|Year : 2019 | Volume
| Issue : 3 | Page : 780-784
Intracervical local anesthesia versus NSAID analgesics for pain relief during office hysteroscopy
Olfat Nouh1, Hala A Wahab1, Mazen A El Zahry2, Hossam El Ktatny3
1 Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
2 Obstetrics and Gynecology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
3 Faculty of Medicine Assuit University, Egypt
|Date of Submission||26-Nov-2019|
|Date of Decision||30-Nov-2019|
|Date of Acceptance||17-Dec-2019|
|Date of Web Publication||10-Feb-2020|
Mazen A El Zahry
Al Azhar University, Cairo
Source of Support: None, Conflict of Interest: None
Introduction Office hysteroscopy provides great predictive value for multiple patients categorized as having infertility, abnormal uterine bleeding (AUB), or missed intra uterine contraceptive device (IUCD); however, pain during procedure is still a hindering problem. Multiple studies were done, but still no clear evidence-based data have been settled.
Aim To compare intracervical injection of mepivacaine hydrochloride versus intramuscular injection of NSAIDs before hysteroscopy procedure in office hysteroscopy.
Patients and methods This was a single-blind randomized comparative study. Both sample size and randomization were done by a computer program. Patients were classified into two groups: group 1 was subjected to intracervical injection of 5 ml of mepivacaine hydrochloride at position 4 and 8 o’ clock of the vaginal portion of the cervix, at least 15 min before procedure was done, and group 2 received NSAID intramuscular injection 15 min before the procedure. Hysteroscopy was done, and if any abnormality was detected, an intervention was done. A descriptive scale of pain was used, classified as mild, moderate, or severe (assigned by interruption of the procedures).
Results There was a statistically significant difference between both groups in the three pain grades. However, there was no statistically significant difference between both groups for vomiting. In spite of number of operative cases being low in both groups, the number in study group was double that of control. However, pain during cervical handling and bleeding were two remarkable annoying factors owing to lengthy procedures and occasional considerable bleeding.
Conclusion Intracervical injection of a local anesthetic is an effective method in reducing pain during hysteroscopy but time of procedure should be taken into consideration.
Keywords: intracervical anesthesia, outpatient hysteroscopy, pain
|How to cite this article:|
Nouh O, Wahab HA, El Zahry MA, El Ktatny H. Intracervical local anesthesia versus NSAID analgesics for pain relief during office hysteroscopy. Sci J Al-Azhar Med Fac Girls 2019;3:780-4
|How to cite this URL:|
Nouh O, Wahab HA, El Zahry MA, El Ktatny H. Intracervical local anesthesia versus NSAID analgesics for pain relief during office hysteroscopy. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Feb 29];3:780-4. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/780/278030
| Introduction|| |
Hysteroscopy even though diagnostic is a painful procedure; however, tolerability and acceptance among patients is quite variable .
Office hysteroscopy has substituted many of the diagnostic and invasive therapeutic tools. However, the issue of pain encountered during procedure and need to referral for general anesthesia is still not solved. Moreover, variation in study design has added to the problem of being able to reach an evidenced-based protocol. Need to understand mechanism of pain transmission during procedure is important to choose proper technique and desired dose. Many papers have studied the effect of local anesthesia on pain relief during hysteroscopy procedures.
Mechanism of nerve supply of the uterus has been properly studied. Uterus has motor and sensory nerve supply, sympathetic and parasympathetic. It is known that body of uterus is sensitive to distension, and cervix is sensitive to dilation and stretch, whereas both are insensitive to touch, cutting, and burning. Uterus receives nerve supply from sympathetic nervous system through T5 and T6 motor neurons, T10, T11, and T12, and L1 sensory neurons, and parasympathetic through S2, S3, and S4. All reach uterus through branches of inferior hypogastric plexus (Franken Hauser plexus) .
Paracervical block has been widely used for anesthesia of upper vagina, cervix, and lower uterine segment. By injecting 5–10 ml of local anesthetic agent, each side 2–3 ml in right and left lateral fornix at 4 o’clock and 8 o’clock position, then wait for 5–10 min. Complications such as paracervical hematoma, subgluteal abscess, and postpartum neuropathy have been reported .
A systematic review comparing different methods of local anesthesia, paracervical, intracervical, topical, transcervical, and intracavitary, has been done. Procedures like hysteroscopy and endometrial curettage were done. They concluded that paracervical anesthesia is the best for pain control during hysteroscopy as an outpatient procedure. All papers used different methods for pain assessment; some used continuous visual analog scale, and others used ordinal, numerical, or descriptive scale. However, hysteroscopy was associated with endometrial curettage, so it was not standardized so it was a long procedure that interferes with standardization of results . In our study, the procedure was hysteroscopy whether diagnostic or operative dose without endometrial curettage.
| Patients and methods|| |
This was a single-blind randomized controlled study done at Kasr Al-Ainy from May 2018 to August 2018. A total of 80 patients were enrolled in the study and randomly assigned into two groups. The sample size was calculated by a computer program with reference to power of study 80%, confidence interval 95%, SD 0.5, and needed change to shift severe degree pain descriptive scale to mild degree. Numerical descriptive method was compared to numerical continuous visual analog scale, so needed change was 9. Patients were divided randomly by computer into two groups: study and control.
Ethics approval and funding: this was a self-funded study and was approved by the Ethical Committee of Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, number: I18002.
Patients coming for hysteroscopy, under 40 years of age, with no history of renal or hepatic disease, no hypersensitivity to local anesthetic agents, and no significant vaginal or cervical infection were included.
All patients not fulfilling inclusion criteria were excluded. Cases were randomized by a computer program.
The study group received intracervical mepivacaine hydrochloride, and the control group received intracervical saline injection and NSAIDs oral 15 min before the procedure.
