Topical anesthesia for minor gynecological procedures: a review

Comparative efficacy of lidocaine-prilocaine cream and vaginal misoprostol in reducing pain during levonorgestrel intrauterine device insertion in women delivered only by cesarean delivery: A randomized controlled trial

OBJECTIVE

To compare efficacy of lidocaine-prilocaine (LP) cream versus misoprostol versus placebo before levonorgestrel-releasing intrauterine device (LNG-IUD) insertion.

METHODS

This randomized controlled trial (RCT) was conducted in a tertiary referral hospital from April 30, 2020 to March 1, 2021 on 210 parous women willing to receive LNG-IUD and delivered only by elective cesarean delivery (CD). Participants received 200 μg vaginal misoprostol or 5 ml of LP cream 5% or placebo 3 h before LNG-IUS insertion. Primary outcome was pain during LNG-IUD insertion, while secondary outcomes were pain 10 min post-procedure, ease of insertion, patient satisfaction, insertion time, and drug side effects.

RESULTS

Pain during LNG-IUS insertion was reduced in LP group and misoprostol group compared to placebo group (2.1 ± 1.0 vs 3.7 ± 1.6; p <0.001) and (2.3 ± 1.3 vs 3.7 ± 1.6; p <0.001), respectively. Ease of procedure and patient satisfaction were significantly higher in LP and misoprostol groups than placebo (P <0.001). Need for additional analgesia was significantly higher in placebo group than in the other two groups (P = 0.009). Adverse events were not significantly different between the three groups except vomiting and abdominal cramps, which were higher with misoprostol.

CONCLUSION

LP cream and 200 μg of vaginal misoprostol administration before LNG-IUD insertion in women delivered only by elective CD effectively reduced pain during insertion and 10 min post-procedure with easier insertions, high patient satisfaction, and tolerable side effects. Pain reduction with LP cream was clinically significant.

Loop Excision for Precancers of the Uterine Cervix: Local or General Anaesthetic?

Aim

In Germany, treatment of HSIL or AIS of the uterine cervix by loop excision is performed almost exclusively under general anaesthesia (GA). International studies and guidelines show high acceptance of local anaesthesia (LA) due to hermeneutic, medical, and economic factors. We performed an observational comparative study aiming to prove advantages of local anaesthesia within the German health system.

Patients and Methods

In a prospective observational study, patients diagnosed with HSIL or AIS of the uterine cervix were treated at the Institute for Cytology and Dysplasia, Berlin, by loop excision in 2021. We started with a feasibility study : 303 patients diagnosed with HSIL/AIS of the uterine cervix and her colposcopist answered an electronic questionnaire with respect to loop excision under LA. Since we found a high acceptance for LA in patients and colposcopists, we initiated a comparative study LA vs. GA: 322 patients underwent loop excision and selected their mode of anaesthesia: n = 206 LA vs. n = 116 GA. 114 patients of the feasibility study had to undergo loop excision and became part of the comparative study (n = 79 for the LA group, n = 35 for the GA group). All patients received a standardised questionnaire to document their pain score within 24 h after treatment on a visual analogue scale, i.e. VAS, between 0 and 100. 178 patients of the LA group and 80 patients of the GA group completed and returned the questionnaire and form the cohort for our comparison of LA vs. GA. With 191 of these 258 patients, i.e. 74%, a telephone survey was performed to ask for patient satisfaction and the rates of recurrence after a mean interval of 1 year post surgery. We postulate that there will be no clinically relevant significant difference in satisfaction and postoperative pain between patients in the LA group and the GA group.

