Local anesthetic versus forced coughing at colposcopic-guided biopsy: a prospective study

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.

Innovative Diagnostic and Therapeutic Interventions in Cervical Dysplasia: A Systematic Review of Controlled Trials

Cervical dysplasia is a common precancerous lesion affecting 1% to 2% of women worldwide. Significant progress in the diagnosis and treatment of cervical dysplasia have been made in the last decade. We performed a systematic literature search of the databases PubMed and Cochrane Central Register of Controlled Trials to identify controlled clinical trials reporting on the efficacy and safety of diagnostic and therapeutic interventions for cervical dysplasia. Data were analyzed according to PRISMA guidelines. In total, 33 studies reporting on 5935 women were identified. We recommend intravenous or intracervical lidocaine for pain reduction during colposcopically-directed cervical biopsies but not topical lidocaine, music, or video colposcopy. Monsel’s solution might be used to control bleeding after cervical biopsies. The acetic acid test should be scored 1 min after the application of acetic acid and should be followed by Lugol’s iodine test for an optimal yield of LSIL/HSIL. LEEP/LLETZ remains the standard and techniques such as SWETZ, C-LETZ, and TCBEE are not superior. LEEP/LLETZ should be performed under local anesthesia and with direct colposcopic vision. Cryotherapy and thermoablation might be used in women with LSIL, especially in women with HIV infection, but LEEP/LLETZ remains the standard for HSIL. Topical imiquimod remains an experimental procedure. In conclusion, significant progress has been made in the last decade regarding both diagnostic interventions as well as therapeutic interventions for women with cervical dysplasia. Based on >30 controlled clinical trials, we were able to formulate specific and evidence-based recommendations.

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.

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.

Predicting Factors for High-Grade Cervical Dysplasia in Women With Low-Grade Cervical Cytology and Nonvisible Squamocolumnar Junction

OBJECTIVE

To assess the risk of developing high-grade cervical dysplasia among women with low-grade cervical cytology and nonvisible squamocolumnar junction (SCJ) at colposcopic examination.

METHODS

Data of consecutive women with low-grade intraepithelial lesion(≤LSIL) undergoing colposcopic examination, which was unsatisfactory (due to the lack of the visualization of the entire SCJ), were retrospectively reviewed. The risk of developing high-grade cervical intraepithelial neoplasia (CIN2+) was assessed using Kaplan-Meier and Cox models.

RESULTS

Data of 86 women were retrieved. Mean (standard deviation [SD]) age was 36.3 (13.4) years. A total of 71 (82.5%) patients had high-risk human papillomavirus (HR-HPV) at the time of diagnosis. Among the 63 patients undergoing repetition of HPV testing, 15 (24%) and 48 (76%) women had positive and negative tests for HR-HPV at 12 months, respectively. We observed that 5 (33%) of 15 patients with HPV persistence developed CIN2+, while only 1 (2%) patient of 48 patients without HPV persistence developed CIN2+ (odds ratio [OR]: 23.5; 95% confidence interval [CI]: 2.46-223.7; P < .001). The length of HR-HPV persistence correlated with an increased risk of developing CIN2+ ( P < .001; P for trend). High-risk HPV persistence is the only factor predicting for CIN2+ (hazard ratio: 3.19; 95% CI: 1.55-6.57; P = .002).

CONCLUSIONS

High-risk HPV persistence predicts the risk of developing CIN2+ in patients with unsatisfactory colposcopic examination. Further studies are warranted in order to implement the use of HPV testing in patients with unsatisfactory colposcopy.

The Use of the Colposcopically Directed Punch Biopsy in Clinical Practice: A Survey of British Society of Colposcopy and Cervical Pathology (BSCCP)-Accredited Colposcopists

OBJECTIVES

The colposcopically directed punch biopsy has been an integral component of colposcopic practice. In light of the changing landscape of the cervical screening programme, a study was conducted to investigate the current practice of British Society of Colposcopy and Cervical Pathology-accredited colposcopists on technique and rationale for performing a punch biopsy.

MATERIALS AND METHODS

A web-based questionnaire survey was e-mailed to all British Society of Colposcopy and Cervical Pathology-accredited colposcopists. Questions included selection criteria for performing a punch biopsy, number of biopsies, and technique. Results were analyzed by specialty, experience, and workload.

