Pain Relief for Obstetric and Gynecologic Ambulatory Procedures

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.

Assessment of pain at different steps of diagnostic hysteroscopy using room temperature normal saline versus warmed normal saline solution as distension medium: A randomized controlled trial

Objectives:

Compare pain intensity at entry into the cervical os, during uterine distension and 15 min after the procedure, in patients undergoing diagnostic hysteroscopy with room temperature normal saline versus that with saline warmed to 38–40°C, using visual analog scale (VAS) score. Furthermore, compare the time taken and failed procedures between them.

Materials and Methods:

This was a randomized controlled, prospective study conducted at a Tertiary Care Center on 100 patients planned for diagnostic hysteroscopy with a 4 mm 30° hysteroscope using vaginoscopy technique. They were divided into two groups of 50 each, with control undergoing the procedure using normal saline at room temperature and the test with saline warmed to 38–40°C as distension medium. Primary outcomes were VAS at the point of entry into the internal os (T0), 1 min later (T1), and 15 min after the procedure (T15). Secondary outcomes were procedural acceptance, time taken, and failed procedures.

Results:

The mean VAS in the control group at T0, T1, T15 was 3.31 (1.461;‒0.870–0.245), 2.46 (1.398;‒0.539–0.498), 0.75 (0.911;‒0.379–0.338), respectively, as compared to the test group of 3.62 (1.282;‒0.870–0.245), 2.48 (1.148;‒0.540–0.498), 0.77 (0.911;‒0.379–0.379), respectively. About 73.5% of controls and 68.8% in the test group were willing to undergo the procedure again. About 93.9% of controls would recommend it further as against 93.8% among the test controls. The time taken and number of failed procedures showed no statistical difference.

Conclusion:

No significant difference was noted in terms of outcomes measured by warming the distension medium.

A virtual reality system for pain and anxiety management during outpatient hysteroscopy-A randomized control trial

BACKGROUND

Visual and acoustic virtual reality (VR) has been increasingly explored as a non-pharmacological tool for pain relief in clinical settings.

OBJECTIVE

We aimed to evaluate the effectiveness of VR as a distraction technique in the management of acute pain during operative hysteroscopy in the outpatient setting.

METHODS

A prospective, open-label, randomized control trial in a tertiary university-affiliated medical centre between April and August 2020. Overall, 82 women were randomly allocated to undergo operative hysteroscopy either with the use of VR (n = 44, study group) or with standard treatment (control group, n = 38). VR was applied throughout the procedure and no anaesthesia was given. The primary outcome measures included self-reported intraoperative pain. Other objectives included vital parameters as pulse rate (PR) and respiratory rate (RR) before and during the first 3 min of the procedure. Pain and anxiety outcomes were measured as numeric rating scores.

RESULTS

The baseline parameters were similar between groups. The mean duration for the procedure was 8.1 ± 3.2 vs. 7.3 ± 6.0 min for the study and the control groups (p = 0.23). There were no statistically significant differences between the reported pain scores during the procedure [median (interquartile range) 5.0 (3.0-7.2) vs. 5.0 (3.0-8.0), respectively; p = 0.67]. While neither intraoperative heart rate nor respiratory rate differed between groups [14.0 (13.0-16.0) vs. 14.0 (11.0-16.5); p = 0.77)], the increase of heart rate was found greater in the VR group [+7.0 (8.5) vs. +1.0 (12.2); p = 0.01].

CONCLUSION

VR was not effective in reducing pain during an outpatient operative hysteroscopy.

SIGNIFICANCE

The use of a Virtual reality system was found ineffective in reducing pain during and after an office operative hysteroscopy without anaesthesia, in a thorough examination of both continuous physiological parameters and women's self-reported measures.

10% lidocaine spray for pain control during intrauterine device insertion: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Various medications have been investigated for their efficacy in pain reduction during intrauterine device (IUD) insertion, but there is currently no standard recommendation. This study aimed to investigate the efficacy of 10% lidocaine spray in reducing pain during copper-containing intrauterine device (Cu-IUD) insertion.