Results

In the feasibility study , 90% (272 of 303) of patients diagnosed with HSIL or AIS were considered eligible for LA by their colposcopists. 75% (227 of 303) of patients were open to loop excision under LA. In the comparative study , 63 of 206 women of the LA group were interviewed preoperatively: 89% would accept a pain score above 20 during the procedure, 33% a pain score above 50 and 11% of max. 20. Postoperatively, the median VAS pain score for loop excision under local anaesthesia was 13.1 in 178 patients, and pain during injection of local anaesthesia was 20.9 (p < 0.001). The VAS pain score 20 minutes post surgery did not differ significantly between 178 patients after local anaesthesia versus 80 patients after general anaesthesia (p = 0.09). The surgeons estimated the patient's pain significantly less than the patients themselves with an underestimate of -14.63 points on the VAS (p < 0.001). Within 7 days following loop excision under LA, 95.5% of 178 patients would choose local anaesthesia as their preferred method for a potential repeat loop excision, 8.8% of which would like additional painkillers, and 4.5% would choose general anaesthesia.In a telephone follow-up survey of 133 women from the LA group after a mean of 12 months post surgery, 97% were "satisfied" or "very satisfied" with the treatment carried out. For patient satisfaction and postoperative pain, no clinically relevant significant difference was seen between the LA and the GA group.The rate of secondary bleeding (6.7% vs. 8.1%, p = 0.72), recurrence of HSIL/AIS (3.6% vs. 5.2%, p = 0.62), and the distribution of the histopathological R status (R0 89.5% vs. 81.1%, p = 0.73; R1 5.3% vs.12.2%, p = 0.57, Rx 4.1% vs. 5.4%, p = 0.65) showed no significant difference when comparing the LA group versus the GA group.

Conclusion

Following loop excision under local anaesthesia, more than 95% of patients would choose this method again for repeat surgery. One year post surgery, 97% of the patients were "satisfied" or "very satisfied" with the treatment under local anaesthesia. Offering local anaesthesia for loop excision to patients should be mandatory and included in current guidelines.

Sedated masculinity: the use of anaesthesia during vasectomy in Israel

Vasectomy is considered a permanent form of contraception for men that can help reduce reproductive inequality. Its underutilisation in the context of the threats it may pose to perceptions of traditional masculinity has been closely investigated, but the lived experience of the procedure itself has been largely overlooked. This paper examines the experience of having a vasectomy in Israel, focusing on the recommended form of anaesthesia. Drawing on 15 semi-structured interviews with Israeli men who have experienced vasectomy, we found that the choice of anaesthesia has a significant impact on the meaning and experience of vasectomy. Unlike the widespread use of local anaesthesia during vasectomy in other countries, vasectomy in Israel is performed almost exclusively under twilight sedation administered intravenously. Based on our findings, we argue that framing vasectomy as an operation that requires sedation is related to views of masculinity and reproduction. Our data suggest that vasectomy in Israel is constituted as a potentially traumatic event, and anaesthesia is employed to protect patients from feelings of embarrassment and discomfort. We conclude that the prevailing method of sedation perpetuates the silencing and marginalisation of vasectomy as a contraceptive method, and consequently, its very limited accessibility in Israel.

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.

Comparison of the Effects of Lidocaine-Prilocaine Cream and Lidocaine Injection on the Reduction of Perineal Pain While Doing and Repairing Episiotomy in Natural Vaginal Delivery: Randomized Clinical Trial

Background

Doing and repairing episiotomy in a natural vaginal delivery is a painful phenomenon and various methods have been used to reduce its pain. Nowadays, topical ointments are being increasingly used due to low systemic absorption and ease of use.

Objectives

The present study aimed to compare the effects of lidocaine-prilocaine cream (XYLA cream) and lidocaine injection on the reduction of pain while doing and repairing episiotomy.

Methods

This randomized clinical trial was conducted on 98 pregnant women with the gestational age of > 37 weeks. In the intervention group that contained 50 women, 5 gr XYLA cream was applied to the episiotomy area one hour prior to delivery. It was also applied to healthy wound edges to numb the area while repairing episiotomy. In the control group, lidocaine 2% injection was used at the time of delivery. The two groups were compared regarding demographic characteristics, delivery characteristics, pain intensity based on visual analogue scale (VAS), and satisfaction with the applied technique.

Results

The results showed no significant differences between the two groups with respect to age, occupation, mother’s weight and education level, gestational age, parity, number of deliveries, and infant’s weight and head circumference (P > 0.05). Also, no significant difference was found between the two groups concerning the length of the active, second, and third phases of labor (P > 0.05). Considering postpartum complications (episiotomy wound infection), the infection was detected in three participants in the XYLA cream group and four individuals in the lidocaine group, but the difference was not statistically significant (P = 0.376). It should be noted that the application of XYLA cream did not cause eye irritation in any of the infants. The results also revealed no significant differences between the two groups regarding pain intensity and satisfaction with the applied technique after doing and repairing episiotomy (P = 0.288).

