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    Pain management of office-based hysteroscopy

     

    Pain management

    Speculum placement

    Speculum placement can be uncomfortable and in some studies of women undergoing dilation and curettage, average pain scores with dry speculum placement have been reported to be as high as 34 mm (mild pain) on a 0–100-mm visual analog scale. Using gel can reduce the discomfort of speculum placement to 14 ±12 mm (minimal pain).5 We recommend putting a small amount of gel on both blades of the speculum before inserting.

    Cervical manipulation, cannulation, and dilation

    Local anesthesia

    Local anesthesia can help attenuate the pain of tenaculum placement, and cervical manipulation including cannulation and dilation. Different iterations of local anesthesia have been proposed, including injectable anesthesia such as a paracervical block (PCB) or intracervical block, and topical anesthesia such as lidocaine spray and intrauterine instillation. In a meta-analysis of these methods, injectable anesthesia was found to be effective at reducing procedural pain, but topical anesthesia was not.6 Local anesthesia with a PCB has been found to decrease pain with introduction of the hysteroscope during transcervical sterilization.7 Injectable anesthesia itself is known to cause discomfort, so in order to decrease this effect, we recommend using buffered lidocaine. This is created by adding 2 mL of sodium bicarbonate (Figure 1). Data are limited on the effect of waiting after the PCB and before starting the procedure. Extrapolating from studies of other common office-based procedures such as office dilation and curettage, we have found that waiting 3–5 minutes following injection does not improve procedural pain.8 In one study, pain associated with hysteroscopy and endometrial biopsy in postmenopausal women was reduced when the procedure was started 10 minutes after mepivacaine was used for PCB.9 While we do not wait between administering the PCB and starting the procedure, you may consider waiting in patients who are uncomfortable with the initial cervical dilation and manipulation.

    When administering local anesthesia, it is important to recognize the signs and symptoms of lidocaine toxicity. These include numbness or tingling around the mouth or face, tinnitus, and in extremely rare cases, cardiac dysrhythmias and seizures. Recommendations for maximum dosing state that providers should not exceed 4.5 mg/kg 1% lidocaine without epinephrine or 7 mg/kg 1% lidocaine with epinephrine.

    In our practice, we recommend intracervical injection of 2–3 cc of 1% buffered lidocaine at the anterior cervix prior to placement of the tenaculum. Following placement of the tenaculum, the remaining can be injected in equal aliquots at 4 and 8 o’clock at the cervicovaginal junction as a PCB. The PCB reduces pain associated with placement of the tenaculum and cervical dilation.7 Start your PCB by placing your needle below the paravaginal mucosa, aspirate, and inject 1–2 mL. Next, advance the needle through the area you have already anesthetized, aspirate and inject an additional 1–2 mL and keep going until approximately 9 mL have been injected.

    Once you start the procedure, if your patient is still having pain with cervical cannulation and dilation, consider injecting additional lidocaine until maximum dosing is attained (Figure 2) and/or inject 10–15 mL of normal saline instead. This second injection can be given paracervically or intracervically at 10, 2, 4, and 8 o’clock. While it is not an anesthetic, the distension of nerve innervation with saline can reduce pain.10

    Because local anesthesia affects only some aspects of the hysteroscopic procedure, other interventions are needed to address uterine distension, the release of prostaglandins, and pain of tubal manipulation during placement of the transcervical coils.

     

    Rameet Singh, MD, MPH
    Dr Singh is Chief, Division of Family Planning at University of New Mexico School of Medicine, Albuquerque.
    Lauren Thaxton, MD, MBA
    Dr Thaxton is Family Planning Fellow at University of New Mexico School of Medicine, Albuquerque.

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    • [email protected]
      Great article. Succinct. I use almost all those strategies with great success. One woefully missing aspect of the article is the discomfort that can arise with patient and physician in regards to patient positioning. Having your feet in regular metal stirrups for 20-30 minutes can be uncomfortable and downright dangerous when a patient is sedated. Comfortable and secure positioning is important with every case. Besides spending $10-$15k on a procedure table (which negates your in-office reimbursements), surgeons can employ tools like the GStirrup. Patients can easily dose-off during these procedures, and secure placement of their legs is crucial to your reputation and to the patient's satisfaction with the procedure.

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