METHODS

This study was a randomised, double-blind, placebo-controlled trial. Reproductive-age women were randomised at a 1:1 ratio into 10% lidocaine spray or placebo spray group. A 10 cm visual analogue scale (VAS) was used to evaluate pain during several steps of the IUD insertion procedure, and after the procedure.

RESULTS

One hundred and twenty-four women were included and 62 women were randomised in each group. Baseline characteristics between groups were similar. The 10% lidocaine spray group demonstrated significantly lower median VAS immediately after IUD insertion than the placebo group (2.95 (IQR=1.00-5.63) vs 5.00 (IQR=3.35-7.00), respectively; p=0.002). Similarly, women receiving 10% lidocaine spray reported significantly lower median VAS than those receiving placebo during tenaculum use and uterine sounding. The maximum median VAS occurred immediately after Cu-IUD insertion. The proportion of women who reported VAS≥4 during uterine sounding and after IUD placement was significantly lower in the 10% lidocaine group than in the placebo group (p<0.05). Median change in VAS from baseline to IUD placement was significantly different between 10% lidocaine spray group and placebo group (1.85 (IQR=0.08-4.03) vs 3.6 (IQR=2.40-5.80), respectively; p=0.004).

CONCLUSION

10% lidocaine spray was found to be an effective local anaesthetic method for reducing pain during insertion of Cu-IUD.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT03870711.

Could the Valsalva manoeuvre be an alternative to the tenaculum for intrauterine device insertion?

OBJECTIVES

This study investigated whether the Valsalva manoeuvre (VM) could be an alternative to use of the tenaculum for intrauterine device (IUD) insertion. The aims were to establish whether VM could provide good patient comfort and enable the insertion to be performed successfully with adequate pain control in cases where the cervix could not be passed spontaneously.

METHODS

Women who attended the outpatient clinic of Alanya Education and Research Hospital between November 2017 and December 2020 for IUD insertion were randomly assigned to the VM (n = 52) or tenaculum (n = 55) group. Insertion in the latter group was carried out by grasping the cervix with a single-toothed tenaculum. In the VM group, no tenaculum was used to grasp the cervix; instead, the woman was asked to perform VM during insertion.

RESULTS

IUD insertion success rates were similar between the groups. Procedural anxiety scores were slightly higher in the tenaculum group. Pain scores measured during the procedure were significantly higher in the tenaculum group compared with the VM group. Severe pain was reported by 58.2% of women in the tenaculum group, whereas 57.7% of women in the VM group reported no pain.

CONCLUSION

In cases where an IUD cannot be passed through the cervical canal spontaneously, the procedure should be attempted using VM before using a tenaculum. The use of VM may lead to lower pain and anxiety levels as well as increased patient comfort.

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.

Advances in abortion care technology and management

PURPOSE OF REVIEW

To review emerging evidence specific to abortion care, including diagnostic testing and pain management.

RECENT FINDINGS

Recent advances in abortion care include improvements in gestational age dating, Rh status testing, and pain management methods. When ultrasound technology is available, the use of crown-rump length (CRL)-based dating is more accurate up to 13 weeks and composite CRL and biometry between 13 and 14 weeks. Evidence supports using updated fetal foot length-to-gestational age reference ranges for postprocedure gestational age confirmation. Serum tests for two placental proteins, pregnancy-associated plasma protein A and a disintegrin and metalloproteinase 12, show potential for identifying pregnancies with gestational age more than 70 days. Early research using flow cytometry demonstrates that fetal RBC exposure after first-trimester uterine aspiration is insufficient to cause maternal Rh-sensitization, supporting elimination of Rh testing and anti-D-immunoglobulin provision prior to 8 weeks gestation. Recent studies exploring pain management strategies have not generated a standardized approach. Auricular acupuncture appears to be promising.

SUMMARY

Emerging data on improvements in gestational age dating and eliminating laboratory testing prior to early abortion procedures could have important implications for expanding access to early abortion care and telemedicine. Person-centered, novel pain management modalities, such as auricular acupuncture, help to improve client experience, by addressing both pain and anxiety.