Conclusions

The results indicated that XYLA cream had no specific complications and had an effect similar to lidocaine injection while doing the episiotomy.

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.

Surgical and nonsurgical interventions for vulvar and clitoral pain in girls and women living with female genital mutilation: A systematic review

BACKGROUND

Vulvar and clitoral pain are known complications of female genital mutilation (FGM). Several interventions have been used to treat these conditions. This review focuses on surgical and nonsurgical interventions to improve vulvar and clitoral pain in women living with FGM.

OBJECTIVE

To evaluate the impact of nonsurgical and surgical interventions for alleviating vulvar and clitoral pain in women living with any type of FGM and to assess the associated adverse events.

SEARCH STRATEGY

The search included the following major databases: Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov. These were searched from inception until August 10, 2015 without any language restrictions.

SELECTION CRITERIA

Study designs included randomized controlled trials, cluster randomized trials, nonrandomized trials, cohort studies, case-control studies, controlled before-and-after studies, historical control studies, and interrupted time series with reported data comparing outcomes among women with FGM who were treated for clitoral or vulvar pain with either surgical or nonsurgical interventions.

DATA COLLECTION AND ANALYSIS

Two team members independently screened studies for eligibility.

RESULTS

No studies were included.

CONCLUSION

Limited information exists on management of vulvar and clitoral pain in women living with FGM. This constitutes an important area for further research.

PROSPERO REGISTRATION

CRD42015024521.

Blood concentration of prilocaine and lidocaine after the use of topical anesthesia (Oraqix® ) in lacerated wounds

BACKGROUND/AIM

Soft tissue injuries have been reported as being sutured using only topical anesthesia applied in the laceration wound. The objective of this study was to assess the pharmacokinetic profile of components of Oraqix^® (2.5% prilocaine and 2.5% lidocaine) when applied in a laceration as compared to intact skin application in the mouse.

MATERIALS AND METHODS

A total of 200 BALB/c male mice were used in this study. The mice were divided into three groups: group A: shaved and laceration group (80 mice); B: shaved and intact skin group (80 mice); and C: control group (shaved, no treatment; 40 mice) which underwent the same procedures but without application of Oraqix^® . Blood samples were collected over 90 min. Plasma sample analysis employing liquid chromatography coupled with the tandem mass spectrometric (LC-MS/MS) method was used to determine plasma concentrations of lidocaine and prilocaine. Pharmacokinetic analysis of mouse plasma concentrations was carried out by standard non-compartmental methods.

RESULTS

Absorption of both lidocaine and prilocaine was rapid. C_max and AUC values of lidocaine were significantly increased by fourfold and twofold, respectively, in lacerated mouse skin compared to intact skin. Similarly, prilocaine's C_max and AUC values were also increased by 2.5-fold and fourfold, respectively, in lacerated skin compared to intact skin.

CONCLUSION

When Oraqix^® was applied directly into the skin laceration, the plasma concentration of lidocaine and prilocaine was significantly increased as compared to when applied on intact skin. The present study, albeit in mice, indicates that the plasma levels of lidocaine and prilocaine can reach very high levels when the thermosetting gel Oraqix^® is placed directly in wounds.

Meatotomy using topical anesthesia: A painless option

Aim:

Urethral meatotomy is an office procedure often done under local anesthesia with or without penile block or under short general anesthesia. Whatever may be the method, the patient has to bear the pain of injection. To avoid painful injections, in the present study, topical anesthesia in the form of eutectic mixture of prilocaine and lidocaine anesthetics (EMLA/Prilox) has been used to perform such procedures and its effectiveness determined.

Materials and Methods:

A total of 48 consecutive patients with meatal stenosis who attended urology outdoor were enrolled in this study. After exclusion, in 32 patients, 3-4 g of Prilox cream was applied over the glans and occlusive covering was maintained for 45 min before the procedure. Meatotomy was done in a standard manner with hemostat application at the stenosed segment for 2-3 min followed by ventral incision at meatus. The patient's pain perception was measured using visual analog score.

