Anesthetic Effect of Intrauterine Lidocaine Plus Naproxen Sodium in Endometrial Biopsy

Intrauterine Levobupivacaine Instillation for Pain Control in Women Undergoing Diagnostic Hysteroscopy

Objectives

Many women experience pain and discomfort after hysteroscopic procedure. Pain and discomfort after hysteroscopic procedures can be explained by the cervical dilatation, intrauterine manipulation, and/or hydrodistension. This study designed to evaluate the efficacy of intrauterine levobupivacaine instillation for pain control in women undergoing diagnostic hysteroscopy.

Materials and Methods

One hundred and twenty (120) women scheduled for diagnostic hysteroscopy and endometrial biopsy due to uterine bleeding were included in this study and randomized either to levobupivacaine group or controls. At the end of hysteroscopy, 5 mL of 0.5% levobupivacaine was instilled intrauterine in levobupivacaine group, while 5 mL of 0.9% saline was instilled intrauterine in controls. Participants were kept in the hospital for 12 h after diagnostic hysteroscopy to detect the postoperative (PO) pain intensity using visual analog scale (VAS), and PO required analgesics.

Results

The VAS was significantly lower in levobupivacaine group compared to controls 3 h. PO (1.31 ± 1.02 vs. 1.62 ± 0.76, respectively), (P = 0.01), 6 h. PO (0.81 ± 1.24 vs. 1.53 ± 0.88, respectively), (P = 0.004), and 9 h. PO (0.55 ± 1.25 vs. 1.12 ± 0.95, respectively), (P = 0.01). The total PO required analgesics were significantly lower in levobupivacaine group compared to controls (P = 0.005).

Conclusion

The intrauterine levobupivacaine instillation was simple, and effective for pain relief after diagnostic hysteroscopy, it significantly decreased pain score assessed by VAS at 3, 6, and 9 h., PO, and it significantly decreased PO required analgesics.

The efficacy of oral naproxen and cervical lidocaine spray on perceived pain during hysterosalpingography

Objective

This study was carried out to evaluate the efficacy of the combined use of oral naproxen and cervical lidocaine spray during hysterosalpingography (HSG) compared to the use of oral naproxen or cervical lidocaine spray alone. Materials and Methods: This prospective randomised controlled study was carried out using a total of 240 patients who were randomly assigned to four groups. Group 1 received cervical lidocaine spray only, Group 2 received oral naproxen only, Group 3 received cervical lidocaine spray and naproxen tablet, whereas Group 4 was the control group. A visual analogue scale was used for subjective pain assessment at three pre-defined steps.

Results

The mean pain scores of the patients in each of the four groups are Group 1 (3.6 ± 2.0, 5.1 ± 1.8, 5.8 ± 2.2); Group 2 (2.7 ± 1.4, 3.6 ± 2.0 and 3.9 ± 1.9); Group 3 (2.8 ± 1.5, 3.4 ± 2.0 and 4.2 ± 2.3); Group 4 (4.7 ± 1.7, 5.9 ± 1.7 and 5.3 ± 1.7) at T1, T2 and T3, respectively. Pain perception was statistically significantly reduced by naproxen and combined naproxen plus lidocaine spray at all the stages of HSG while cervical lidocaine spray had a statistically significant reduction in pain perception only during cervical instrumentation.

Conclusion

Oral naproxen and combined naproxen plus cervical lidocaine spray were effective in reducing HSG-associated pain during all the stages of HSG. However, combined oral naproxen and lidocaine spray did not show superior efficacy over oral naproxen alone. Cervical lidocaine spray was not an effective method.

Methods of pain control during endometrial biopsy: A systematic review and meta-analysis of randomized controlled trials

AIM

To review effectiveness of methods for reducing pain during endometrial biopsy.

METHODS

PubMed, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases were searched for randomized controlled trials that examined effectiveness of pain control methods for endometrial biopsy. Risk of bias was assessed from sequence generation, allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Heterogeneity was examined from forest plot, statistical tests of homogeneity, and I² statistic. For meta-analysis of pain scores, weighted mean difference with 95% confidence interval (CI) were estimated.

RESULTS

Twenty-six studies were included in the review. Marginally significant reduction in the pain score during the procedure in participants with intrauterine lidocaine relative to control was observed (mean difference [MD] -1.31, 95% confidence interval [CI] -2.70 to 0.09, P = 0.07). Subgroup analysis showed that in studies that used low-pressure suction devices, intrauterine lidocaine was associated with statistically significant reduction in pain during the procedure (MD -2.22, 95% CI -3.72 to -0.73, P = 0.004). There was a significantly lower pain score during biopsy in the anesthetic spray group compared to control (MD -0.96, 95% CI -1.53 to -0.39, P = 0.001). Significant heterogeneity on types of intervention and outcome measures among studies that examined paracervical block and nonsteroidal anti-inflammatory drugs (NSAID) was observed. However, paracervical block and NSAID were associated with significant pain reduction compared to placebo in most of the related studies.

CONCLUSION

Intrauterine anesthetics, anesthetic cervical spray, paracervical block and oral NSAID provide effective pain control during endometrial biopsy.

