Intracutaneous sterile water injection versus oral paracetamol for renal colic during pregnancy: a randomized controlled trial

Intradermal Sterile Water Injection: Safe and Effective Alternative for Relief of Acute Renal Colic in the Emergency Department

BACKGROUND

The optimal pain relief method for acute renal colic in the emergency department remains controversial.

OBJECTIVE

We compared the safety and efficacy of intradermal sterile water injection (ISWI) to treatment with intramuscular (IM) diclofenac, intravenous (IV) opioids, and IV paracetamol in patients with acute renal colic.

METHODS

This randomized, single-blind study included 320 patients with renal colic to one of four treatment groups. The first group received ISWI at four different points around the most painful flank area. Patients in the DI, PARA, and TRAM groups received 75 mg IM diclofenac, 1 g IV paracetamol, and 100 mg IV tramadol, respectively. Pain intensity was measured using a visual analog scale (VAS) before treatment and 15, 30, and 60 min after treatment.

RESULTS

VAS scores 15 and 30 min after treatment were significantly lower in group ISWI than in groups DI, PARA, and TRAM. However, there were no significant differences in the decrease in the pain score at baseline and at 60 min after treatment. In addition, fewer patients required rescue analgesia in group ISWI than in group TRAM. However, no significant differences were observed between group ISWI and group DI or PARA in terms of the need for rescue analgesia. Finally, there were significantly fewer adverse events in group ISWI than in groups DI and TRAM.

CONCLUSIONS

ISWI had similar efficacy, faster pain relief, and lower need for rescue analgesia compared with diclofenac, paracetamol, and tramadol for the management of acute renal colic. In addition, ISWI was well-tolerated and had no adverse effects.

Management of urolithiasis in pregnancy: A systematic review and meta-analysis

PURPOSE

Management of nephrolithiasis is unique in pregnancy and requires multidisciplinary care. To identify the effectiveness or safety of temporary drainage or definitive treatment methods to manage urolithiasis in pregnancy.

METHODS

The search strategy aimed to find both published and unpublished studies was conducted in August 2021. Studies published in any language on any date were considered for inclusion.

RESULTS

Of a total of 3349 publications, 36 studies were included in our qualitative evaluation and 32 studies in the quantitative synthesis. The commonly reported method was stent insertion (n = 29 studies), pneumatic (n = 12), laser (n = 9) lithotripsy, and stone removal using any devices (basket, grasper, or forceps) (n = 11). In seven studies, the authors reported the outcomes of conservative management, and the results showed that the stone-free rate is 54%, and symptom relief occurred in 62% of women. Seven eligible studies reported that 79.9% of urolithiasis were expulsed through stent insertion, while this rate was 94.6% among percutaneous nephrostomy use in two included studies, 88.5% for pneumatic lithotripsy (n = 7 studies), and 76.4% for laser lithotripsy (n = 4 studies), or 95.4% for stone removal method. In addition, adverse events were reported in less than 10% of pregnant women.

CONCLUSIONS

The results showed that stent, pneumatic or laser lithotripsy, and ureteroscopic stone removal were the commonest used methods in the included studies. They can be effective and safe treatment approaches without major maternal or neonatal complications, and could be introduced as an effective and safe therapeutic method for urolithiasis during pregnancy. However, most of the included studies had moderate quality according to critical appraisal checklists. Further prospective studies are needed to reach a conclusion.

Sterile water injections for management of renal colic pain: a systematic review

BACKGROUND

Since the 1950s a small number of centres have used sterile water injections (SWI) to treat renal colic pain. We undertook this review to determine the efficacy of SWI to manage the pain of renal colic.

METHODS

We searched the electronic databases PubMed, Cochrane Central Register, CINAHL, and Scopus from database inception to 7 November 2021 for randomized controlled trials that met the inclusion criteria.