Primary outcome was absence of pain completely during outpatient hysteroscopy and complete procedure without interruption. Secondary outcome includes incidence of vasovagal stimulation with and without local anesthesia.
All patients were subjected to history taking and verbal consent to participate in our study. Patients were allocated to either study group or control group by a computer program. Patients were put in a lithotomy position. Casco speculum was applied exposing the cervix, and betadine sterilization of the cervix was done. Then, it was properly washed with saline as heavy metals of disinfectant may cause irritation with injection. Multiple toothed vulsellum was used just to fix cervix. Group 1, the study arm, was given three cartridges of mepivacaine hydrochloride filled in 10-ml syringe, and the control arm was given NSAID diclofenac sodium oral tablet 15 min before the procedure and intracervical injection of 5 ml saline as in study arm. Aspiration was done first to exclude and avoid intravascular injection then infiltrate slowly intracervically at both four and eight positions. Instruments are removed and at least 5 min later procedure was started. Hysteroscopy (rigid, 2.9 mm sheath) was introduced gently through vaginoscope entry, exploring vagina, cervix, and uterine cavity. Patients were monitored for pain all through the procedure by descriptive scale: mild, moderate, and severe (moderate, who needed to take rest then continue, and severe, who necessitated interruption of the procedure). All patients were monitored for signs of vasovagal attack (low blood pressure and bradycardia) before and if needed during the procedure. Occurrence of symptoms such as pallor, sweet, and fainting was noted. All patients were monitored after procedure for persistence of colicky pain.
| Results|| |
A total of 80 patients were enrolled in our study with 50 in the study group who were given three cartridges of mepivacaine hydrochloride filled in 10-ml syringe, and 30 patients in the control arm, who were given NSAID diclofenac sodium oral tablet 15 min before the procedure and intracervical injection of 5-ml saline as in the study arm ([Table 1],[Table 2],[Table 3]).
|Table 2 Demonstrates a significant difference of pain grades in control group versus study arm with P value of 0.001|
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|Table 3 A significant difference between number and percent of people with interruption of procedures in each group, more in control than in study group, with a P value of 0.001|
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| Discussion|| |
A total of 80 cases were enrolled in our study: 50 in the study group with intracervical injection of 5-ml mepivacaine hydrochloride 162 mg, and 30 in the control group, given NSAIDs and placebo (saline intracervical injection). We used descriptive analysis for pain scale.
Our study found that this technique is effective in pain control, with significant P value of less than 0.001. Risk of interruption of procedure was more in the control group than in the study group, with a significant P value less than 0.001.
The study was conducted on both diagnostic and therapeutic cases, but operative cases were smaller in number. This is owing to the fact that cases were randomly distributed without any previous knowledge of their history or predicting the possible needed intervention. Meanwhile bias was minimized.
On the contrary, many factors were considered troublesome during the procedures that superimpose the importance and superiority of general anesthesia, such as insertion of a speculum. Grasping of the cervix and bleeding at site of cervical injection were adverse effects of our technique regarding pain, time consumption, and blood loss.
Hysteroscopy even though diagnostic is a painful procedure; however, tolerability and acceptance of patients are quite variable. However, every patient is studied and assessed as a separate case according to procedure to be done, expected time needed, tolerability of a particular patient to pain, and then finally, patient counseling is the mainstay for decision making .
Malcolm in 2010 compared the effectiveness of different methods of local anesthesia as pain control during hysteroscopy procedure only in diagnostic cases and concluded that paracervical is the most effective. However, they concluded that other techniques of local cervical anesthesia are not evaluated properly because of limitation of technique and heterogeneity of research design .
Vercellini and colleagues, examined the effect of paracervical anesthesia in pain relief during outpatient hysteroscopy and endometrial biopsy. They concluded that it is not effective in completing procedure without pain. However, addition of endometrial biopsy to hysteroscopy procedure may be the cause of patient intolerability .
Lau and colleagues disagreed with the previous study. He did an RCT on effectiveness of paracervical anesthesia in hysteroscopy procedure and concluded that it is not only effective but carries risk of complications such as inadvertent intravascular injection. However, this adverse effect can be easily avoided by carful administration and routine aspiration before injection to avoid an expected intravenous injections .
Al-Sunaidi and Tulandi compared anesthetic effect of local intracervical versus combined local and paracervical. He concluded that both were comparable but combined method was associated with less pain ,. In comparison to this study, ours was more simple with comparable results.
O’Flynn et al.  did a meta-analysis conducted on different methods of local anesthesia during outpatients hysteroscopy, and they concluded that there was a significant reduction of pain score in all types than placebo.
Brix et al.  compared paracervical and sedation to general anesthesia and concluded that local anesthesia with sedation can be recommended as a first-choice anesthetic technique for operative ambulatory hysteroscopy.
Centini et al.  compared postoperative outcome between paracervical block and intravenous sedation versus general anesthesia in hysteroscopy polypectomy and found significant reduction in operative time, with P value less than 0.014 and significant reduction in pain during daily activity and walking of P value less than 0.001.
Asgari and colleagues compared paracervical block and intravenous conscious sedation versus general anesthesia as control, and he concluded that both are comparable in reducing pain and have great advantage of low risk in comparison with general anesthesia. This procedure was superior to general anesthesia regarding complications and allows to complete the procedure with minor degree of pain .
Conclusion and recommendations
Outpatient hysteroscopy is a painful procedure whether diagnostic or therapeutic with intervention. A method of anesthesia should be offered. Local anesthesia is a good and safer alternative to general anesthesia. Cost wise and time are important for selection of best method of anesthesia for every patient. We suggest a larger trial to be done with the addition of mild conscious intravenous anesthesia to intracervical injection that may increase the effect even in prolonged procedures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]