Intrauterine lidocaine and naproxen for analgesia during intrauterine device insertion: randomized controlled trial

Background

This study evaluates oral naproxen and intrauterine instillation of lidocaine for analgesia with intrauterine device (IUD) placement as compared to placebo.

Methods

This was a randomized, double-blind, placebo-controlled trial. Patients desiring levonorgestrel 52 mg IUD or Copper T380A IUD were randomized into treatment groups. Patients received either oral naproxen 375 mg or placebo approximately 1 h prior to procedure in conjunction with 5 mL of 2% lidocaine or 5 mL of intrauterine saline. The primary outcome was pain with IUD insertion measured on a visual analog scale immediately following the procedure. Prespecified secondary outcomes included physician pain assessment, post procedure analgesia, satisfaction with procedure, satisfaction with IUD, and pain assessment related to IUD type.

Results

From June 4, 2014 to October 28, 2016 a total of 160 women desiring Copper T380A or levonorgestrel 52 mg intrauterine device insertion and meeting study criteria were enrolled and randomized in the study. Of these, 157 (78 in the Copper T380A arm, 79 in the levonorgestrel 52 mg) received study treatment medication. There were 39 in naproxen/lidocaine arm, 39 in placebo/lidocaine arm, 40 in naproxen/placebo arm, and 39 in placebo/placebo arm. There were no differences in the mean pain scores for IUD placement between treatment groups (naproxen/lidocaine 3.38 ± 2.49; lidocaine only 2.87 ± 2.13; naproxen only 3.09 ± 2.18; placebo 3.62 ± 2.45). There was no difference in self-medication post procedure or in satisfaction with the procedure and IUD among women in the treatment arms or by type of IUD.

Conclusion

Naproxen with or without intrauterine lidocaine does not reduce pain with IUD placement.

Clinical trial registration

Clinicaltrials.gov, NCT02769247. Registered May 11, 2016, Retrospectively registered.

Efficacy of Intrauterine Lidocaine Instillation in Reducing Pain during Endometrial Biopsy by Novak

Abnormal uterine bleeding in women aged 35 years or over is an important clinical sign of many gynecological conditions. The diagnoses of these conditions require the pathological report of the endometrial tissue. Outpatient-based endometrial biopsy is an excellent option compared to standard fractional uterine curettage or hysteroscopy with endometrial biopsy in providing a definite diagnosis for abnormal uterine bleeding as it is less painful and does not require high potency anesthesia. This study evaluates the effect of intrauterine lidocaine on the patient's pain score during endometrial biopsy by the Novak curette. We included patients aged 35 years or more who had abnormal uterine bleeding between December 2016 and March 2018. The study was conducted at Thammasat University Hospital, Pathum Thani, Thailand. 250 patients were randomly allocated to either receive intrauterine lidocaine (study group) or normal saline (control group). Assessment of pain severity was evaluated using a visual analogue scale (VAS) score at 6 time-points, namely, before performing the procedure, when grasping the cervix by the tenaculum, during the intrauterine instillation of lidocaine or normal saline, during the uterine curettage, and then 15 minutes and 2 hours after the procedure. This study showed that there was significant pain reduction in patients who received intrauterine instillation of lidocaine compared to placebo, during uterine curettage, as well as 15 minutes and 2 hours after procedure (p<0.0001). Patient satisfaction was not significantly different between the two groups, while physician satisfaction significantly improved in the lidocaine group. Serious complications were not found during this study. (This research project had been approved for registration at Thai Clinical Trials Registry. TCTR identification number is TCTR20161031003.).

The Efficacy of Lidocaine Spray in Pain Relief during Outpatient-Based Endometrial Sampling: A Randomized Placebo-Controlled Trial

Abnormal vaginal bleeding is one of the most frequent problems found in gynecology. Endometrial histopathology is needed for definite diagnosis. It was obtained either from endometrial tissue sampling or from standard uterine curettage. Office endometrial tissue sampling is an easy and low morbid procedure. It is usually associated with pain and discomfort. Topical anesthetic agent is needed for pain relieving. This study was conducted in outpatient gynecology clinic, Thammasat University Hospital, Thailand. It was a double blind randomized controlled trial. A total of 140 participants were enrolled in study and control group. Each group consisted of 70 cases. Study group received topical spray of 10% lidocaine (40 mg) before endometrial aspiration. Topical spray of 0.9% normal saline was performed in control group. Novak curettage was an application for endometrial tissue obtaining in this study. Visual analog scale (10cm-VAS) was used for pain evaluation. Demographic character of both groups showed no statistical difference. The percentage of participants who had severe pain (VAS≥7) during tenaculum application and Novak curettage insertion and during procedure were 28.5% (20/70) versus 12.9% (9/70), 55.7% (39/70) versus 38.5% (27/70), and 78.5% (55/70) versus 60% (42/70) in control and study group, respectively. Both groups had no significant differences of postoperative pain at 15 minutes and 2 hours. This study indicates that topical lidocaine spray can relieve pain during endometrial tissue sampling.