RESULTS

Six trials were included in the review (n = 894 patients). Two placebo controlled trials were included in the meta-analysis. Other trials compared SWI to Diclofenac, Morphine, or oral Paracetamol. The overall quality of the trial was low. Compared to a placebo SWI demonstrated a significant reduction in self-reported pain at 30 min (Mean difference [MD] = -4.68, 95% Confidence Interval [CI] = -5.21, -4.15. p < 0.001, I² = 0%) and at or beyond 60 min post-injection (MD = -5.34 95% CI = -5.85, -4.82, p ≤ 0.001, I² = 0%). Pain relief provided by SWI was significantly better than oral paracetamol and equivalent to Diclofenac and Morphine. No significant side-effects were attributed to SWI use in any trials.

DISCUSSION/CONCLUSION

SWI could be a suitable alternative for management of renal colic pain where alternatives such as non-steroidal anti-inflammatory and opioid drugs are either unavailable or contraindicated. However, further research is required to establish the role of SWI in renal colic pain management.

Effect of topical local anaesthesia on injection pain associated with administration of sterile water injections - a randomized controlled trial

Background

Sterile water injections can provide effective pain relief during childbirth, particularly for low back pain related to childbirth. However, the pain associated administering the injections can negatively impact women’s impressions of the procedure. It may discourage women from considering repeat doses despite the quality of analgesia experienced. Determining strategies to reduce the pain related to the administration of sterile water injections would improve the acceptability of the technique. Therefore, the aim of this study was to evaluate the effect of topical local anesthesia on the pain associated with administration of sterile water injections.

Methods

The study was designed as a multi-arm single-blind, randomized, controlled trial and 120 female healthy students were randomly divided according to one of four groups. The Intervention group received sterile water injections with topical local anesthesia. Control group 1 received sterile water injections without topical local anesthesia, control group 2 received injections of isotonic saline 0.9% with topical local anesthesia and control group 3 received injections of isotonic saline 0.9% without topical local anesthesia. Pain Immediately after the injections and subsidence in pain were recorded using a visual analogue scale. Sensations in the injection area were reported 15 min and the day after the injections.

Results

The main finding of this study was that local anesthesia with EMLA® reduces the pain associated with the administration of intracutaneous sterile water injections. There was a significant difference in the self-assessed pain score immediately following the injections between the control (73.3 mm) and intervention groups (50.0 mm), p = 0.001. No adverse side effects were reported.

Conclusion

Local anesthesia with EMLA® reduces the pain associated with intracutaneous administration of sterile water injections.

Trial registration

The study was registered 08/07/2014 at ClinicalTrials.gov Identifier: NCT02213185.

Management of ureteric stone in pregnancy: a review

Background

Urolithiasis in pregnancy is a major health concern and is one of the most common causes for non-obstetrical abdominal pain and subsequent hospital admission during pregnancy. The incidence of urinary calculi during pregnancy varies in the range of 1/200 to 1/2000. Acute ureteric colic in pregnancy is associated with significant potential risks to both mother and fetus. Significant anatomic and functional changes occur in pregnancy which not only lead to stone formation but also create diagnostic dilemma. The diagnosis of ureteric calculi can be incorrect in about 28% of pregnant patients.

Main body

Management of ureteric stone during pregnancy is remaining to be a challenge for the treating urologist. Because of the inability to use good imaging options for the diagnosis confirmation and more invasive approach for the treatment, management continues to be difficult. The main threats are preterm labor with delivery and premature rupture of membranes. Other pregnancy complications are obstructive uropathy, gestational diabetes mellitus, recurrent abortions and pre-eclampsia. Management of diagnosed ureteric stone is unique in the pregnant population and requires multi-disciplinary care. It should be individualized for each patient and moves preferably from conservative to invasive approaches sequentially. With continued advancements in endourological techniques, few definitive treatment options are also available for such patients.

Conclusion

There are several lacunae related with the diagnostic imaging, medical expulsive therapy, reliability of ureteral stent/percutaneous nephrostomy insertions and safety of ureteroscopy during pregnancy. Herein, we review the management of ureteric stone during pregnancy, the various diagnostic modalities and treatment options with their advantages and disadvantages. We also proposed our management algorithm to deal with such clinical scenario in this particular population.

