Topical Anesthetic (Lidocaine-Prilocaine) Cream Application Before Speculum Examination in Postmenopausal Women

EMLA (lidocaine-prilocaine) cream for pain relief during hysterosalpingography: a systematic review and meta-analysis of randomised placebo-controlled trials

We systematically investigated the efficacy and safety of EMLA (5% lidocaine-prilocaine cream) versus placebo for pain relief among infertile patients undergoing hysterosalpingography (HSG). We screened four databases from inception until 25 November 2020. We included only randomised placebo-controlled trials (RCTs) and assessed their risk of bias. The main efficacy outcomes included safety and pain scores during the different stages of HSG. The pooled outcomes were summarised as mean difference (MD) with 95% confidence interval (CI). Three RCTs were included, comprising 258 patients (131 and 127 patients received EMLA and placebo, respectively). All RCTs revealed an overall low risk of bias. EMLA significantly reduced pain perception during cervical instrumentation of tenaculum and cannula (MD = -1.53, 95% CI [-2.59, -0.47], p = 0.005) and at 24 h after completion of HSG (MD = -1.30, 95% CI [-2.57, -0.03], p = 0.04). Despite EMLA decreased pain perception during the other procedural stages of HSG, the differences were not statistically significant compared with placebo. EMLA was safe and free of local and systemic adverse reactions. This meta-analysis advocates that topical application of 5% EMLA cream is safe and correlates with decreased pain perception during HSG, particularly during the cervical instrumentation step and at 24 h after HSG completion.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Adding a nonpainful end to reduce pain recollection of Pap smear screening: a randomized controlled trial

ABSTRACT

The pain experienced during Pap tests is a crucial gap in reducing cervical cancer burden. This study sought to investigate whether adding a nonpainful step at the end of Pap tests helps women recall less pain. We conducted a randomized controlled trial on women aged 30 to 70 years at a cervical cancer screening center. A nonpainful step was added at the end of Pap test in the modified Pap group. The outcomes included recalled pain after Pap smear screening, real-time pain, and 1-year willingness to receive further Pap tests. Among 266 subjects in the intention-to-treat analysis, the modified Pap group (n = 133) experienced lower 5-minute recalled pain than the traditional Pap group on a 1 to 5 numeric scale (mean [SD], 1.50 [0.77] vs 2.02 [1.12]; P < 0.001) and a 0 to 10 visual analog scale (2.12 [1.79] vs 3.12 [2.23]; P < 0.001). In exploratory subgroup analyses, the association between the modified Pap test and reduced 5-minute recalled pain was not affected by predicted pain, demographic, or socioeconomic characteristics, but it was more apparent in postmenopausal women. Consistently, the modified Pap test attenuated 1-year recalled pain on both pain scales. Furthermore, the modified Pap test increased 1-year willingness grade to receive further Pap tests (adjusted β [SE], 2.11 [0.27]; P < 0.001). In conclusion, adding a nonpainful step at the end of Pap smear screening reduces on-site and long-term recalled pain and strengthens willingness to undergo subsequent Pap tests regularly. The modified Pap test contributes to cervical cancer screening participation.

Factors Associated with Unsatisfactory Pap Tests Among Sexually Active Trans Masculine Adults

Purpose: Unsatisfactory collection of cells during Papanicolaou (Pap) tests prevents the detection of cervical cancer and dysplasia. Prior research found that trans masculine (TM) individuals are significantly more likely than cisgender women to have an unsatisfactory Pap test. The purpose of this study was to identify factors that place some TM individuals at greater risk for an unsatisfactory Pap test than others. Methods: Between 2015 and 2016, 150 TM adults were enrolled in a cross-sectional survey assessing demographics, health characteristics, health care experiences, trauma history, and unsatisfactory Pap test history. Bivariate and multivariable logistic regression analyses conducted in 2020 examined associations between age, length of time on testosterone, smoking history, having to educate a provider about transgender people to receive appropriate care, anticipated health care stigma, post-traumatic stress disorder (PTSD) symptoms, and lifetime history of unsatisfactory Pap tests. Results: Of all participants, 20.2% had an unsatisfactory test in their lifetime, age ranged from 21 to 50 years, 55.1% used testosterone for 1 year or more, and 41.3% had PTSD symptoms. In the multivariable model, older age (adjusted odds ratio [AOR] = 1.15; 95% confidence interval (CI) = 1.04-1.27; p < 0.01), 1 year or more lifetime testosterone use (AOR = 3.51; 95% CI = 1.02-12.08; p = 0.046), and PTSD symptoms (AOR = 3.48; 95% CI = 1.10-11.00, p = 0.03) were significantly associated with increased odds of having an unsatisfactory Pap test. Conclusions: Older age, testosterone use, and PTSD symptoms are associated with lifetime unsatisfactory Pap tests among TM adults. Clinicians should assess TM patients' trauma and testosterone use history before Pap tests and utilize trauma-informed practices that facilitate the collection of adequate Pap samples.