The optimal analgesic method in saline infusion sonogram: A comparison of two effective techniques with placebo

Objective:

Operations performed with local anesthesia can sometimes be extremely painful and uncomfortable for patients. Our aim was to investigate the optimal analgesic method in saline infusion sonograms.

Materials and Methods:

This study was performed in our Clinic of Obstetrics and Gynecology between March and August 2011. Ninety-six patients were included. Patients were randomly divided into groups that received saline (controls, group 1), paracervical block (group 2), or paracervical block + intrauterine lidocaine (group 3). In all groups, a visual analogue scale score was performed during the tenaculum placement, while saline was administered, and 30 minutes after the procedure.

Results:

When all the patients were evaluated, the difference in the visual analogue scale scores in premenopausal patients during tenaculum placement, during the saline infusion into the cavity, and 30 minutes following the saline infusion sonography were statistically different between the saline and paracervical block groups, and between the saline and paracervical block + intrauterine lidocaine group. However, there was no statistically significant difference between paracervical block and paracervical block + intrauterine lidocaine groups.

Conclusion:

As a result of our study, paracervical block is a safe method to use in premenopausal patients to prevent pain during saline infusion sonography. The addition of intrauterine lidocaine to the paracervical block does not increase the analgesic effect; moreover, it increases the cost and time that the patient stays in the dorsolithotomy position by 3 minutes.

Effect of Cervical Lidocaine Gel for Pain Relief in Pipelle Endometrial Sampling

OBJECTIVE

To evaluate the efficacy of cervical lidocaine gel in reducing patient discomfort during Pipelle endometrial sampling.

MATERIALS AND METHODS

From September 2012 to January 2013, 137 patients were evaluated with Pipelle endometrial biopsy. For group 1 (77 women), 2% lidocaine gel was applied to the cervical canal 3 min before endometrial sampling. For group 2 (60 women), a placebo gel was applied. The pain experienced by the patients during biopsy was evaluated using a 100 mm visual analog scale.

RESULTS

The pain score was significantly lower during suction curettage (T3) in the group 1 than in the group 2. There was no significant difference between the groups in terms of pain score in other stages of the procedure (2.6±1.3 and 4.5±1.4; p=0.03).

CONCLUSION

Cervical 2% lidocaine gel is simple and effective for decreasing pain associated with Pipelle endometrial biopsy.

Effectiveness of Intrauterine Lignocaine in Addition to Paracervical Block for Pain Relief during Dilatation and Curettage, and Fractional Curettage

PURPOSE OF STUDY

Dilatation and curettage (D&C) and fractional curettage (F/C) are commonly performed gynecological procedures. Randomized controlled trials have concluded that topical anesthesia effectively reduces pain in endometrial sampling and hysteroscopy. Our study was aimed at investigating this modality of pain relief in setting of a developing country where, due to lack of resources, successful completion of these procedures in an outpatient setting is a necessity.

METHODS

This study was a prospective, randomized, placebo-controlled, double-blind study conducted in 84 patients. All patients received either intrauterine 2 % lignocaine or normal saline along with oral NSAID and paracervical block prior to the procedure. The pain was analyzed at three steps: at the time of curette, immediately post-procedure, and 30 min later using 10-cm visual analog score.

RESULTS

The patients in the experimental and control groups were well matched for age, parity, body mass index, menopausal status, and the indications for intervention. At all the three stages, pain perceived in the lignocaine group was significantly less as compared to that in placebo group. As compared to lignocaine group (55 %), significantly higher number of women in placebo group (88 %) perceived severe pain during endometrial curettage (p = 0.001).

CONCLUSIONS

The present study indicates that two percent intrauterine lignocaine significantly decreases the pain perception during intrauterine gynecological procedures such as D&C and F/C. This is a simple, effective, inexpensive, and low-risk intervention which can potentially increase the patient acceptability and compliance with such procedures.

Effect of lidocaine spray in pain management during office-based endometrial sampling: A randomised placebo-controlled trial

Office-based endometrial sampling is the most frequently performed gynaecological procedure. The procedure is usually associated with pain and discomfort. Several anaesthetic and analgesic techniques (e.g., non-steroidal anti-inflammatory drugs, paracervical block, misoprostol and topical anaesthetics) are used for pain management during endometrial sampling. There is no comprehensive study using lidocaine in spray form; we sought to investigate the analgesic efficacy of 10% lidocaine spray in patients undergoing office-based endometrial biopsy. We conducted a prospective, randomised (lidocaine spray (n = 60) and placebo (n = 60), respectively), double-blind study. The mean pain score during procedure was 3.51 ± 1.51 in the lidocaine spray group and 5.11 ± 1.66 in the placebo group. Lidocaine spray treatment significantly lowered the pain scores compared with placebo (p < 0.001). Lidocaine spray can be accepted as a non-invasive, easy to apply and more comfortable anaesthetic method for office-based endometrial sampling.

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.

Prophylactic ibuprofen does not improve pain with IUD insertion: a randomized trial

OBJECTIVE

To evaluate if ibuprofen 800mg reduces pain with intrauterine device (IUD) insertion among U.S. women.