Results:

Out of 32, only one patient that had inappropriate application of cream, had a perception of pain during the procedure. Rest all the patient had no discomfort during the procedure. Mean visual analog score was 1.8 which is not a significant percepted pain level. No patient had any major complication.

Conclusion:

Use of topical anesthesia in form of Prilox (EMLA) cream for meatotomy is safe and effective method that avoids painful injections and anxiety related to it and should be considered in most of such patients as an alternative of conventional penile blocks or general anesthesia.

Lidocaine-Prilocaine Cream as Analgesia for IUD Insertion: A Prospective, Randomized, Controlled, Triple Blinded Study

Introduction:

Copper IUD is a long term and reversible contraception which equals tubal ligation in terms of sterilization. One of the barriers to using this contraception method is the fear and the pain associated with its insertion. Eutectic mixture of local anesthetics (EMLA) 5% is a local anesthetic that contains 25 mg lidocaine and 25 mg of prilocaine per gram. Application of topical analgesic cream to the cervix for laser surgery, hysteroscopy and hysterosalpingography is known

Aims:

this study aimed to determine the effect of EMLA on IUD insertion pain.

Methods:

This triple blind clinical trial was conducted on 92 women in a clinic in Hamedan in 2012. After applying the cream on the cervix, pain in three steps, after using Tenaculum, after inserting hystrometr and after inserting IUD and removing IUD insertion tube were assessed with visual analog scale and were compared in EMLA group and placebo group

Statistical analysis used to determine and compare the pain of independent t tests, Mann-Whitney U test and repeated measures analysis of variance and chi-square tests to determine the homogeneity of variables and Fisher’s exact test was used

Results:

Insertion hystrometr was determined as the most painful IUD insertion. The mean pain at step 2 (inserting hystrometr) was (3/11±2/53) in EMLA group, (5/23±2/31) in placebo group. EMLA cream significantly reduced the pain after using tenaculum (P<0/001), pain inserting Hystrometr (P< 0/001) and pain at IUD insertion and removing insertion tube (P< 0/001)

Conclusions:

Topical Application of EMLA 5% cream as a topical anesthetic on the cervix before insertion IUD reduced the pain during this procedure.

Safety aspects and side-effects of ExEm-gel and foam for uterine cavity distension and tubal patency testing

A state-of-the-art overview of the safety and side-effects of ExEm-gel for uterine cavity distension and ExEm-foam for tubal patency testing is presented. A literature search was carried out using PubMed, textbooks, pharmaceutical databases and reports of toxicity tests. Information on clinical use in humans and experiments in animal models was collected and grouped according to the following components: glycerol, hydroxyethyl cellulose and purified water; subjects included toxicity test, influence on sperm cells, oocytes, blastocyst development, uterine cavity distension, tubal patency testing, pain and obstetric applications. No unknown side-effects of gel or foam, or unexpected concerns about safety, were reported. More information than expected was available on the absence of effects of the components on various human tissues. Although it is difficult to prove that the search is complete, and it is possible that side-effects remain unreported, the combination of glycerol, hydroxyethyl cellulose and purified water is considered to be safe for intrauterine application and tubal patency testing, indicating an optimal risk-benefit ratio in clinical use. The safest strategy, however, is to restrict clinical examinations with gel and foam to the pre-ovulatory phase of the menstrual cycle.

The efficacy and safety of topical EMLA cream application for minor surgery of the adult penis

Background and Objectives:

A variety of surgical procedures of the penis can be performed under local anesthesia. We evaluated the efficacy and safety of EMLA cream anesthetic in such procedures.

Materials and Methods:

In total 330 adult patients were subjected to minor penile surgery including: Complete circumcision (73), short frenulum plasty (168), meatotomy (14), fulguration of penile warts (56) and fulguration of urethral (meatal) warts (19). The level of anesthesia obtained by EMLA cream application along with any adverse effects was recorded.