RESULTS

A total of 749 colposcopists responded, 50.2% of the 1,493 total. The respondents were obstetrician and gynecologists (42.9%), gynecologists/oncologists (33.6%), and nurse colposcopists (19.8%). Most colposcopists (78.3%) had more than 5-year colposcopy experience and saw in excess of 11 new cases (73.4%) of abnormal cervical cytology/month. Most colposcopists (56%) aimed to take 2 biopsies to diagnose cervical intraepithelial neoplasia, and very few (16.2%) reported routinely taking random biopsies from normal areas of cervix. Looking at the trends in management in the case scenarios, there was a lower threshold for performing punch biopsy before large loop excision of the transformation zone in younger (age, <25 years) or nulliparous women versus older women (age, >40 years; p < .05). Colposcopists were more likely to take biopsies in women with low-grade cytology/colposcopic findings (71.2%, always or most of the times) as compared with high-grade cytology/colposcopic findings (40.3%, never or rarely).

CONCLUSIONS

Colposcopically directed punch biopsy is routinely used by colposcopists; however, techniques, number of biopsies taken, and rationale for performing a biopsy vary greatly between colposcopists.

Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment

BACKGROUND

Pre-cancerous lesions of cervix (cervical intraepithelial neoplasia (CIN)) are usually treated with excisional or ablative procedures. In the UK, the National Health Service (NHS) cervical screening guidelines suggest that over 80% of treatments should be performed in an outpatient setting (colposcopy clinics). Furthermore, these guidelines suggest that analgesia should always be given prior to laser or excisional treatments. Currently various pain relief strategies are employed that may reduce pain during these procedures.

OBJECTIVES

To assess whether the administration of pain relief (analgesia) reduces pain during colposcopy treatment and in the postoperative period.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE (1950 to March week 3, 2016) and Embase (1980 to week 12, 2016) for studies of any design relating to analgesia for colposcopic management. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared all types of pain relief before, during or after outpatient treatment to the cervix, in women with CIN undergoing loop excision, laser ablation, laser excision or cryosurgery in an outpatient colposcopy clinic setting.

DATA COLLECTION AND ANALYSIS

We independently assessed study eligibility, extracted data and assessed risk of bias. We entered data into Review Manager 5 and double checked it for accuracy. Where possible, we expressed results as mean pain score and standard error of the mean with 95% confidence intervals (CI) and synthesised data in a meta-analysis.