STUDY DESIGN

We conducted a randomized, double-blind, placebo-controlled trial of women undergoing IUD insertion approximately 2-6weeks following first-trimester uterine aspiration. Subjects were randomized to receive ibuprofen 800mg or placebo 30-45min prior to IUD insertion. A 100-mm visual analog scale (VAS) was administered to measure pain after speculum insertion (baseline) and immediately following IUD insertion.

RESULTS

A total of 202 women were enrolled, with 101 randomized to each group (ibuprofen or placebo). Sociodemographic characteristics and baseline VAS scores were similar between groups. The median pain score with IUD insertion was 41.5mm in the placebo group and 38.0mm in the ibuprofen group (p=.50). Mean and median pain scores did not differ between placebo and ibuprofen when nulliparous and parous women were analyzed independently. Overall, median pain scores were 17.5mm higher in nulliparous women than parous women (p=.004). Median pain scores did not differ by age, IUD-type, history of dysmenorrhea or time since aspiration.

CONCLUSIONS

Administration of ibuprofen 800mg prior to IUD insertion does not reduce pain associated with the procedure for U.S. women. Overall, nulliparous women report more pain with IUD insertion than multiparous women.

Vaginal misoprostol versus a rectal nonsteroidal anti-inflammatory drug to reduce pain during Pipelle endometrial biopsies: a prospective, randomized, placebo-controlled trial

BACKGROUND

To evaluate and compare the efficacy of vaginal misoprostol and a rectal nonsteroidal anti-inflammatory drug (NSAID) on pain relief during Pipelle endometrial biopsies in a placebo-controlled randomized study.

METHODS

One hundred and fifty-one women who had an indication for a Pipelle endometrial biopsy were randomized into three groups as follows: group 1, vaginal misoprostol; group 2, rectal NSAID, and group 3, control. After the procedure, the women were asked to record their pain severity on a visual analog scale. The secondary outcome of the study was patient acceptability, and vasovagal symptoms and analgesic requirements after the procedure were also recorded.

RESULTS

There were no statistically significant differences in the demographic characteristics of the patients. The primary study outcome was the comparison of the median visual analog scale pain scores of groups 1 and 2 versus group 3 (controls); no statistically significant differences were found (p = 0.502). In addition, the patient acceptability (Likert scale), vasovagal symptoms and analgesic requirements after the procedure were similar among the groups (p = 0.204, 1 and 0.546, respectively).

CONCLUSION

Our study did not demonstrate a reduction in pain relief during Pipelle endometrial biopsies for patients receiving vaginal misoprostol or a rectal NSAID when compared to patients receiving placebo treatment.

Evidence-based pain management for endometrial biopsies and IUD insertions

Intrauterine device (IUD) insertions and endometrial biopsies (EMB) are common outpatient office procedures performed by advanced practice nurses. There are currently no guidelines for pain management with either IUD insertions or EMB procedures. Combination modalities are the most likely to impact pain perception, but more research is required in this area.

Transcervical intrauterine levobupivacaine or lidocaine infusion for pain control during endometrial biopsy

BACKGROUND

Endometrial biopsy is a common procedure for the investigation of many gynecological disorders including abnormal uterine bleeding, postmenopausal bleeding, abnormal cytology and infertility. Most women experience some degree of discomfort and pain during the procedure. Pain may occur during dilation of the cervix for insertion of the catheter and during endometrial biopsy, which further aggravates pain by inducing uterine contraction.

OBJECTIVES

To determine pain levels during endometrial biopsy by comparing intrauterine instillation of levobupivacaine or lidocaine with placebo in a randomized, double-blinded trial in pre- and postmenopausal women.

METHODS

Ninety patients were allocated to either control or experimental groups before endometrial biopsy. The trial medication was intrauterine anesthesia, either 5 mL 0.9% saline (control group), or 5 mL 0.5% levobupivacaine or 2% lidocaine (experimental groups). Resident doctors used the same endometrial biopsy technique to minimize the risk of technical variation. All tissue specimens were sent for cytopathological examination. The pathologists, who were blinded to the study solution, analyzed all tissue specimens. The primary outcome measure was pain experienced during the procedure. Pain was assessed using a 10 cm visual analogue pain scale. All observed adverse effects were recorded until the patients were discharged.

RESULTS

Pain scores of the intrauterine lidocaine and levobupivacaine groups were found to be significantly lower than the control group. There was no difference between the levobupivacaine and lidocaine groups with regard to pain scores. There was a moderately positive correlation between pain scores and endometrial thickness. No complications were observed due to the procedure. Most of the biopsy results were proliferative and secretory endometrium. Insufficient material causing inconclusive results was observed mostly in the control group.

CONCLUSION

Transcervical intrauterine topical instillation of levobupivacaine or lidocaine causes pain relief during endometrial biopsy. However, further studies are needed to evaluate the effectiveness of intrauterine anesthesia, to determine optimal concentration, volume and waiting time according to the type of local anesthetic agent, and to assess the applicability of the method to other intrauterine procedures.

