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

Pain Management for In-Office Uterine and Cervical Procedures

SUMMARY

In-office gynecologic procedures, such as intrauterine device insertion, endometrial biopsy, hysteroscopy, intrauterine imaging, and cervical biopsy, among others, are common procedures experienced by many patients. There is an urgent need for health care professionals to have a better understanding of pain-management options and to not underestimate the pain experienced by patients and for patients to have more autonomy over pain-control options during in-office procedures. The way pain is understood and managed by health care professionals is also affected by systemic racism and bias of how pain is experienced. Specific populations, such as adolescents and those with a history of chronic pelvic pain, sexual violence or abuse, and other pain conditions, may also have increased or decreased tolerance of pain and resistance to pain medications. Several pain-management interventions being used have limited or conflicting evidence supporting their effectiveness at providing adequate pain control during in-office gynecologic procedures. Health care professionals therefore must be cautious when extrapolating data on what works for one procedure to another. Shared decision making with the patient should be practiced when discussing pain-management options because options that work for one patient may not work for another. Future research on pain and the management of pain must be more racially and ethnically diverse. Studies should include gender-diverse participants, focus on patient preferences and goals, and consider the needs of patients of various ages and those who have a history of trauma.

Effectiveness of lidocaine spray on radial arterial puncture pain: A randomized double-blind placebo controlled trial

OBJECTIVE

Radial arterial puncture is a painful procedure. The aim of this study was to evaluate the effect of lidocaine spray (10%) on pain associated with radial artery blood withdrawal for arterial blood gas analysis.

METHODS

This randomized, controlled, double-blind study was performed between December 2018 and September 2019. Before radial arterial puncture, 10% lidocaine or placebo spray was applied to each patient by the attending physician, who was blinded with regard to random assignment. The spray was administered six times on the site from a distance of 5 cm. After waiting for 5 min, a radial arterial puncture was performed routinely. The pain levels of patients during radial arterial puncture and 5 min after puncture were evaluated with the visual analog scale (VAS). The Wilcoxon test was used to compare pain scores during puncture.

RESULTS

The research was performed with 67 patients (34 patients in the lidocaine group, 33 patients in the placebo group) who were admitted to the emergency department and required ABG analysis. Forty-three patients were men, and 24 were women. The ages of the patients ranged between 19 and 86 years, and the mean (± standard deviation) age was 56.3 ± 16.6 years. Pain levels, as measured by VAS, were significantly lower in the lidocaine group (24.00 mm IQR:[14.75-33.75]) compared with the placebo group (33.00 mm IQR:[22.00-61.50]) during radial arterial puncture (p = 0.011).

CONCLUSIONS

The level of pain perceived during radial arterial puncture was significantly lower in those who were administered lidocaine spray. Lidocaine spray application can be used in pain management related to radial arterial puncture.

Endometrial Biopsy: Indications and Technique

Abnormal uterine bleeding is a frequent medical concern for premenopausal and postmenopausal patients. Endometrial biopsy is a safe, cost-effective option offered in the office setting. Although endometrial biopsy may result in insufficient tissue or false-negative results, data suggest that endometrial biopsy is 90% sensitive for endometrial cancer and 82% sensitive for atypical hyperplasia, with specificity of 100% for postmenopausal patients and similar results in premenopausal patients. Topical cervical analgesia and oral nonsteroidal anti-inflammatory drugs decrease a patient's discomfort during endometrial biopsy. Aftercare instructions and how patients want to receive results should be reviewed in advance of performing the endometrial biopsy.

10% lidocaine spray for pain control during intrauterine device insertion: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Various medications have been investigated for their efficacy in pain reduction during intrauterine device (IUD) insertion, but there is currently no standard recommendation. This study aimed to investigate the efficacy of 10% lidocaine spray in reducing pain during copper-containing intrauterine device (Cu-IUD) insertion.

METHODS

This study was a randomised, double-blind, placebo-controlled trial. Reproductive-age women were randomised at a 1:1 ratio into 10% lidocaine spray or placebo spray group. A 10 cm visual analogue scale (VAS) was used to evaluate pain during several steps of the IUD insertion procedure, and after the procedure.

RESULTS

One hundred and twenty-four women were included and 62 women were randomised in each group. Baseline characteristics between groups were similar. The 10% lidocaine spray group demonstrated significantly lower median VAS immediately after IUD insertion than the placebo group (2.95 (IQR=1.00-5.63) vs 5.00 (IQR=3.35-7.00), respectively; p=0.002). Similarly, women receiving 10% lidocaine spray reported significantly lower median VAS than those receiving placebo during tenaculum use and uterine sounding. The maximum median VAS occurred immediately after Cu-IUD insertion. The proportion of women who reported VAS≥4 during uterine sounding and after IUD placement was significantly lower in the 10% lidocaine group than in the placebo group (p<0.05). Median change in VAS from baseline to IUD placement was significantly different between 10% lidocaine spray group and placebo group (1.85 (IQR=0.08-4.03) vs 3.6 (IQR=2.40-5.80), respectively; p=0.004).

CONCLUSION

10% lidocaine spray was found to be an effective local anaesthetic method for reducing pain during insertion of Cu-IUD.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT03870711.

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.

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.

Lidocaine for pain control during intrauterine device insertion

AIM

The aim of this study was to compare the effects of topical lidocaine spray, cream and injection on pain perception during intrauterine device (IUD) insertion.

METHODS

Multiparous women of reproductive age were randomized into control, lidocaine cream, spray and injection groups. A 10 cm visual analog scale was used for all patients to evaluate pain during the three steps of the IUD insertion procedure. Baseline pain assessment was made immediately after the administration of analgesics, the second pain assessment was performed immediately after use of the tenaculum, and the third pain assessment was performed after IUD insertion.

RESULTS

Two hundred patients were enrolled in the study. The groups were similar in terms of demographic characteristics. The lidocaine injection group exhibited higher baseline pain scores (P < 0.001). Pain associated with tenaculum use was lower in the lidocaine spray group. Pain related to IUD insertion was lower in the lidocaine spray and injection groups (P < 0.001); however, lidocaine spray was superior to injection for the reduction of IUD insertion related pain (P = 0.001).

CONCLUSION

Lidocaine spray is a good option for reducing the pain experienced during insertion of an IUD. It reduces pain related to both tenaculum use and IUD insertion. Spray application is both easy and rapid. Paracervical lidocaine injection also reduces pain during IUD insertion, but has no effect on tenaculum-related pain; moreover, the injection itself is painful. Therefore, this option is not a plausible method for reducing pain during IUD insertion.