Results:

The use of EMLA on mucosal lesions provided excellent level of local anesthesia in almost all patients (245/246, 99.5%). Anesthesia of skin lesions was in part influenced by the site of application. Circumcision patients showed the lowest efficacy of the EMLA cream as the majority (~80%) required some form of further anesthesia until the completion of the procedure. No significant adverse effects were noted. A transient erythema was present in almost all mucosal applications.

Conclusions:

The topical anesthetic EMLA cream is a useful, efficient and safe tool for minor surgical procedures of the penis at the office setting, with the exception of circumcision, where an additional type of anesthesia is likely to be necessary. Side effects can be kept to a minimum when the suggested doses are respected (especially at mucosal application) and the time allowed for action is carefully tailored to the site of application and the type of procedure.

A pharmacokinetic study of a topical anesthetic (EMLA® ) in mouse soft tissue laceration

The use of topical anesthesia instead of injection of local anesthetics for managing soft tissue lacerations in the emergency situations may be a relief for both patients and surgeons. Topical anesthesia in the form of a cream eutectic mixture of local anesthetics (EMLA®) containing 2.5% lidocaine and 2.5% prilocaine has been reported as an efficient anesthetic on skin before venipuncture anesthesia and as an alternative to injection anesthesia in some minor surgery situations. The aim of this study was to compare the pharmacokinetics of EMLA® when applied in a laceration with topical skin application in the mouse. A total of 120 Albino Laboratory-bred strain mouse (BALB-c) male mice were divided into three groups with regard to application mode of EMLA®. Group A: with laceration, 48 mice; Group B: on intact shaved skin, 48 mice; Group C: control group (24 mice) with same procedures but without application of EMLA®. Blood levels were collected at 0, 10, 20, 30, 45, 60, 75, and 90 min post-EMLA® application. Plasma sample analysis was carried out by employing liquid chromatography coupled with tandem mass spectrometric (LC-MS/MS) method, and the pharmacokinetic analysis of the mouse plasma samples was estimated by standard non-compartmental methods. The pharmacokinetic parameters of lidocaine and prilocaine were significantly altered following EMLA® application to lacerated mouse skin in contrast to intact skin. The absorption of lidocaine and prilocaine was rapid following application of EMLA® to lacerated and intact mouse skin. Maximum drug plasma concentration (C(max) ) and area under the drug plasma concentration-time curve (AUC) values of lidocaine were significantly increased by 448.6% and 161.5%, respectively, following application of EMLA to lacerated mouse skin in comparison with intact mouse skin. Similarly, prilocaine's C(max) and AUC values were also increased by 384% and 265.7%, respectively, following EMLA application to lacerated mouse skin, in contrast to intact skin. Further pharmacokinetic studies on different carriers of lidocaine/prilocaine are warranted before any firm conclusions for the clinic can be drawn.

Paced mating behavior persists in rats with vaginocervical Lidocaine

The present study tested whether the topical application of a local anesthetic (Lidocaine) to the vaginocervical region altered the pattern of paced mating behavior displayed by gonadectomized, hormone-primed female rats. Both rats receiving Lidocaine and rats receiving vehicle exhibited the expected lengthening of contact-return latency as the intensity of the mating stimuli increased (mount<intromission<ejaculation). Although rats given Lidocaine versus vehicle received a greater number of intromissions, no other group differences were observed. The present study found no evidence for a change in behavioral responsiveness following the vaginocervical application of Lidocaine.

Local anesthesia in transrectal ultrasound-guided prostate biopsy: EMLA cream as a new alternative technique

OBJECTIVES

The aims of the present study were to evaluate the efficacy of eutectic mixture of local anesthetics (EMLA) cream in transrectal-guided prostate biopsy and to compare its effect with that of other injectable anesthetic procedures.

MATERIAL AND METHODS

Eighty male patients with prostate-specific antigen (PSA) levels > 4 ng/ml or who had prostate nodules on digital rectal examination were randomly divided into four groups. In Group 1 (controls), prostate biopsy was performed after application of a placebo cream. In Group 2, local surface anesthesia with EMLA cream was performed 15 min before biopsy. Periprosthetic nerve blockade was performed with 1% prilocaine and 1% lidocaine in Groups 3 and 4, respectively. Pain was evaluated using a visual analog scale (VAS) after each core biopsy. In addition, blood pressure, heart rate and oxygen saturations were recorded after each biopsy and then at 5-min intervals for 15 min.

