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Rund NMA, El Shenoufy H, Islam BA, El Husseiny T, Nassar SA, Mohsen RA, Alaa D, Gad Allah SH, Bakry A, Refaat R, Gehad MA, Kotb MMM, Osman OM, Ashour ASA, Ali AS, Taher A, Kholaif K, Hashem AT, Elsallamy AAH, Nour DA, Dahab S, Talaat B, Almohammady M. Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized, Double-blind Trial. J Minim Invasive Gynecol 2021; 29:85-93. [PMID: 34217851 DOI: 10.1016/j.jmig.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/11/2021] [Accepted: 06/24/2021] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVE To determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women. DESIGN Randomized, double-blind trial. SETTING Tertiary referral hospital. PATIENTS A total of 180 nulliparous women undergoing diagnostic OH. INTERVENTIONS We randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group. MEASUREMENTS AND MAIN RESULTS The primary outcome was pain during OH measured using a 100-mm visual analog scale (0 = no pain; 100 = worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p = .1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p = .003, and p <.001, respectively). Side effects were comparable in both study groups. CONCLUSION Vaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.
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Affiliation(s)
- Nansy Mohamed Ali Rund
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University (Drs. Rund, Islam, and Nassar), Cairo
| | - Hossam El Shenoufy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Bassem Aly Islam
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University (Drs. Rund, Islam, and Nassar), Cairo
| | - Tarek El Husseiny
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Salma Ashraf Nassar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University (Drs. Rund, Islam, and Nassar), Cairo
| | - Reham A Mohsen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Doaa Alaa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Sherine H Gad Allah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ahmed Bakry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Rania Refaat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, 6th October City, Giza (Drs. Refaat and Elsallamy)
| | - Mahmoud Ahmed Gehad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha (Drs. Gehad and Talaat), Egypt
| | - Mohamed Mahmoud Mohamed Kotb
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Omneya M Osman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ahmed S A Ashour
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ahmed Said Ali
- Faculty of Medicine, Al-Azhar University (Dr. Ali), Cairo.
| | - Ayman Taher
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Khaled Kholaif
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ahmed T Hashem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Ayman Aly Hamed Elsallamy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, 6th October City, Giza (Drs. Refaat and Elsallamy)
| | - Dalia Adel Nour
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Sherif Dahab
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
| | - Bassem Talaat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha (Drs. Gehad and Talaat), Egypt; Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, (Dr. Talaat) Egypt
| | - Maged Almohammady
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University (Drs. El Shenoufy, El Husseiny, Mohsen, Alaa, Gad Allah, Bakry, Kotb, Osman, Ashour, Taher, Kholaif, Hashem, Nour, Dahab, and Almohammady), Cairo
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De Silva PM, Wilson L, Carnegy A, Smith PP, Clark TJ. Cervical dilatation and preparation prior to outpatient hysteroscopy: a systematic review and meta-analysis. BJOG 2020; 128:1112-1123. [PMID: 33219606 DOI: 10.1111/1471-0528.16604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are uncertainties about the benefit of routine cervical preparation and/or cervical dilatation before outpatient hysteroscopy. OBJECTIVE To determine if cervical preparation and/or routine mechanical dilatation reduces pain during outpatient hysteroscopy. SEARCH STRATEGY MEDLINE, EMBASE, CINAHL and CENTRAL were searched on 19 October 2020, using keywords 'hysteroscopy', 'cervical preparation', 'cervical ripening', 'cervical dilatation', 'outpatient', 'office' and/or 'ambulatory' and associated medical subject headings. SELECTION CRITERIA Randomised controlled trials investigating the benefit of cervical preparation and/or cervical dilatation on pain in women undergoing outpatient hysteroscopy were included. DATA COLLECTION AND ANALYSIS Two independent reviewers selected eligible trials and extracted data on pain, feasibility, adverse events and satisfaction/acceptability for meta-analysis. MAIN RESULTS The literature search yielded 807 records, of which 24 were included for review and 19 provided data for meta-analysis. No trials investigated the role of routine mechanical cervical dilatation. Cervical preparation significantly reduced pain during outpatient hysteroscopy; standard mean difference (SMD) -0.67, 95% confidence interval (CI) -1.05 to -0.29. Feasibility also improved as priming provided significantly easier hysteroscopic entry (SMD 0.89, 95% CI 0.32-1.46), greater cervical dilatation (SMD 0.81, 95% CI 0.08-1.53) and shorter procedural times (SMD -0.51, 95% CI -0.88 to -0.13). Cervical preparation, however, incurred significantly more adverse effects, mainly comprising genital tract bleeding, abdominal pain and gastrointestinal symptoms (odds ratio 2.94, 95% CI 1.58-5.47). There were limited data regarding satisfaction, acceptability and complications. CONCLUSIONS Cervical preparation reduces pain and improves feasibility associated with outpatient hysteroscopy but increases the risk of adverse effects. TWEETABLE ABSTRACT Cervical preparation before outpatient hysteroscopy reduces pain, enhances feasibility but increases adverse effects.
