Forced coughing versus local anesthesia and pain associated with cervical biopsy: a randomized trial

Is Forced Coughing Effective in Reducing Pain During Cervical Biopsy?: A systematic review and meta-analysis

This review aimed to compare the potential analgesic effect of forced coughing (FC) with that of local anaesthetics (LA) or placebo during cervical biopsy. A total of 5 electronic databases-Scopus, PubMed, Web of Science, Cochrane Library and Google Scholar-were systematically searched from inception till March 2021. Data were extracted from 6 randomised controlled trials and analysed. During cervical biopsy, the overall effect favoured LA over FC (mean difference [MD] = 1.06, 95% confidence interval [CI]: 0.58 to 1.54; P <0.0001). Compared to no pain management, pooled data were comparable between the two groups (MD = -1.2, 95% CI: -3.35 to 0.94; P = 0.27). Procedure duration was significantly longer in the LA group than in the FC group (MD = -1.94, 95% CI: -2.47 to -1.41; P <0.00001). FC and LA are both useful pain-lowering modalities during cervical biopsy, depending on the setting and their availability.

2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia

This guideline provides evidence-based guidance on the risk-based management of cervical dysplasia in the colposcopy setting in the context of primary HPV-based screening and HPV testing in colposcopy. Colposcopy management of special populations is also discussed. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC) and the Canadian Partnership Against Cancer (CPAC). The literature informing these guidelines was obtained through a systematic review of the relevant literature via a multi-step search process led by information specialists. The literature was reviewed up to June 2021 with manual searches of relevant national guidelines and more recent publications. Quality of the evidence and strength of recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include gynecologists, colposcopists, screening programs and healthcare facilities. Implementation of the recommendations is intended to promote equitable and standardized care for all people undergoing colposcopy in Canada. The risk-based approach aims to improve personalized care and reduce over-/under-treatment in colposcopy.

HPV screening in the urine of transpeople - A prevalence study

BACKGROUND

There is limited data on human papillomaviruses (HPV) prevalence in transpeople due to low acceptance rate of screening methods. HPV tests from self-collected urine are gender-neutral, have a high acceptance, and have a comparable accuracy in females to clinician-collected samples. The aim of this study was to evaluate both the HPV prevalence in the urine in a large cohort of 200 transpeople with common risk profiles and the acceptability of such screening method.

METHODS

The study was conducted at the outpatient clinic for transpeople at the Department of Obstetrics and Gynaecology, Medical University of Vienna, Austria. 200 transpeople have been enrolled between May and October 2021. Inclusion criteria were gender identity dysphoria, age over 18 years, and adequate language skills.Subjects were asked to answer a survey concerning gender identity, established risk factors for HPV infections as well as their preference regarding urine or provider-collected cytology-/HPV-based screening, and to provide a urine sample. Five patients not able to provide urine were excluded. HPV genotyping was performed using a validated multiplex real-time PCR assay, which simultaneously detects 28 HPV genotypes. This trial is registered at ClinicalTrials.gov, NCT04864951.

FINDINGS

Overall HPV positivity was 19·0% (37/195), 24·2% in female to male, 11·8% in male to female, 26·3% in genderqueer/non binary/other subjects, 27·9% in subjects currently having a cervix, and 26·0% in subjects born with cervix. Independent of gender reassignment surgery, being born with a cervix was associated with a higher risk of HPV infections (p = 0·008), yet 42·3% (44/104) have never attended cervical cancer screening. Overall, 79·0% (154/195) of transpeople would prefer urine HPV tests to provider-collected HPV screening.

INTERPRETATION

HPV testing in self-collected urine samples provides a unique opportunity for screening of this hard-to-reach population and should be evaluated in further studies.

FUNDING

None.

The Effect of Forced Cough to Minimize Pain and Discomfort at the Time of Colposcopy-Guided Cervical Biopsy

OBJECTIVE

The aim of the study was to determine whether forced cough during colposcopy-guided cervical biopsy affected pain and anxiety levels.

MATERIALS AND METHODS

The study was conducted at the University Hospital (Newark, NJ) Ambulatory Care Center from December 2016 to June 2018 and evaluated 110 patients at the time of a colposcopy-guided cervical biopsy. Study patients were randomized to either cough or no cough group during the biopsy procedure. Pain level was assessed using a visual analog pain scale before, during, and immediately after a colposcopy-guided cervical biopsy. Study patients also completed a standardized anxiety survey before and after the procedure. T tests, Pearson χ, or Cochran-Mantel-Haenszel were used to compare baseline characteristics between the cough and no cough groups. Multivariate linear regression analysis was used to identify potential confounders and then compare pain levels across both groups.

RESULTS

There was no statistically significant difference in pain scores between the cough and no cough group when analyzed for each demographic variable even when confounders were accounted for. The anxiety scores for both study groups before and after the procedure were similar and not significantly reduced.