RESULTS

Average VAS scores in Groups 1-4 were 5.5, 2.9, 2.4 and 2.2, respectively. There was a statistically significant difference in VAS scores between the treatment groups and the placebo group (p = 0.000). There were no statistically significant differences in VAS scores between the three treatment groups (p2-3 = 0.126, p2-4 = 0.303, p3-4 = 0.537). We detected no statistically significant differences between the groups based on the hemodynamic data (pMAP = 0.899). Moreover, these measurements did not show statistically significant changes with time in any of the groups (p > 0. 05).

CONCLUSION

Intrarectal application of EMLA cream provides equal anesthesia to periprostatic nerve blockade with prilocaine and lidocaine.

The influence of a eutectic mixture of lidocaine and prilocaine on minor surgical procedures: a randomized controlled double-blind trial

BACKGROUND

A eutectic mixture of lidocaine and prilocaine (EMLA) has been shown to be effective in reducing pain from needle sticks, including those associated with blood sampling and intravenous insertion.

OBJECTIVE

To evaluate the effectiveness of EMLA cream applied before needle puncture for local anesthetic administration before minor surgical procedures in this double-blind, randomized, controlled, parallel-group study.

MATERIALS AND METHODS

Patients were randomly assigned to receive EMLA or placebo cream (Aqueous) applied under an occlusive dressing. After the procedure, patients were asked to rate the needle prick and procedure pain on a visual analog scale (0=no pain; 10=maximum pain).

RESULTS

A total of 94 minor surgical procedures (49 in EMLA and 45 in control) were performed. The mean needle-stick pain score in the EMLA group was significantly lower than in the control group (2.7 vs. 5.7, p<.001, Mann-Whitney U-test). There was also significantly lower procedure pain in the EMLA group than in the control group (0.83 vs. 1.86, p=.009). There were no complications associated with the use of EMLA.

CONCLUSION

EMLA effectively reduces the preprocedural needle-stick pain and procedural pain associated with minor surgical procedures.

Healing pattern of experimental soft tissue lacerations after application of novel topical anesthetic agents - an experimental study in rabbits

Topical anesthetics based on a combination of 2.5% lidocaine and 2.5% prilocaine are efficient in eliminating pain from needle stick when placed on skin and oral mucosa. This suggests their application in soft tissue lacerations before suturing to enable pain-free exploration and suturing of traumatic lacerations without prior injection needle stick. The aim of the present study was to study the healing of experimental oral lacerations after topical anesthetic substances were placed in the lacerations. Thirty-six standardized incisions were made bilaterally in the lower and the upper labial mucosa of nine white New Zealand rabbits. All wounds were intentionally contaminated with saliva to simulate laceration wounds in trauma situation. EMLA cream and Oraqix thermosetting gel were applied into 30 lacerations and six lacerations were left untreated as control. In some lacerations the topical anesthetic agent was left in the wound, while in others they were rinsed off by saline before suturing the laceration wound. The rabbits were then killed after 3 days, 2 weeks and 4 weeks of healing and the lips were processed for histological evaluation. Similar normal histological healing patterns were seen in wounds in which EMLA and Oraqix were applied compared with control lacerations at all stages of healing. No adverse tissue or foreign body reactions were seen in any of the lacerations. We conclude that EMLA and Oraqix can be used in oral mucosal lacerations prior to suturing without the risk of adverse tissue reaction.

Comparison of topical anesthetics (EMLA/Oraqix vs. benzocaine) on pain experienced during palatal needle injection

OBJECTIVE

The aim of this study was to compare the topical anesthetic effect of 20% benzocaine gel with 2.5% lidocaine/2.5% prilocaine (L/P) cream and gel on the pain experienced during palatal anesthetic infiltration.

STUDY DESIGN

Two groups were studied, each containing 20 subjects. Two types of L/P mixtures were tested, an anesthetic cream (EMLA) and a thermosetting gel (Oraqix), and benzocaine was used as control. The topical agents were applied on the palatal mucosa at the canine region. A needle prick was given on each side every 2 minutes during a period of 10 minutes. The subjects recorded their findings using verbal and VAS scales.