Virtual reality for acute pain in outpatient hysteroscopy: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of virtual reality as a distraction technique in the management of acute pain and anxiety during outpatient hysteroscopy.

DESIGN

Parallel group, prospective randomised controlled trial.

SETTING

UK University Hospital.

METHODS

Forty consenting, eligible women were randomised to virtual reality intervention (immersive video content as a distraction method) or standard care during outpatient hysteroscopy from August to October 2018.

MAIN OUTCOME MEASURES

Pain and anxiety outcomes were measured as a numeric rating score (scale 0-10).

RESULTS

Compared with standard care, women with virtual reality intervention experienced less average pain (score 6.0 versus 3.7, mean difference 2.3, 95% CI 0.61-3.99, P = 0.009) and anxiety (score 5.45 versus 3.3, mean difference 2.15, 95% CI 0.38-3.92, P = 0.02).

CONCLUSION

Virtual reality was effective in reducing pain and anxiety during outpatient hysteroscopy in a mixed-methods randomised control trial. Its wide potential role in ambulatory gynaecological procedures needs further evaluation.

TWEETABLE ABSTRACT

Virtual reality can be used as a part of a multimodal strategy to reduce acute pain and anxiety in patients undergoing outpatient hysteroscopy.

Lidocaine-Prilocaine Cream Compared With Injected Lidocaine for Vulvar Biopsy: A Randomized Controlled Trial

OBJECTIVE

To compare pain control during vulvar biopsy after either application of 5% lidocaine-prilocaine cream or injection of 1% lidocaine.

METHODS

In a single-site randomized trial, patients who needed vulvar biopsy on a non-hair-bearing surface were recruited from a gynecologic oncology clinic to compare lidocaine-prilocaine cream (placed at least 10 minutes before biopsy) with lidocaine injection (at least 1 minute prior). A sample size of 53 participants in each arm (N=106) was planned. Pain was recorded using a 100 mm visual analog scale at three time points: baseline, after application of anesthesia, and after biopsy. The primary outcome was highest pain score recorded. Secondary outcomes were pain score at biopsy, patient experience, and tolerability and acceptability. Linear regression was used to compare the primary outcome between arms while controlling for baseline vulvar pain. A convenience analysis was performed in March 2019.

RESULTS

From October 2018 to March 2019, 38 patients completed informed consent and were randomized. Participants were women with median age of 60 years. Most characteristics between groups were similar. Nineteen were analyzed in the lidocaine-prilocaine group, and 18 were analyzed in the lidocaine injection group. The median highest pain score in the lidocaine-prilocaine group was 20.0 mm vs 56.5 mm in the lidocaine injection group. Controlling for baseline pain, the highest pain score in the lidocaine-prilocaine arm was 25.7 mm lower than in the lidocaine injection arm (95% CI [-45.1 to -6.3]; P<.01). Patients randomized to lidocaine-prilocaine had a significantly better experience than those receiving injected lidocaine (median experience score 2.0 mm vs 17.0 mm; P=.02).

CONCLUSION

Lidocaine-prilocaine cream before vulvar biopsy resulted in a lower maximum pain score and a significantly better patient rating of the biopsy experience when compared with lidocaine injection. Lidocaine-prilocaine cream, alone, is a reasonable option to use for vulvar biopsy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03654417.

Pain perception with cervical tenaculum placement during intrauterine device insertion: a randomised controlled trial

INTRODUCTION

'Slow' and 'cough' techniques for tenaculum placement are commonly used. This trial sought to determine if one method of placement resulted in less pain for patients.

METHODS

This study was a randomised controlled trial of patients presenting for intrauterine device placement. Sixty-six participants were randomised to tenaculum placement via the 'slow' method (closure of tenaculum over a 5-s period) versus the 'cough' method (closure of tenaculum at the time of patient's cough). The primary outcome was pain at time of tenaculum placement measured on a 100 mm visual analogue scale. The study was powered to detect a 16 mm difference in pain. Secondary outcomes included pain with insertion and provider satisfaction with tenaculum grasp. Pain scores were analysed with Wilcoxon rank-sum test.