The effect of different local anesthesia methods on pain relief in outpatient endometrial biopsy: randomized clinical trial

INTRODUCTION

Endometrial biopsy is necessary for diagnosing the reason of abnormal uterine bleeding in perimenopausal women. Currently outpatient endometrial biopsy is used for evaluation of abnormal uterine bleeding which is associated with moderate to severe pain. Using lidocaine is one of the procedures which is used for pain relief while biopsy. This study is aimed at comparing the effect of different local anesthesia procedures on pain relief during endometrial biopsy.

METHODS

In this randomized clinical trial, 160 multiparous 40-55 years old women with AUB, candidates for endometrial biopsy, were randomly assigned into four equal groups, to receive: 1-intrauterine lidocaine; 2-cervical spray lidocaine; 3- intrauterine lidocaine plus cervical spray lidocaine; or 4-intrauterine distilled water. Pain relief was measured at 3 different times: during endometrial biopsy, just after and 15 minutes after biopsy.

RESULTS

Pain intensity was reduced significantly at different times in intrauterine lidocaine and intrauterine lidocaine with cervical spray lidocaine receivers in compare with the groups which received cervical spray lidocaine and distilled water. The mean of difference pain relief during biopsy and 15 minutes after that was reduced significantly in the group which received intrauterine lidocaine and intrauterine lidocaine with cervical spray lidocaine in comparison with the other two groups.

CONCLUSION

Intrauterine lidocaine was effective during endometrial biopsy, and using it with cervical spray lidocaine had no more beneficial effect.

Intrauterine infusion of lidocaine does not reduce pain scores during IUD insertion

BACKGROUND

Potential pain with IUD insertion is a concern for women. Studies have found that systemic and local cervical therapies do not reduce pain scores. Since intrauterine infusion of lidocaine may reduce pain with endometrial aspiration, in this pilot study, we tested whether such infusion through an inexpensive endometrial aspirator could reduce IUD insertion pain scores with IUD insertion.

STUDY DESIGN

In this randomized, double-blinded, placebo control pilot study of 40 women undergoing IUD insertion, pain scores of women receiving 1.2 mL 2% lidocaine versus normal saline (1:1) infused 3 min prior to IUD insertion were measured using a 0-9-point scale.

RESULTS

Pain at tenaculum placement was similar between groups. There was no difference in mean pain scores during IUD insertion of women infused with lidocaine (2.95) versus normal saline (3.75), p=.37. Considerable variation in pain scores was noted; 46% of subjects had pain scores ≤2 while 33% had pain scores ≥5.

CONCLUSION

Use of 2% lidocaine administered through an endometrial aspirator did not significantly reduce IUD insertion pain scores in this pilot study.

Intrauterine anesthesia for gynecologic procedures: a systematic review

OBJECTIVE

To assess the effectiveness of intrauterine local anesthesia in reducing pain associated with outpatient gynecologic procedures.

DATA SOURCES

We searched online databases PubMed or MEDLINE, Embase, Google Scholar, and Clinicaltrials.gov and hand-searched reference lists from reviews evaluating pain-control methods for gynecologic office procedures. We identified randomized controlled trials using intrauterine local anesthetic in gynecologic procedures.

METHODS

Titles and abstracts were screened for 1,236 articles. We identified 45 potential articles for inclusion. We excluded 22 of these studies because: 1) they were not randomized controlled trials; 2) they did not describe a quantifiable dose of medication used in the study; 3) they did not investigate an intrauterine anesthetic; 4) they did not study a potentially awake, outpatient procedure; and 5) they did not clearly report results or represented duplicate publication. Twenty-three articles were ultimately included for review.

TABULATION, INTEGRATION, AND RESULTS

Two authors independently reviewed full search results and assessed eligibility for inclusion and independently abstracted data from all articles that met criteria for inclusion. Disagreements regarding eligibility or abstraction data were adjudicated by a third independent person. Our primary end point was the reported effect of intrauterine local anesthesia on patient-reported pain scores. As a result of heterogeneity in study methods, outcome measures, and reporting of outcomes, results could not be combined in a meta-analysis. Good evidence supports use of intrauterine anesthesia in endometrial biopsy and curettage, because five good-quality studies reported reduced pain scores, whereas only one good-quality study reported negative results. We found moderate evidence to support intrauterine anesthesia in hysteroscopy, because one good-quality study and two fair or poor quality studies reported reduced pain scores, whereas two good-quality studies had negative results. Good evidence suggests that intrauterine anesthesia is not effective in hysterosalpingography; three good-quality studies reported that pain scores were not reduced, and no good quality studies showed a beneficial effect in that procedure. Evidence was insufficient concerning first-trimester abortion, saline-infusion ultrasonogram, tubal sterilization, and intrauterine device insertion.

CONCLUSION

Intrauterine local anesthesia can reduce pain in several gynecologic procedures including endometrial biopsy, curettage, and hysteroscopy and may be effective in other procedures as well.