RESULTS

Pain scores were significantly less (P < .05) with EMLA and Oraqix than with benzocaine.

CONCLUSION

Topical application of EMLA and Oraqix before palatal anesthetic infiltration is associated with less pain than with benzocaine gel.

Lidocaine–Prilocaine (EMLA) cream as analgesia for hysterosalpingography: a prospective, randomized, controlled, double blinded study

BACKGROUND

The aim of our study is to evaluate the efficacy of applying lidocaine 25 mg-prilocaine-25 mg/G cream (EMLA 5%) on the uterine cervix for pain relief when performing hysterosalpingography (HSG).

METHODS

Eighty-two patients undergoing HSG as part of infertility evaluation were randomized into groups receiving EMLA (42) or placebo cream (40) in a double-blinded prospective study from which four women were later excluded. The cream was applied to the uterine cervix by means of a cervical cup 30 min before the HSG. Pain perception related to the HSG procedure was scored by visual analogue scale (VAS) at five predefined steps: after speculum application, after cervical instrumentation of the tenaculum and cannula, at the end of uterine filling, at completion of tubal spillage, and immediately following instrument removal. In addition, the patients were asked to retrospectively rate the pain during the entire procedure in a telephone interview the following day.

RESULTS

Cervical instrumentation was found to be the most painful step of HSG (P < 0.001). When comparing the VAS pain scores, cervical instrumentation in the EMLA-treated patients was associated with significantly less pain than the control group: 3.3 +/- 2.9 versus 4.9 +/- 2.7, respectively (P = 0.02).

CONCLUSIONS

Topical application of EMLA 5% cream on the uterine cervix before performing HSG significantly reduced the pain during this procedure.

Lidocaine–Prilocaine Administration during Transrectal Ultrasound-Guided Prostatic Biopsy: A Randomized, Single-Blind, Placebo-Controlled Trial

BACKGROUND AND PURPOSE

As many as 96% of patients report some kind of discomfort/pain during transrectal ultrasonography (TRUS)-guided prostate biopsy, and when pain is severe, it may be necessary to decrease the planned number of biopsies or interrupt the procedure. Various modalities have been recommended to alleviate the pain, but reports on efficacy are contradictory. We assessed the possible benefit of intrarectal and perianal lidocaine-prilocaine (EMLA) cream.

PATIENTS AND METHODS

A series of 98 patients without active anal and prostatic conditions underwent TRUS and, 10 to 31 days later, TRUS-guided biopsy. They were asked to grade their discomfort/pain using a 10- point linear visual analog pain scale (VAS). After TRUS, patients were divided into three groups on the basis of the VAS scores. Group 1 (N = 8) had pain scores <or=2 (mild pain/discomfort). Group 2 (N = 75) had pain scores between 2 and 5 (moderate pain/discomfort). Group 3 (N = 15) had pain scores >or=5 (severe pain/discomfort). Each group was then randomized to receive local anesthesia with intrarectal and anal EMLA cream (subgroup A) or intrarectal and anal ultrasound gel as placebo (subgroup B). Pain scoring was repeated after the biopsy.

RESULTS

In group 1, there were no significant differences in pain scores between subgroups A and B. In group 2, we could not complete the biopsy in one patient of subgroup B. A statistically significant difference was noticed between the VAS scores of subgroup A and subgroup B (P < 0.0001). In group 3, we were not able to complete biopsy in 5 patients of subgroup B. We noticed significantly higher VAS scores in subgroup B between TRUS and prostate biopsy (P < 0.0001), whereas similar scores were observed in subgroup A (P = NS). A statistically significant difference (P < 0.0001) was noticed between subgroup A and subgroup B scores during biopsy.

CONCLUSIONS

In patients with high tolerance for simple TRUS, needle trauma does not significantly alter tolerability, and anesthetic provides little benefit for prostatic biopsy. However, the opposite is true in patients presenting moderate to significant pain/discomfort at TRUS, who may benefit from intrarectal/anal administration of EMLA during prostate biopsy.