Addressing Anxiety and Fear during the Female Pelvic Examination

METHODS

We reviewed the literature pertaining to anxiety and fear surrounding the pelvic examination to help guide health care providers' on available screening options and to review options for individualized patient management.

RESULTS

Anxiety and fear are common before and during the pelvic examination. In fact, the pelvic exam is one of the most common anxiety-provoking medical procedures. This exam can provoke negative physical and emotional symptoms such as pain, discomfort, anxiety, fear, embarrassment, and irritability. These negative symptoms can interfere with preventative health screening compliance resulting in delayed or avoided care and significant health consequences.

CONCLUSION

Assessing women for anxiety related to pelvic examinations may help decrease a delay or avoidance of examinations. Risk factor and symptom identification is also a key component in this. General anxiety questionnaires can help identify women with anxiety related to pelvic examinations. Strategies to reduce anxiety, fear and pain during a pelvic examination should routinely be implemented, particularly in women with high-risk factors or those identified with screening techniques as having anxiety, fear or pain with examinations. Treatment options should be targeted at understanding the patient's concerns, starting conversations about pelvic examinations early, educating patient's about the examination and offering the presence of a chaperone or support person. During an examination providers should ensure the patient is comfortable, negative phrases are avoided, the correct speculum size is utilized and proper lubrication, draping, dressing and positioning are performed. Treating underlying gynecologic or mental health conditions, consideration of cognitive behavioral therapy and complementary techniques such as lavender aromatherapy and music therapy should also be considered when appropriate.

Lidocaine-prilocaine cream versus local infiltration anesthesia in pain relief during repair of perineal trauma after vaginal delivery: a systematic review and meta-analysis

Background: Perineal trauma is a common problem that may affect women during vaginal delivery; this trauma can be either spontaneous (tear) or intentional (episiotomy). When repair of perineal trauma is required, adequate analgesics must be obtained. Topical products as lidocaine-prilocaine (EMLA) cream is one of the suggested methods, but still there is lack of evidence with regard to its efficacy and safety.Objective: The aim of this review is to assess the evidence of utilizing EMLA cream in comparison to local perineal infiltration anesthesia for pain control during perineal repair after vaginal delivery.Data sources: Medline, Embase, Dynamed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov and the Cochrane Library were searched electronically from January 2006 to May 2018 for studies investigating the effect of lidocaine-prilocaine cream in relieving pain during repair of perineal trauma.Methods of study selection: All randomized controlled trials assessing effect of lidocaine-prilocaine cream versus local infiltration anesthesia in relieving pain during repair of perineal trauma were considered for this meta-analysis. Fifteen studies were identified of which four studies deemed eligible for this review. Quality and risk of bias assessment was performed for all studies.Data extraction: Two researchers independently extracted the data from the individual articles and entered into RevMan software. The weighted mean difference (WMD) and 95% confidence interval (CI) was calculated. Statistical heterogeneity between studies was assessed by the Higgins chi-square and (I²) statistics. When heterogeneity was significant, a random-effects model was used for meta-analysis. Otherwise, the fixed effect meta-analysis was used when there was no significant heterogeneity.Results: Pooled analysis of result in "pain score" was insignificant between the two groups (WMD -1.11; 95% CI (-2.55 to 0.33); p = .13). Furthermore, the use of additional analgesia showed no statistically significant difference between the two groups (WMD 1.34; 95% CI (0.66-2.71), p = .42). Regarding patient satisfaction, an overall analysis of three studies showed significant results favoring EMLA cream group users (WMD 4.65; 95% CI (1.96-11.03), p = .0005). The pooled analysis of the outcome "duration of repair" showed the significantly shorter duration of repair in EMLA cream users (n = 92) than local infiltration anesthesia (n = 95) (1.72 min; 95% CI (-2.76 to -0.67), p = .001).Conclusions: This meta-analysis suggests that topical lidocaine-prilocaine cream gives comparable results in reducing pain during perineal repair after vaginal delivery.

Anesthetic Cream Use During Office Pessary Removal and Replacement: A Randomized Controlled Trial

OBJECTIVE

To estimate the effect of lidocaine-prilocaine cream on patient pain at the time of office pessary removal and reinsertion.

METHODS

In this double-blind, randomized placebo-controlled trial, participants undergoing routine pessary care in a urogynecology office at a tertiary referral center were randomized to application of 4 g of either lidocaine-prilocaine or placebo cream 5 minutes before pessary change. Visual analog scale pain scores were collected from the patient at baseline, after pessary removal, and after pessary reinsertion. Physicians also recorded their estimate of patient pain at pessary removal and reinsertion. The primary outcome was the participant-reported visual analog scale pain score at the time of pessary removal and reinsertion. A sample size of 26 per group (n=52) was planned to estimate an absolute mean difference in visual analog scale pain of 2.1 cm at the time of pessary removal. An analysis of covariance was used to evaluate pain at removal and reinsertion as a function of treatment assignment controlling for baseline pain.