MAIN RESULTS

We included 19 RCTs (1720 women) of varying methodological quality in the review. These trials compared a variety of interventions aimed at reducing pain in women who underwent treatment for CIN, including cervical injection with lignocaine alone, lignocaine with adrenaline, buffered lignocaine with adrenaline, prilocaine with felypressin, oral analgesics (non-steroidal anti-inflammatory drugs (NSAIDs)), inhalation analgesia (gas mixture of isoflurane and desflurane), lignocaine spray, cocaine spray, local application of benzocaine gel, lignocaine-prilocaine cream (EMLA cream) and transcutaneous electrical nerve stimulation (TENS).Most comparisons were restricted to single trial analyses and were under-powered to detect differences in pain scores between treatments that may or may not have been present. There was no difference in pain relief between women who received local anaesthetic infiltration (lignocaine 2%; administered as a paracervical or direct cervical injection) and a saline placebo (mean difference (MD) -13.74; 95% CI -34.32 to 6.83; 2 trials; 130 women; low quality evidence). However, when local anaesthetic was combined with a vasoconstrictor agent (one trial used lignocaine plus adrenaline while the second trial used prilocaine plus felypressin), there was less pain (on visual analogue scale (VAS)) compared with no treatment (MD -23.73; 95% CI -37.53 to -9.93; 2 trials; 95 women; low quality evidence). Comparing two preparations of local anaesthetic combined with vasoconstrictor, prilocaine plus felypressin did not differ from lignocaine plus adrenaline for its effect on pain control (MD -0.05; 95% CI -0.26 to 0.16; 1 trial; 200 women). Although the mean (± standard deviation (SD)) observed blood loss score was less with lignocaine plus adrenaline (1.33 ± 1.05) compared with prilocaine plus felypressin (1.74 ± 0.98), the difference was not clinically as the overall scores in both groups were low (MD 0.41; 95% CI 0.13 to 0.69; 1 trial; 200 women). Inhalation of gas mixture (isoflurane and desflurane) in addition to standard cervical injection with prilocaine plus felypressin resulted in less pain during the LLETZ (loop excision of the transformation zone) procedure (MD -7.20; 95% CI -12.45 to -1.95; 1 trial; 389 women). Lignocaine plus ornipressin resulted in less measured blood loss (MD -8.75 ml; 95% CI -10.43 to -7.07; 1 trial; 100 women) and a shorter duration of treatment (MD -7.72 minutes; 95% CI -8.49 to -6.95; 1 trial; 100 women) than cervical infiltration with lignocaine alone. Buffered solution (sodium bicarbonate buffer mixed with lignocaine plus adrenaline) was not superior to non-buffered solution of lignocaine plus adrenaline in relieving pain during the procedure (MD -8.00; 95% CI -17.57 to 1.57; 1 trial; 52 women).One meta-analysis found no difference in pain using VAS between women who received oral analgesic and women who received placebo (MD -3.51; 95% CI -10.03 to 3.01; 2 trials; 129 women; low quality evidence).Cocaine spray was associated with less pain (MD -28.00; 95% CI -37.86 to -18.14; 1 trial; 50 women) and blood loss (MD 0.04; 95% CI 0 to 0.70; 1 trial; 50 women) than placebo.None of the trials reported serious adverse events and majority of trials were at moderate or high risk of bias (13 trials).

AUTHORS' CONCLUSIONS

Based on two small trials, there was no difference in pain relief in women receiving oral analgesics compared with placebo or no treatment (MD -3.51; 95% CI -10.03 to 3.01; 129 women). We consider this evidence to be of a low to moderate quality. In routine clinical practice, intracervical injection of local anaesthetic with a vasoconstrictor (lignocaine plus adrenaline or prilocaine plus felypressin) appears to be the optimum analgesia for treatment. However, further high quality, adequately powered trials should be undertaken in order to provide the data necessary to estimate the efficacy of oral analgesics, the optimal route of administration and dose of local anaesthetics.

Cervical Strip Biopsy for High-Grade Cervical Intraepithelial Lesions: a Valid Alternative to Conventional Punch Technique

Introduction: To evaluate, if targeted strip biopsies decrease trauma/pain perception while maintaining diagnostic accuracy in patients with the diagnosis of high-grade squamous intraepithelial lesions of the uterine cervix. Patients and Methods: Between July 1st and December 31st 2014 we performed colposcopically directed strip biopsies in 102 patients with colposcopic suspicion of high-grade squamous intraepithelial lesions of the uterine cervix. We used a 3 mm curette for harvesting tissue samples under VITOM® videocolposcopy. So far, 60 patients underwent additional loop excision. Histologic examination of strip biopsies and loop specimens included routine hematoxylin and eosin staining as well as immunohistochemical staining for p16, Ki 67 and stathmin-1. Results: 55 patients (53 %), were histologically diagnosed with cervical intraepithelial neoplasia grade 3 on strip biopsies. Adenocarcinoma in situ was diagnosed in 2 patients (2 %), cervical intraepithelial neoplasia grade 2 in 35 patients (34 %), and cervical intraepithelial neoplasia grade 1 in 10 patients (10 %). The agreement between histologic results of strip biopsy and loop specimen was highly significant: In all 60 strip biopsies diagnosed with high-grade squamous intraepithelial lesions this diagnosis was confirmed histologically during follow-up loop specimen excision (high-grade squamous intraepithelial lesions in 58 patients, invasive disease in 2 patients). The pain level experienced during strip biopsy was rated on average 0.25 on a scale from 0 to 10. No clinically significant bleeding was reported. Conclusion: Targeted strip biopsies with a 3 mm curette are a reliable procedure to diagnose high-grade squamous intraepithelial lesions of the uterine cervix and yield high patient satisfaction (Video 1).