Local anaesthesia and cervical dilatation for outpatient diagnostic hysteroscopy

Pain Relief and Outpatient Hysteroscopy: A Literature Review

Our early experience in setting up an ambulatory hysteroscopy service provoked a review of the literature, due to an unacceptably high failure rate. A literature review has been undertaken to establish the accepted success rates and reasons for failure, and to assess evidence for various analgesic protocols through randomized controlled trials. The data suggest the procedure is acceptable to most patients, with a completion success rate over 90%, and the use of analgesia may enhance the success rate. Analgesic protocols studied were nonsteroidal anti-inflammatory drugs, intracervical block, paracervical block, transcervical block, and topical analgesia. Failures are due predominantly to pain, stenosis, and poor view.

Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial

OBJECTIVE

To assess the efficacy of lignocaine spray during outpatient hysteroscopy in reducing the need for additional anesthesia and reducing the discomfort of the procedure.

DESIGN

A randomized double-blind, placebo-controlled trial.

SETTING

An undergraduate university teaching hospital in London.

PATIENT(S)

One hundred twenty patients undergoing outpatient hysteroscopy.

INTERVENTION(S)

Application of lignocaine spray to the cervix, cervical canal, and uterine cavity during outpatient hysteroscopy.

MAIN OUTCOME MEASURE(S)

The need to use additional anesthesia and the pain experienced at various steps of the procedure.

RESULT(S)

Women treated with active spray experienced significantly less pain when the cervix was grasped with a tenaculum at the start of hysteroscopy. There were no other significant differences in the outcome of hysteroscopy between the placebo and lignocaine groups, although there was a significant reduction in the use of additional anesthesia in both groups compared with historical controls.

CONCLUSION(S)

Lignocaine spray has beneficial effects on cervical but not uterine sensation. Pretreatment with either lignocaine or placebo seems to reduce the need for additional intracervical anesthesia during hysteroscopy.

Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy

OBJECTIVE

To evaluate patient acceptance and the clinical feasibility of carbon dioxide compared with normal saline for uterine distension in outpatient hysteroscopy.

DESIGN

Prospective, randomized clinical trial.

SETTING

Outpatient hysteroscopy clinic in a university hospital.

PATIENTS

One hundred fifty-seven patients undergoing outpatient hysteroscopy.

INTERVENTIONS

Outpatient hysteroscopy was performed with carbon dioxide or normal saline with endometrial biopsy when indicated.

MAIN OUTCOME MEASURES

Need for local anesthesia, cervical dilatation, view of uterine cavity, need to change from carbon dioxide to normal saline distension, procedure time, patient discomfort (lower abdominal pain, shoulder tip pain, nausea) and complications.

RESULTS

Carbon dioxide was used for uterine distension in 79 women and normal saline was used in 78. Cervical dilatation was required more often with carbon dioxide hysteroscopy, although there was no increased requirement for local anesthesia. Hysteroscopic vision was similar between the two media, but eight carbon dioxide cases had to be converted to liquid distension. Procedure times were significantly longer for carbon dioxide hysteroscopy as was the occurrence of bubbles during the procedure. Lower abdominal pain and shoulder tip pain were significantly worse with carbon dioxide distension. Although the incidence of nausea and vomiting was higher with the use of carbon dioxide, the differences did not achieve statistical significance.

CONCLUSION

The use of normal saline for uterine distension had no adverse affects on the hysteroscopic view. It provided a shorter operating time and was well accepted by patients. Because of its easy availability and low cost, normal saline is an excellent alternative to carbon dioxide in women undergoing outpatient hysteroscopy.

A series of 1000 consecutive out-patient diagnostic hysteroscopies

OBJECTIVE

To review the success of out-patient diagnostic hysteroscopy.

METHOD

Retrospective review of 1000 consecutive out-patient hysteroscopies.

RESULTS

Hysteroscopy was successfully performed in 96%. Cervical dilatation was required in 15.0% and local anaesthesia was administered in 31.4%; 77.3% of those requiring cervical dilatation received local anaesthesia. Intrauterine pathology was noted in 49.3%. The procedure failed in 40 (4%) patients for the following reasons: pain or anxiety in 23, cervical stenosis in 11, equipment failure in 4, and extreme uterine retroversion and inadvertent false cavity formation in one case each.

CONCLUSION

Out-patient diagnostic hysteroscopy is a safe, well tolerated and successful investigation procedure in the majority of patients and should be the procedure of choice for suspected intrauterine pathology.

Hysteroscopic findings in patients with a cervical polyp

OBJECTIVE

Our objective was to determine the presence of intrauterine lesions in patients with a cervical polyp.

STUDY DESIGN

We performed a retrospective analysis to determine the influence of hormonal treatment and age on 165 patients with a cervical polyp and bleeding on admission. All 165 patients underwent a diagnostic hysteroscopy to rule out intrauterine lesions, including polyps, fibroids, hyperplasia, and adenocarcinoma.

RESULTS

Endometrial polyps were found in up to 26.7% of patients who had a cervical polyp. In patients undergoing a combined pill treatment this incidence was much lower (8.3%). Menopausal patients had a 56.8% incidence of cervix-related endometrial polyps, and hormone replacement therapy did not significantly increase (45.7% vs 28.6%) the incidence of coexisting polyps. All cervical polyps present during tamoxifen treatment were associated with endometrial polyps. Abnormal vaginal bleeding was of no clinical significance in excluding concomitant endometrial polyps.

CONCLUSIONS

All menopausal patients with a cervical polyp could benefit from a diagnostic hysteroscopy. Premenopausal patients receiving a combined pill treatment are the least likely to have coexistent endometrial polyps.