CONCLUSIONS

We observed a trend that cough reduced pain associated with the colposcopy-guided cervical biopsy but did not reach statistical significance. A similar outcome was observed in anxiety level, where anxiety was reduced in the cough group but was not statistically significant as compared with the no cough group. Further studies are necessary to assess various modalities in reducing pain and anxiety associated with colposcopy-guided cervical biopsy.

Role of Oral Tramadol 50 mg in Reducing Pain During Colposcopy-Directed Cervical Biopsy: A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to assess safety and efficacy of 50-mg tramadol in reducing patient-perceived pain during colposcopy.

MATERIAL AND METHODS

We conducted a randomized double-blind placebo-controlled trial in the colposcopy unit of a tertiary referral hospital, Cairo, Egypt, from April 2018 to October 2018. Our primary outcome was pain during colposcopy-guided ectocervical punch biopsy. Our secondary outcomes were pain during speculum insertion, acetic acid application, Lugol iodine application, endocervical curettage (ECC), endocervical brushing, 10-minute postprocedure, and additional analgesia requirement. Pain was assessed using 10-cm visual analog scale.

RESULTS

One hundred fifty women were randomized into 2 groups: tramadol group (n = 75) received oral 50-mg tramadol tablets, and control group (n = 75) received placebo tablets. Both groups showed no significant difference in anticipated pain score (p = .56), pain scores during speculum insertion (p = .70), application of acetic acid (p = .40), and Lugol iodine (p = .79). However, the mean pain scores were significantly lower in tramadol group compared with placebo at ectocervical biopsy (p = .001), ECC (p = .001), endocervical brushing (p = .001), and 10 minutes after colposcopy (p = .001). Need for additional analgesia was significantly lower in tramadol group (p = .03).

CONCLUSIONS

Oral tramadol 50 mg significantly reduces pain perception during colposcopy-guided ectocervical biopsy, ECC, endocervical brushing, and 10 minutes after colposcopy with tolerable adverse effects.

Comparison of pain and proper sample status according to usage of tenaculum and analgesia: a randomized clinical trial

Objective

Colposcopic biopsy is a discomfortable procedure. Additionally, it creates negative influence on sexuality. This study aimed to investigate the relationships among tenaculum, pain perception, and biopsy size during colposcopy.

Methods

In total, 228 patients who underwent colposcopy-directed biopsy were included, and randomized into 4 groups based on whether analgesic and tenaculum were used and replaced (tenaculum with n=58/without analgesic n=56, no tenaculum replacement with n=57/without analgesic n=57). Lidocaine hydrochloride (40 mg) plus adrenaline (0.025 mg) was administered in the analgesic groups. The pain was assessed using a linear visual analog scale. The biopsy specimen size was measured in millimeters.

Results

The mean age of the patients was 42.85±8.88 years. The most frequent colposcopy indications were atypical squamous cells of undetermined significance and human papilloma virus-positive results on cervical cytology (30.2%; n=69). Low- and high-grade intraepithelial lesions were noted in 14.91% (n=34) and 10.96% (n=25) women through colposcopy-directed biopsy results, respectively. Tenaculum replacement increased pain perception in the without analgesic group; however, no statistically significant differences were noted between of the groups with and without tenaculum replacement with analgesic. The size and number of biopsy specimens were not associated with tenaculum replacement and analgesic use.

Conclusion

Administration of analgesics decreased discomfort and pain in patients. Tenaculum replacement aided colposcopists in manipulating the cervix. Additionally, administration of analgesics relieved pain in the tenaculum replacement group.

Trial Registration

ClinicalTrials.gov Identifier: NCT03279666

Mechanisms of "Cough-Trick" for Pain Relief during Venipuncture: An Experimental Crossover Investigation in Healthy Volunteers

Objectives

The easily performed “cough-trick” (CT) reduces pain during venipuncture (VP), although the underlying mechanism remains unclear. The aim was to investigate the pain-reducing effect of CT during VP in comparison with two distraction methods, as well as under the influence of naloxone.

Methods

54 healthy male volunteers participated in 3 investigations. Pain during standardized VP with CT was compared to a “weak” distraction (squeezing a rubber ball; investigation 1; n=20) and to a “strong” distraction (inflating a tourniquet to a given pressure; investigation 2; n=21). In investigation 3 (n=13), pain at a VP without intervention was compared to pain at VP with CT under naloxone; pressure pain thresholds before and after naloxone administration were also measured. Pain was assessed using a 100 mm visual analogue scale. Data were compared within each sample using Student's t-test for paired samples.

Results

Pain intensity at VP with CT was lower than under “weak” distraction (mean difference 5 mm; 95% CI: 0.5 to 9.6; P=0.03). Pain levels under CT and “strong” distraction were comparable. There was no difference between pain under CT after naloxone infusion and pain without intervention. Pressure pain threshold decreased (mean difference 1 mm; 95% CI: 0.1 to 1.0 mm; P=0.02) after naloxone administration.