Intradermal sterile water injection versus diclofenac sodium in acute renal colic pain: A randomized controlled trial

OBJECTIVES

We aimed to evaluate the efficacy of intracutaneous sterile water injection (ISWI) to relieve the pain of acute renal colic compared with diclofenac and placebo.

METHODS

The study included 150 patients presented to the Emergency Department with renal colic randomized into 3 groups: control group received intracutaneous injections of 0.5 cm³ isotonic saline in the flank, group A received intracutaneous injections of 0.5 cm³ ISWI in the flank, and group B received an intramuscular injection of 75 mg Diclofenac in the gluteal region. The severity of the pain was assessed by a visual analogue scale system at baseline and 30, 45 min, and 60 min after injections. Subjects with inadequate pain relief at 1 h received rescue analgesia.

RESULTS

The mean baseline pain score was 9.6 ± 0.61 in the ISWI group, 9.72 ± 0.64 in the diclofenac group and 9.26 ± 0.89 in the control group. The mean pain score at 30 min of the control group was reduced to 6.9 ± 1.56. This mean at 30 min after ISWI and diclofenac injections were reduced to 1.98 ± 1.41 and 1.88 ± 1.19 respectively. The mean of pain sore of the ISWI and diclofenac group at 45 and 60 min was constant. Rescue analgesics at 1 h were required by 47 patients receiving the saline injection and by 4 patients and by 7 patients receiving ISWI and diclofenac injection respectively.

CONCLUSIONS

ISWI and diclofenac were equally effective for the pain relief of acute renal colic.

Comparing Intradermal Sterile Water with Intravenous Morphine in Reducing Pain in Patients with Renal Colic: A Double-Blind Randomized Clinical Trial

OBJECTIVE

The present study was conducted to investigate the effect of intradermal administration of sterile water compared to intravenous morphine on patients with renal colic.

METHODS

This double-blind, randomized clinical trial study was conducted in 2017 to compare the therapeutic effects of intradermal sterile water with those of intravenous morphine on patients with renal colic presenting to the emergency departments (ED) of Imam Khomeini and Golestan Hospitals in Ahvaz, Iran. The first group received 0.5 ml of intradermal sterile water, and the second group 0.1mg/kg of intravenous morphine plus 0.5 ml of intradermal sterile water in the most painful area or the center of the painful area in the flank. The pain severity was measured using a visual analogue scale (VAS), and the medication side-effects were recorded at the beginning of the study and minutes 15, 30,45 and 60.

RESULTS

A total of 94 patients were studied in two groups. The mean severity of pain was 2.97 ± 1.51 in the sterile water group and 2.34 ± 1.89 in the morphine group at minute 30 (P=0.042), 2.58 ± 1.43 in the sterile water group and 1 ± 1.23 in the morphine group at minute 45 (P<0.001), and 1.89 ± 1.7 in the sterile water group and 0.52 ± 0.79 in the morphine group at minute 60 (P<0.001).

CONCLUSION

Morphine reduces pain faster and more effectively than intradermal sterile water; nevertheless, treatment with intradermal sterile water can be used as an appropriate surrogate or adjunct therapy for pain control, particularly in special patients or in case of medication scarcity.

The Effect of Subcutaneous and Intracutaneous Injections of Sterile Water and Normal Saline on Pain Intensity in Nulliparous Women: A Randomized Controlled Trial

BACKGROUND

Normal vaginal delivery is considered a painful process and it is difficult to tolerate the pain. The goal of this study was to compare the effect of injection of sterile distilled water and normal saline on pain intensity in nulliparous women.