RESULTS

Sixty-six women were enrolled, 33 randomised to each group. Demographics were similar in each group. The primary outcome of pain with tenaculum placement showed a median pain score of 44 (IQR=21, 63) with slow placement and 32 (IQR=19, 54) with cough placement. There was no significant difference in pain scores between methods of tenaculum placement (p=0.16). There was no significant difference in overall pain scores (p=0.12). Provider satisfaction was not associated with one method of placement (p=1). Pre-procedure anxiety was significantly associated with pain at the time of tenaculum placement (p=0.01).

CONCLUSIONS

Neither the slow method nor cough method is superior for pain reduction or provider satisfaction. Pain with tenaculum use is significantly associated with anxiety.

CLINICAL TRIAL REGISTRATION

NCT02969421.

Evaluation and ranking of different interventions for pain relief during outpatient hysteroscopy: A systematic review and network meta-analysis

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.

Diclofenac versus a combination of hyoscine and diclofenac for outpatient hysteroscopy: A placebo controlled randomized clinical trial

OBJECTIVE

to compare the effect of administering diclofenac sodium and/or oral hyoscine in pain perception during and after outpatient diagnostic hysteroscopy without anesthesia.

STUDY DESIGN

a randomized, double-blind placebo-controlled clinical trial was performed in an University Hospital. We included 217 patients submitted to office hysteroscopy for the following indications: diagnosis of abnormal uterine bleeding, endometrial polyps, submucous myomas, infertility and recurrent miscarriage. Patients were allocated into 3 groups: (Group 1) placebo, (Group 2) diclofenac sodium 50 mg and (Group 3) diclofenac sodium 50 mg plus Hyoscine-N-Butylbromide 10 mg. The primary outcome was the visual analogue score immediately after the procedure. The secondary outcomes included Likert acceptance scale, the need for extra analgesia after the procedure, need to stay in the observation room and the occurrence of vagal symptoms.

RESULTS

Groups were similar according to age, color, age of menarche, gravity, c-section, abortion, presence of pelvic pain, presence of uterine scar, height and body mass index. Patients in all three groups demonstrated similar visual pain scores when submitted to office hysteroscopy (Group 1: 4.18 ± 3.1, Group 2: 4.68 ± 2.9, group 3: 4.45 ± 2.9, P = 0.59). Moreover, patients presented high acceptance scores of the procedure, similar between groups. We performed a subgroup analysis in patients in treatment for chronic pelvic pain and, in this subgroup, prior medication with diclofenac sodium isolated or associated with hyoscine were both effective in decreasing pain levels when compared to placebo (Group 1: 6.0 ± 1.9, Group 2: 3.6 ± 2.1, group 3: 4.2 ± 1.5, P = 0.04).

CONCLUSION(S)

Office hysteroscopy is a well tolerated procedure and prior use of analgesic medication was not effective in decreasing pain. In selected patients with chronic pelvic pain the use prior analgesic medication may be beneficial.

Updates in office hysteroscopy: a practical decalogue to perform a correct procedure

Nowadays, hysteroscopy is the gold standard for the diagnosis and treatment of intrauterine pathologies as it represents a safe and minimally invasive procedure that allows the visualization of the entire uterine cavity. Numerous technological innovations have occurred over the past few years, contributing to the development and widespread use of this technique. In particular, the new small-diameter hysteroscopes are equipped with an operating channel in which different mechanical instruments can be inserted, and they allow not only to examine the cervical canal and uterine cavity but also to perform biopsies or treat benign diseases in a relatively short time without anesthesia and in an outpatient setting. In this scenario, the operator must be able to perform hysteroscopy in the correct way to make this procedure increasingly safe and painless for the patient. This review aims to describe the ten steps to perform a correct office hysteroscopy, starting from patient counseling to the therapy after the procedure.