Transcervical intrauterine levobupivacaine infusion or paracervical block for pain control during endometrial biopsy

The aim of this study was to determine pain during endometrial biopsy by comparing the use of intrauterine instillation of levobupivacaine or paracervical block with a placebo in a randomized, double-masked trial in premenopausal and postmenopausal women. A total of 90 women were enrolled in the study. Patients were allocated to either the control or case groups. Group 1 consisted of 30 cases with intrauterine anesthesia with 5 ml 0.5% levobupivacaine. Group 2 consisted of 30 patients who underwent paracervical block with lidocaine. No analgesic agent was given to the remaining 30 patients; these cases comprised the control group. The primary outcome measures were pain or discomfort experienced during the procedure. When the pain scores of the different groups were compared, the scores in the intrauterine levobupivacaine and paracervical block groups were found to be significantly lower compared to those in the control group. There was no difference between the levobupivacaine and paracervical block groups in terms of pain scores. There was a marked positive correlation between biopsy indications and pain scores. Pain scores were lower in cases with the indication of polymenorrhea, hypermenorrhea and metrorraghia compared to those in the cases with other indications. In conclusion, the transcervical intrauterine instillation of levobupivacaine or paracervical block with lidocaine brings about pain relief during and after endometrial biopsy.

Comparison of oral nonsteroidal analgesic and intrauterine local anesthetic for pain relief in uterine fractional curettage: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

We sought to investigate the analgesic efficacy of oral dexketoprofen trometamol and intrauterine lidocaine in patients undergoing fractional curettage.

STUDY DESIGN

A randomized, double-blind, placebo-controlled trial was conducted on 111 women. Subjects were randomly assigned into 4 groups to receive either 25 mg of dexketoprofen or similar-appearing placebo tablets and either 5 mL intrauterine 2% lidocaine or saline. The main outcome measure was the intensity of pain measured by a 10-cm visual analog scale. Pain scoring was performed prior to, during, and 30 minutes after the procedure.

RESULTS

No statistically significant difference was found among the mean pain scores of women during the procedure in the dexketoprofen and saline, placebo and lidocaine, and dexketoprofen and lidocaine groups. The mean pain scores in all 3 groups revealed significant reduction when compared with placebo and saline combination (P = .001).

CONCLUSION

Administration of intrauterine lidocaine or oral dexketoprofen appears to be effective in relieving fractional curettage associated pain. However, a combination of them does not work better in further reduction of pain.

Comparison of the efficacy of intrauterine lidocaine, paracervical block and oral etodolac for decreasing pain in endometrial biopsy

OBJECTIVE

To compare the effectiveness of paracervical block, intrauterine lidocaine and oral etodolac in decreasing the pain caused by pipelle endometrial sampling. A secondary goal of this study was to determine the adverse effects and compare possible effects of these methods on pulse and blood pressure.

MATERIAL AND METHODS

The study was performed between April 2006 and October 2006 in the Obstetrics and Gynecology Department of Van Yüzüncü Yıl University Research Hospital. One-hundred twenty patients were randomized into four groups: 1. Group: Paracervical block was performed with 3 ml 2% prilocaine solution. 2. Group: Five ml of 2% lidocaine solution was instilled through the endocervix into the uterine cavity. 3. Group: Subjects received 400 mg oral etodolac tablet 1-1.5 hour before the procedure. 4. Group: No method of anesthesia was used in the control group. Endometrial sampling was performed with pipelle. Severity of pain during the procedure was scored by the subjects according to the "6-point Verbal Rating Scale (VRS)". Blood pressure and pulse rate were measured before, during and 30 minutes after the procedure.

RESULTS

Pain scores in intrauterine lidocaine group (2(nd) group) were found statistically significantly lower than the other three groups (p<0.05).

CONCLUSION

Intrauterine lidocaine anesthesia technique decreases pain in endometrial sampling with pipelle more efficiently than paracervical block or oral etodolac. While indication of menorrhagia and endometrial thickness more than 5 mm increased pain scores, intrauterine lidocaine application or paracervical block decreased the scores significantly (p<0.05).

Analgesic efficacy of intravenous paracetamol for outpatient fractional curettage: a randomised, controlled trial

OBJECTIVE

To determine the efficacy of intravenous (i.v.) paracetamol for decreasing pain associated with fractional curettage.

MATERIALS AND METHODS

This double-blind, randomised, placebo-controlled trial included 70 women who underwent fractional curettage. Patients were randomly assigned to receive i.v. infusion of either 1000 mg paracetamol (n = 36) or 0.9% normal saline as placebo (n = 34) prior to the procedure. The main outcome measure was the intensity of pain assessed by a 10-cm visual analogue scale. Pain scoring was performed at t(1) = prior to the procedure, t(2) = during the procedure and t(3) = 30 min after the procedure. Statistical analysis was performed using the Student's t-test, chi-squared and Pearson's correlation analysis.

RESULTS

The pain scores at t(2) and t(3) were significantly higher than the score at t(1) in both groups. There was no statistically significant difference between the pain scores at t(1), t(2) and t(3) among the two groups. Menopausal status had no effect on the pain scores and on the treatment outcome. The pain scores prior to the procedure were significantly higher in women with a history of endometrial curettage when compared with women who have no history.