Conclusion

Pain-reducing effect of CT during VP is superior to that of simple motor distraction and equivalent to a complex distraction method. This might be due to the activation of segmental pain inhibitory pathways during coughing indicated through the lack of pain reduction due to CT under opioid antagonist blockage.

Treatment of Cervical Dysplasia by Clinicians Who Perform Colposcopy in German-speaking Countries - a Questionnaire-based Study

Introduction In connection with the reorganisation of cervical carcinoma screening, the importance of colposcopy as an integral part of the planned series of clarification testing will greatly increase. Quality standards for performing the colposcopic examination should therefore be defined in detail. A precondition for this is surveying the current standard in clinical practice. The objective of this study was to evaluate the current practice of colposcopy and conisation in Germany by means of a questionnaire aimed at gynaecologists who perform colposcopies in order to document the actual therapeutic standard of treatment of cervical dysplasia.

Materials and Methods Gynaecologists were invited via e-mail or during events to participate in a web-based survey. The questionnaire contained 38 questions on management before, during and after the examination as well as questions on the technical implementation of colposcopy and conisation.

Results From February 2018 to April 2018, 961 e-mails were sent. A response was received in 197 cases (response rate 20.5%). Responses were received for another 40 questionnaires during events (response rate approx. 80%). After taking the inclusion criteria into account, 160 questionnaires were evaluated. The majority of those surveyed take an average of 2 cervical biopsies (67.3%) and nearly all of those surveyed (94.5%) do not use any local anaesthetic. As a standard method for removing cervical precancerous cells, most of the physicians surveyed perform a loop excision with the electrosurgical loop (91.2%) under colposcopic visualisation (61.2%) under general anaesthesia (92.5%). Postoperative bleeding prophylaxis by means of tamponade is performed only in 27.6% of all cases.

Conclusion A differential colposcopy with two colposcopically targeted biopsies and treatment with the electrosurgical loop are the methods most frequently used by clinicians who perform colposcopy in Germany. A uniform procedure should be defined in detail within the scope of directives or guidelines.

Factors affecting pain during outpatient clinic based surgical procedures in gynecologic oncology

Colposcopy-directed punch biopsy (punch biopsy) and endocervical curettage (ECC) are accompanied by considerable pain. However, many physicians perform these procedures without adequate pain management. Therefore, identification of factors affecting pain experienced during the procedures may encourage physician effort in selective pain management. This study investigated factors affecting the severity of pain experienced during punch biopsy and ECC in an outpatient clinic of gynecologic oncology department.In this retrospective, exploratory study, a total of 101 Korean patients with abnormal cervical cytology underwent punch biopsy and ECC under a paracervical block performed for pain relief. Residents under training performed these procedures and recorded patient-reporting maximum Numeric Rating Scale (NRS) scores experienced during the procedures. Residents were classified into four outpatient clinic training groups (1st-4th); the group designators correspond to the resident's experience in performing these procedures. A linear mixed model adjusted for physician factors such as either residents or outpatient clinic training groups was used to analyze the association between each variable and maximum NRS score.Among the outpatient clinic training groups, maximum NRS scores significantly decreased in the 4th group, compared with those in the 1st group although those were not different among groups when adjusted for residents. Some of cervical cytology findings and discrepancies between the severity of cervical cytology results and those of punch biopsy or ECC showed significant associations with maximum NRS scores. However, when adjusted for either residents or outpatient clinic training groups, maximum NRS scores were not different by age, body mass index, presence of menopause, cervical cytology findings, discrepancies between the severity of cervical cytology results and those of punch biopsy or ECC, and tissue volume.There are no significant factors affecting the severity of pain experienced during punch biopsy and ECC.

The analgesic efficacy of forced coughing during cervical punch biopsy: A prospective randomised controlled study

INTRODUCTION

Cervical punch biopsies are a common ambulatory procedure, performed routinely by gynaecologists. The aim of the present study was to assess the efficacy of forced coughing as a pain-reducing technique during cervical punch biopsy compared to a control group.

MATERIALS AND METHODS

The study was a prospective randomised-control trial. The study group comprised 90 women who underwent cervical punch biopsies during investigation of abnormal Pap test results. The women were randomly assigned to 'cough' and control groups. Pain was measured on a 10 cm visual analogue scale (VAS) during different stages of the procedure.

RESULTS

VAS pain score during biopsies was significantly lower in the 'cough' group. The median pain level in the 'cough' group was 1.5, compared to 4.0 in the control group. Eighty percent of the women in the 'cough' group reported a pain level of 2.0 or less compared to 40% of the women in the 'control' group (P = 0.0002). In the second biopsy, 69% of the women reported VAS ≤ 2.0 in the cough group compared to 28% of the patients in the control group. Forced coughing was shown both to reduce anxiety regarding the prospect of future cervical procedures and to decrease patients' desires for future pain management. This was true for 32% of the women in the 'control' group compared to 12% of the women in the 'cough' group (P = 0.05).

CONCLUSION

Forced coughing provides significant pain relief during cervical punch biopsy and reduces the patients' fears and desires for pain medications in future procedures.