Haemodynamic stability after paracervical block: A randomized, controlled, double-blind study comparing bupivacaine-adrenaline with bupivacaine

BACKGROUND

Paracervical block is widely used in gynaecological interventions on cervix and uterus. Many surgeons add adrenaline 100 μg or pitressin 3-5 IU in a total volume of 10-20 mL to reduce total blood loss. We wanted to examine haemodynamic stability in healthy patients given bupivacaine with and without adrenaline.

METHODS

In this randomised, double-blinded, controlled study, 30 healthy women scheduled for cervical conisation got a paracervical block using bupivacaine 50 mg with adrenaline 100 μg (BA-group, n = 14) or without adrenaline (B-group, n = 16) after induction of general anaesthesia. LiDCOplus was used for minimally invasive haemodynamic monitoring. Changes in cardiac output (CO) and systolic blood pressure (SBP) were the primary outcome. Changes in heart rate (HR), stroke volume (SV), and systemic vascular resistance (SVR) were secondary outcome variables. Area under the curve (AUC) ratios and change from baseline to maximal values were used as effect measures comparing the two groups.

RESULTS

The AUC-ratio for CO and SBP was 2.50 (P < 0.001) and 1.70 (P = 0.03), respectively. For HR, SV, and SVR the AUC-ratio was 1.59 (P < 0.01), 1.52 (P < 0.001), and 0.90 (P = 0.14), respectively. CO increased 68% (standard deviation (SD) 42%, P < 0.001), HR increased 41% (SD 26%, P < 0.001), and SV increased 26% (SD 17%, P < 0.001) from baseline to maximal values after 70-90 seconds in the BA-group.

CONCLUSION

Paracervical block with bupivacaine 50 mg and adrenaline 100 μg may give haemodynamic instability in healthy females and is not recommended if haemodynamic side effects are to be avoided.

Office Operative Hysteroscopy: An Update

Hysteroscopy is considered the gold standard for the evaluation of intracavitary pathology in both premenopausal and postmenopausal patients associated with abnormal uterine bleeding, as well as for the evaluation of infertile patients with suspected cavity abnormalities. Office-based operative hysteroscopy allows patients to resume activities immediately and successfully integrates clinical practice into a "see and treat" modality, avoiding the added risks of anesthesia and the inconvenience of the operating room. For 2017, the Centers for Medicare and Medicaid Services has provided a substantial increase in reimbursement for a select number of office-based hysteroscopic procedures. This review provides an update on the indications, equipment, and procedures for office hysteroscopy, as well as the management of complications that may arise within an office-based practice.

Intrauterine lidocaine for pain control during laminaria insertion: a randomized controlled trial

OBJECTIVE

To determine if intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block reduces pain during laminaria insertion, when compared with paracervical block and saline placebo.

STUDY DESIGN

This was a randomized, double blind placebo-controlled trial. Women presenting for abortion by dilation and evacuation (D&E) at 14-24 weeks gestational age were randomized to receive an intrauterine instillation of either 5 mL of 2% lidocaine or 5 mL of normal saline, in addition to standard paracervical block with 20 cc of 0.25% bupivacaine. Our primary outcome was self-reported pain scores on a 100mm Visual Analogue Scale (VAS) immediately following laminaria insertion. Secondary outcome was self-reported VAS pain score indicating the maximum level of pain experienced during the 24-48-h interval between laminaria insertion and D&E procedure.

RESULTS

Seventy-two women were enrolled, and data for 67 women were analyzed, only two of whom were more than 21 weeks on gestation. The range of pain scores at both time points was large (1-90 mm at laminaria insertion; 0-100mm in laminaria-D&E interval). Mean pain scores were not different between treatment groups at laminaria insertion, (33 vs. 32, p=.8) or in the laminaria - D&E interval (43 vs. 44, p=.9).

CONCLUSION

Intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block did not reduce pain with laminaria insertion when compared to paracervical block with saline placebo.

IMPLICATIONS

Intrauterine lidocaine combined with paracervical block does not improve pain control at laminaria insertion when compared with paracervical block and saline placebo. Wide variation in pain scores and persistent pain after laminaria insertion suggests patient would benefit from more effective methods of pain control at laminaria insertion and during the post-laminaria interval.