CONCLUSIONS

Fractional curettage is associated with mild pain. We were unable to detect a significant difference in pain scores in patients undergoing fractional curettage when comparing the use of i.v. paracetamol with placebo. History of prior endometrial curettage seems to be a predictor of the basal pain scores at admission although it does not affect the pain intensity related to the procedure.

Intrauterine lidocaine infusion for pain relief during saline solution infusion sonohysterography: a randomized, controlled trial

STUDY OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine instillation in reducing patient discomfort during saline solution infusion sonohysterography (SIS).

DESIGN

A double-blinded, randomized, controlled trial (Canadian Task Force classification I).

SETTING

Suleyman Demirel University School of Medicine, Department of Obstetrics and Gynecology, Isparta.

PATIENTS

One hundred-six women who underwent SIS.

INTERVENTIONS

Fifty-three patients were allocated to the lidocaine group and 53 to the saline solution group.

MEASUREMENTS AND MAIN RESULTS

The main outcome measures were the intensity of pain during, immediately after, and 20 minutes after the procedure, assessed by a visual analog scale and the patients' distress evaluated by the physician with a 3-point observer scale. There were no statistically significant differences between the study group and the control group in mean age, parity, past cervical surgery, history of chronic pelvic pain and dysmenorrhea, history of curettage, education, socioeconomic status, menopausal status, volume of saline solution infused (mL), tenaculum use, and indication for SIS. Pain scores demonstrated a statistically significant difference between groups during the procedure (placebo 5.09 +/- 1.25 [95% CI 4.74-5.43], lidocaine 3.90 +/- 1.02 [95% CI 3.61-4.18], p <.001); immediately after procedure (placebo 4.03 +/- 0.89 [95% CI 3.78-4.27], lidocaine 3.16 +/- 0.67 [95% CI 2.97-3.34], p <.001); and 20 minutes after procedure (placebo 3.32 +/- 0.54 [95% CI 3.17-3.46], lidocaine 2.43 +/- 0.72 [95% CI 2.23-2.62], p <.001). No significant pain relief in nulliparous patients was obtained by the use of lidocaine (4.88 +/- 1.01 [95% CI 4.60-5.15], 3.88 +/- 0.86 [95% CI 3.64-4.11], 3.22 +/- 0.55 [95% CI 3.06-3.37], respectively; p >.05). Pain rated by the physician during, immediately after, and 20 minutes after the procedure was significantly different between the groups (p <.001), and a significant correlation was noted between the visual analog pain score and the patients' distress recorded by the physician (r = 0.816, r = 0.697, r = 0.676; p <.001, respectively).

CONCLUSION

Intrauterine lidocaine seems to be effective in decreasing pain in parous women undergoing SIS.

Intrauterine lidocaine plus buccal misoprostol in the endometrial biopsy

OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine plus buccal misoprostol in reducing the discomfort caused by endometrial biopsy with a suction curette.

METHODS

In this double-blind, randomized, placebo-controlled trial 126 women undergoing endometrial biopsy were administered a 200-microg tablet of misoprostol buccally, followed by a 5-mL uterine instillation of either of 2% lidocaine or a saline solution. The main outcome measures were the intensity of pain during, immediately following, and 20 min following the biopsy, as assessed on a 10-cm visual analog scale. Statistical analysis was performed using the Friedman test with the Bonferroni correction, the t test, and the chi(2) test.

RESULTS

There were no statistically significant differences between the study and control groups in mean age, parity, or relevant medical history. A statistically significant difference in pain scores was noted in premenopausal women during the procedure (lidocaine, 4.93+/-1.67; placebo, 6.17+/-1.26; P<0.001) as well as immediately later (lidocaine, 4.12+/-1.14 vs. placebo, 5.42+/-1.08; P<0.001) and 20 min later (lidocaine, 3.60+/-1.10; placebo, 4.22+/-1.46; P<0.001). No significant differences in pain scores were observed in postmenopausal women for any of the 3 time points (6.72+/-2.01, 5.18+/-1.22, and 4.56+/-0.80, respectively; P>0.05). The number needed to treat was 2.6 (95% confidence interval, 1.9-4.8).

CONCLUSION

Intrauterine lidocaine plus buccal misoprostol appears to be effective in decreasing pain in premenopausal women undergoing endometrial biopsy with a suction curette.

Efficacy of Intrauterine Lidocaine for Removal of a “Lost” Intrauterine Device

OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine instillation in reducing patient discomfort during the removal of a "lost" intrauterine device (IUD).

METHODS

This double-blinded, randomized, placebo-controlled trial included 68 women who underwent removal procedure for a "lost" IUD. Thirty-four women were allocated to the lidocaine group and 34 to the saline group. The main outcome measure was the intensity of pain during, immediately after, and 20 minutes after the procedure, assessed by a visual analog scale. Statistical analysis was performed using the Friedman test with Bonferroni correction, Student t test, and chi2.