RESULTS

From July 2015 through February 2016, 116 women were screened and 54 were recruited: 28 in the lidocaine-prilocaine cream group and 26 in the placebo group. One patient in the lidocaine-prilocaine cream group was later withdrawn owing to vaginal erosion. The participants were all postmenopausal women, with an average age of 77.8 years. Most characteristics were similar between groups. After adjusting for baseline pain, participants randomized to the lidocaine-prilocaine group had lower pain at pessary removal when compared with those assigned to placebo (mean difference=-2.05, 95% confidence interval -3.69 to -0.41; P=.015).

CONCLUSION

Lidocaine-prilocaine cream use at the time of office pessary removal reduces patient-reported pain. Clinicians may wish to include this simple intervention to optimize patient comfort and compliance.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02380742.

Speculum Lubrication and Patient Comfort: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of the study was to examine the effect of water-based gel lubrication in decreasing discomfort during speculum examination.

MATERIALS AND METHODS

Searches of standard databases were performed. Randomized controlled trials comparing speculums lubricated with water-based gel to no lubrication or water alone in women undergoing gynecologic examinations were included. Selected studies were required to report on the outcome of discomfort experienced during the examination. Six studies met the criteria. Two reviewers independently performed the search and excluded articles that did not meet the inclusion criteria. The primary outcome was change in the visual analog scale (VAS) measure of discomfort. Pooled mean differences and 95% confidence interval (CI) were calculated and heterogeneity was assessed.

RESULTS

Five studies, totaling 2,383 subjects, each noted a significant decrease in the VAS score with use of lubrication. Pooling all studies, the VAS score with lubrication changed -0.87 (95% CI = -1.22 to -0.53, 6 studies, 2,453 subjects). Studies measured discomfort at different points in the examination and noted significant decreases with insertion (mean difference, -0.98; 95% CI = -1.13 to -0.83, 5 studies, 2,383 subjects), opening (mean difference, -1.52; 95% CI = -2.43 to -0.61, 3 studies, 1,864 subjects), and extraction (mean difference, -0.97; 95% CI = -1.29 to -0.65, 2 studies, 284 subjects). These significant decreases were consistent in subgroups of premenopausal, postmenopausal, gynecologic oncology, and radiation therapy patients.

CONCLUSIONS

Water-based gel lubrication decreased discomfort for women undergoing a plastic speculum examination in all populations studied.

[Patient's experience of topical anesthesia by lidocaine vaginal gel for oocyte retrieval]

A recent adverse effect of a paracervical block (cardiac arrest) occurred during an oocyte retrieval (OR), forcing us to reconsider our pain management during OR. Since then, we decided to use intravaginal lidocaine gel as analgesia during OR.

OBJECTIVES

To evaluate the pain during OR after intravaginal lidocaine gel analgesia and to evaluate the motivations of women choosing this technique.

METHODS

A monocentric observational study was performed on 200 patients. Pain was measured using a numeric pain scale during and after oocyte retrieval. The tolerance of the procedure was evaluated through a patient questionnaire.

RESULTS

Median maximal pain was 5±2.3 (0-10) per-retrieval and 3±2.2 (0-10) post-retrieval. The procedure was considered bearable by 85.5% of the patients and 81.5% of them would choose this method in case of new oocyte retrieval. No adverse effect occurred during the study.

CONCLUSION

The use of intravaginal lidocaine gel seems an acceptable analgesia alternative during oocyte retrieval.

The role of gel application in decreasing pain during speculum examination and its effects on papanicolaou smear results

PURPOSE

This study aimed to investigate the effects of water-based gel application in reducing pain or discomfort associated with speculum examination, and compared the presence of unsatisfactory Papanicolaou smear results between gel-applied and control groups.

METHODS

In this prospective randomized controlled study, a total of 1,580 patients were analyzed. The subjects were randomized to a gel group and a control group. For the collection of the smear sample, water-based gel was used in the gel group and dry speculum was used in the control group. All patients were asked to score their pain on a numeric pain scale at two time points during the procedure (insertion and opening phase of speculum). Cytopathologists who analyzed the smear cytology were blinded to the study. Pain intensity during speculum examination, as well as unsatisfactory smear results, were analyzed between the groups.

RESULTS

The pain scores obtained at two different time points of speculum application were significantly lower in the gel group compared to the control group both in premenopausal and postmenopausal women (p < 0.001). The ratios of unsatisfactory cytopathologic examination results were 1.13 and 1.39% for the gel-applied and control groups, which were not significantly different.

CONCLUSION

Lubrication of the outer superior and inferior blade of the plastic vaginal speculum with a small amount of a water-soluble lubricant gel decreases the pain associated with insertion and opening of the vaginal speculum in both premenopausal and postmenopausal women without affecting the quality of the cytology results during the collection of Papanicolaou test specimens.