaesthesia: final report

Background

Optimal applicator insertion is a precondition for the success of cervix cancer brachytherapy (BT). We aimed to assess feasibility and efficacy of MRI-assisted pre-planning, based on applicator insertion in para-cervical anaesthesia (PCA).

Patients and methods.

Five days prior to BT, the pre-planning procedure was performed in 18 cervix cancer patients: tandem-ring applicator was inserted under PCA, pelvic MRI obtained and applicator removed. Procedure tolerability was assessed. High risk clinical target volume (HR CTV) and organs at risk were delineated on the pre-planning MRI, virtual needles placed at optimal positions, and dose planning performed. At BT, insertion was carried out in subarachnoidal anaesthesia according to pre-planned geometry. Pre-planned and actual treatment parameters were compared.

Results

Pre-planning procedure was well tolerated. Median difference between the pre-planned and actual needle insertion depth and position were 2 (0–10) mm and 4 (0–30) degrees, respectively. The differences between the pre-planned and actual geometric and dosimetric parameters were statistically non-significant. All actual needles were positioned inside the HR CTV and outside the organs at risk (OAR).

Conclusions

Our pre-planning approach is well tolerated and effective. Pre-planned geometry and dose distribution can be reproduced at BT.