RESULTS

There were no statistically significant differences between the study group and the control group in mean age, parity history of chronic pelvic pain and dysmenorrhea, history of curettage, education, socioeconomic status, menopausal status, breastfeeding, type of IUD, and duration of IUD. Pain scores demonstrated a significant difference between groups during the procedure (placebo 6.41 +/- 1.15, lidocaine 5.23 +/- 0.69, P < .01), immediately after procedure (placebo 6.05 +/- 1.01, lidocaine 4.94 +/- 0.60, P < .01), and 20 minutes after procedure (placebo 4.32 +/- 0.63, lidocaine 4.44 +/- 0.66, P < .01). The number needed to treat was 3 (95% confidence interval 2-9).

CONCLUSION

Intrauterine lidocaine appears to be effective in decreasing pain in women undergoing the removal procedure of a "lost" IUD.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT00308841.

LEVEL OF EVIDENCE

I.

Four Percent Intrauterine Lidocaine Infusion for Pain Management in First-Trimester Abortions

OBJECTIVE

To study the effects of a 4% intrauterine lidocaine infusion on perceived patient pain in first-trimester abortions.

METHODS

A randomized, double-blind, placebo-controlled trial of 80 women receiving either a 5-mL 4% lidocaine (n = 40) or saline (n = 40) intrauterine infusion and a standard paracervical block before first-trimester abortion. Women completed a series of 100-mm visual analog scales (anchors: 0 = none, 100 mm = worst imaginable) to measure their perceived pain (anticipated pain, after speculum insertion, after intrauterine infusion, after cervical dilation, after suction aspiration, and 30 minutes postprocedure). Eight women volunteered for serum lidocaine levels after the lidocaine infusion.

RESULTS

Groups were similar in respect to age, parity, prior abortion, ethnicity, gestational age, and level of dysmenorrhea. Pain scores demonstrated a significant difference between groups during cervical dilation (saline 55 mm +/- 26, lidocaine 35 mm +/- 30, P < .01) and during aspiration (saline 71 mm +/- 20, lidocaine 43 mm +/- 30, P < .01). The lidocaine group reported significantly more symptoms (ie, oral numbness and tingling) than the saline group (saline 0/39, lidocaine 16/38, 42%, P < .01). The highest serum lidocaine level recorded was 4.0 microg/mL (lidocaine group). There was no difference in overall satisfaction between the 2 groups.

CONCLUSION

Compared with paracervical block alone, the addition of a 4% intrauterine lidocaine infusion resulted in a significant reduction in patient perception of pain during first-trimester abortion. Although subjective symptoms of systemic lidocaine effect were common, no subjects demonstrated serum levels consistent with lidocaine toxicity. However, further studies to determine safety are needed.

LEVEL OF EVIDENCE

I.

Effectiveness of Intrauterine Anesthesia for Pain Relief During Fractional Curettage

OBJECTIVE

To study the effectiveness of intrauterine anesthesia for pain relief during fractional curettage.

METHODS

A double-blinded, randomized, placebo-controlled trial was conducted in 66 patients with abnormal uterine bleeding undergoing fractional curettage under paracervical block, using 10-mL 1% lidocaine plus intrauterine 5-mL 2% lidocaine (n = 33) or saline (n = 33). The primary outcome was the maximum pain score measured with a 10-cm visual analog scale. Other outcomes measured included pain profile, number of patients with pain score more than 4, each patient's global satisfaction index, adverse events, and serum lidocaine profile.

RESULTS

The 2 groups were comparable in age, body mass index, education, socioeconomic status, menopausal status, and parity. Compared with the saline group, the lidocaine group had a significantly lower median value for the maximum pain score (2.3 versus 4.7, P = .022) and fewer patients with a pain score more than 4 (33.3% versus 60.6%, P = .026). The pain scores were lower at the endocervical curettage and the uterine curettage steps. There was no difference between the 2 groups in other outcomes. The number needed to treat to prevent a case with a pain score more than 4 was 3.7 (95% confidence interval 2.4-38.5).

CONCLUSION

The addition of intrauterine anesthesia to paracervical block can further reduce pain during fractional curettage without increasing adverse effects.

LEVEL OF EVIDENCE

I.

Topical Analgesia for Endometrial Biopsy

OBJECTIVE

To estimate whether benzocaine spray applied to the cervix and the endocervical canal before performing office endometrial biopsy improves patient comfort during the procedure.

METHODS

Eighty-eight women were randomly assigned to receive either 20% benzocaine spray or placebo to the outside of the cervix and into the endocervical canal before an endometrial biopsy was performed. The main outcome measure was pain during the endometrial biopsy, assessed by a visual analog scale. Statistical analysis was performed using Wilcoxon rank-sum test and Student t test.

RESULTS

There were no statistically significant differences between the study group and the control group in mean age, race, parity, body mass index, menopausal status, tenaculum use, or history of chronic pelvic pain. No statistically significant differences were found in median pain scores between the 2 treatment groups.

CONCLUSION

Topical benzocaine spray does not appear to offer effective pain control in patients undergoing an endometrial biopsy.

LEVEL OF EVIDENCE

I.