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Affiliation(s)
- P M De Silva
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - L Wilson
- School of Medicine, University of Leeds, Leeds, UK
| | - A Carnegy
- Queen Elizabeth Hospital, University of Birmingham Hospitals NHS Foundation Trust, Birmingham, UK
| | - P P Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - T J Clark
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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3
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Vitale SG, Alonso Pacheco L, Haimovich S, Riemma G, De Angelis MC, Carugno J, Lasmar RB, Di Spiezio Sardo A. Pain management for in-office hysteroscopy. A practical decalogue for the operator. J Gynecol Obstet Hum Reprod 2020; 50:101976. [PMID: 33166706 DOI: 10.1016/j.jogoh.2020.101976] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 12/01/2022]
Abstract
Hysteroscopy is known to be the gold standard for evaluation of intrauterine pathologies, pre-menopausal and post-menopausal abnormal uterine bleeding and, in addition to this, it is a crucial examination in the infertility work-up. In-office operative hysteroscopy incorporates the outstanding possibility of seeing and treating an intracavitary pathology in the same examination, eliminating all the risk related to anesthesia and reducing procedure-related costs. By now, performing operative procedures in the office setting is recognized as feasible and safe. Over the last 20 years, many efforts have been made to implement the in-office operative approach worldwide. However, for some women, in-office hysteroscopy is still considered a painful experience, with reported discomfort at different steps of the hysteroscopic procedures. Moreover, uneventful and tedious sensations might be increased by a high level of anxiety for such examination. For this reason, despite the feasibility of the in-office approach, many clinicians are still afraid of provoking pain during the procedure and rather not to perform surgical procedures in the office, postponing the removal of the pathology in the operating room. To date, there is no consensus concerning pain management for in-office hysteroscopy and different approaches, pharmacological and non-pharmacological aids, as well as several procedural tips and tricks are utilized. Our purpose is to provide a feasible practical decalogue for the operator, to supply adequate management of pain during in-office hysteroscopic procedures, performing challenging operations, shrinking discomfort, aiming to upgrade both women's and operator's satisfaction.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
| | | | - Sergio Haimovich
- Hillel Yaffe Medical Center, Technion-Israel Technology Institute, Hadera, Israel
| | - Gaetano Riemma
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, Florida, USA
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5
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Riemma G, Schiattarella A, Colacurci N, Vitale SG, Cianci S, Cianci A, De Franciscis P. Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review. Climacteric 2020; 23:376-383. [PMID: 32396751 DOI: 10.1080/13697137.2020.1754388] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.
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Affiliation(s)
- G Riemma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Schiattarella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - N Colacurci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - S G Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - S Cianci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - P De Franciscis
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
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7
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Ghamry NK, Samy A, Abdelhakim AM, Elgebaly A, Ibrahim S, Ahmed AA, Abdelbaky WH, Abdallah KM, Badawy MA, Mohammed AH, Hamza M. Evaluation and ranking of different interventions for pain relief during outpatient hysteroscopy: A systematic review and network meta-analysis. J Obstet Gynaecol Res 2020; 46:807-827. [PMID: 32088931 DOI: 10.1111/jog.14221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/27/2020] [Accepted: 02/08/2020] [Indexed: 11/29/2022]
Abstract
AIM To identify the highest-ranked pharmacological and nonpharmacological interventions for pain relief during outpatient hysteroscopy. METHODS We conducted an online bibliographic search in different databases from inception till July 2019. We included randomized controlled trials assessing effect of pharmacological and nonpharmacological interventions on pain relief during outpatient hysteroscopy. Our main outcomes were pain scores at different endpoints of the procedure. We applied this network meta-analysis based on the frequentist approach using statistical package 'netmeta' (version 1.0-1) in R. RESULTS The review included 39 randomized controlled trials (Women n = 3964). Misoprostol plus intracervical block anesthesia (mean difference [MD] = -3.32, 95% confidence interval [CI] [-6.06, -0.59]), misoprostol (MD = -1.92, 95% CI [-3.04, -0.81]) and IV analgesia (MD = -2.01, 95% CI [-3.27, -0.25]) were effective in reducing pain during the procedure compared to placebo. Ranking probability showed that misoprostol plus intracervical block anesthesia was the highest ranked pharmacological treatment for pain relief during the procedure (P score = 0.92) followed by misoprostol alone (P score = 0.78), and IV analgesia (P score = 0.76). Regarding nonpharmacological treatments, transcutaneous electrical nerve stimulation (TENS) showed a significant pain reduction compared to placebo (MD = -1.80, 95% CI [-3.31, -0.29]). TENS ranked as the best nonpharmacological treatment (P score = 0.80) followed by CO2 distention (P score = 0.65) and bladder distention (P score = 0.60). CONCLUSION Combination of misoprostol plus local anesthesia appears to be the most effective pharmacological approach for pain reduction during and after outpatient hysteroscopy. Nonpharmacological approaches as TENS and bladder distention showed considerable efficacy but should be further investigated.
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Affiliation(s)
- Nevein K Ghamry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Samy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | - Safaa Ibrahim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amal A Ahmed
- Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Waleed H Abdelbaky
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Khaled M Abdallah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Mahmoud A Badawy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Ahmed H Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Mohamed Hamza
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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