MATERIALS AND METHODS

This triple-blind clinical trial was conducted on 164 nulliparous women randomly selected from among those who were hospitalized in Motahari Hospital of Jahrom, Iran, from 1 May 2012 to 1 October 2013. Women with a gestational age of 37-42 weeks, dilatation of 4-6 cm, and delivery 180 min after the intervention were selected. The subjects were randomly allocated to four groups of intracutaneous and subcutaneous sterile water and normal saline injections. Pain severity was measured 5 min before the injection and every 30 min up to 3 h after the injection using a visual analog scale. The data were analyzed using Chi-square, Scheffe, and Spearman's correlation tests in SPSS software.

RESULTS

There was no significant difference among the four studied groups concerning gestational age and other demographic characteristics. Chi-square test showed lower pain intensity 120 min after the injection in group 4 (subcutaneous injection of normal saline) (F ₃ = 14.75, p < 0.001) and 150 min after the injection in group 3 (intracutaneous injection of normal saline) (F ₃ = 14.75, p < 0.001). Chi-square test showed that the duration of the second stage of labor was shorter in group 4 participants (subcutaneous injection of normal saline) (F ₃ = -12.23, p < 0.001).

CONCLUSIONS

The study showed that subcutaneous and intracutaneous injection of normal saline reduced the intensity of pain during childbirth.

Renal colic during pregnancy: Diagnostic and therapeutic aspects. Literature review

Introduction

Renal colic during pregnancy is a rare urgency but is one of the most common non-obstetric reasons for hospital admission. The management often means a challenge for the urologist and gynecologist due to the complexity involved in preserving the maternal and fetal well-being.

Material and methods

We performed a literature search within the PubMed database. We found 65 related articles in English. We selected 36 for this review prioritizing publications in the last two decades.

Results

The anatomical and functional changes of the genitourinary system during pregnancy are well documented; also during pregnancy, there are several metabolic pro-lithogenic factors. The most common clinical presentation is flank pain accompanied by micro or macro hematuria. US provides data identifying renal obstruction shown by an increased renal resistance index. MRI allows differentiating the physiological dilatation from the pathological caused by an obstructive stone showing peripheral renal edema and renal enlargement. Low dose CT has been determined to be a safe and highly accurate imaging technique. Once the diagnosis is confirmed, the initial management of patients should be conservative. When conservative management fails the interventional treatment is mandatory, a urinary diversion of the obstructed renal unit either by a JJ stent or through a PCN catheter has to be done. The definitive management of the stone can be done in the postpartum or deferred ureteroscopy can be considered during pregnancy.

Conclusions

Renal colic during pregnancy is an uncommon urgency, so it is important for the urologist to know the management of this condition.

Effects of intracutaneous injections of sterile water in patients with acute low back pain: a randomized, controlled, clinical trial

Intracutaneous sterile water injection (ISWI) is used for relief of low back pain during labor, acute attacks of urolithiasis, chronic neck and shoulder pain following whiplash injuries, and chronic myofascial pain syndrome. We conducted a randomized, double-blinded, placebo-controlled trial to evaluate the effect of ISWI for relief of acute low back pain (aLBP). A total of 68 patients (41 females and 27 males) between 18 and 55 years old experiencing aLBP with moderate to severe pain (scores ≥5 on an 11-point visual analogue scale [VAS]) were recruited and randomly assigned to receive either ISWIs (n=34) or intracutaneous isotonic saline injections (placebo treatment; n=34). The primary outcome was improvement in pain intensity using the VAS at 10, 45, and 90 min and 1 day after treatment. The secondary outcome was functional improvement, which was assessed using the Patient-Specific Functional Scale (PSFS) 1 day after treatment. The mean VAS score was significantly lower in the ISWI group than in the control group at 10, 45, and 90 min, and 1 day after injection (P<0.05, t-test). The mean increment in PSFS score of the ISWI group was 2.9±2.2 1 day after treatment, while that in the control group was 0.9±2.2. Our study showed that ISWI was effective for relieving pain and improving function in aLBP patients at short-term follow-up. ISWI might be an alternative treatment for aLBP patients, especially in areas where medications are not available, as well as in specific patients (e.g., those who are pregnant or have asthma), who are unable to receive medications or other forms of analgesia because of side effects.