Pain management options (or lack thereof) during routine gynecologic procedures has
become a women's health concern with growing prominence. Patients increasingly are
reporting their "excruciating" pain experiences from gynecologic procedures ranging from
pap smears to intrauterine device placements. When pain during gynecologic procedures is
not well managed, gynecologic care quality and frequency suffers - one study found that
in a group of middle-aged black women, those who perceived pap smears to be painful were
almost five times more likely to not adhere to regular pap screening recommendations.
Women, similarly, may avoid other elective gynecologic procedures, such as intrauterine
device placement or saline infusion sonograms, out of fear of pain during the procedure.
Recent evidence has found that local anesthesia can significantly reduce pain during
certain procedures, such as surgical abortion and intrauterine device placement (IUD).
For example, in two randomized controlled trials of nulliparous women undergoing
intrauterine device placement, a 10-20cc buffered 1% lidocaine paracervical block
decreased pain during and following IUD placement. However, this reduction in pain may
not be significant in multiparous women-in systematic review and meta-analysis of
randomized clinical trials (RCTs) of pain management options for women undergoing IUD
placement, paracervical blocks were not found to reduce pain in a statistically
significant fashion. In women undergoing surgical abortion, a 20cc 1% lidocaine injection
significantly reduced pain during dilation and aspiration regardless of parity status.
In reproductive endocrinology and infertility offices, saline infusion sonogram is often
performed in the evaluation of uterine cavity and patency of the fallopian tubes. This is
a procedure that is demonstrated to cause mild to moderate pain in most patients. These
procedures do not standardly receive any local anesthesia, though many practices will
recommend an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) prior to
procedure. Although no previous study has been published on NSAIDs specifically, a
prospective observational study did find that pre-medication of paracetamol + codeine
prior to saline ultrasound assessment of uterine cavity and tubal patency significantly
reduced pain.
While local anesthesia is not routinely offered during these saline infusion sonograms,
several studies have investigated its potential effect. One randomized controlled trial
assessed the pain relief effect of topical and intrauterine lidocaine during saline
ultrasound, and found no difference in pain compared to placebo. Of note, these saline
ultrasounds were only for cavity evaluation, not tubal evaluation, and therefore did not
utilize a balloon catheter. Another randomized controlled trial of 96 Turkish women found
that paracervical block significantly reduced pain during saline infusion sonogram
compared to the placebo group. However, of note, this protocol utilized a tenaculum,
which is not routinely used in saline infusion sonograms in the United States for
fertility evaluation. Additionally, the catheter diameter used was wider than is used in
the clinic (4mm versus 1.67mm). This study also did not appear to evaluate for tubal
patency, as the catheter described was not a balloon catheter.
In this study, the investigators aim to add to the existing literature on pain management
during saline infusion sonograms to determine if lidocaine paracervical blocks decrease
perceived pain in saline ultrasounds that assess for uterine cavity and tubal patency.
This will be accomplished by determining if paracervical block provides clinically
significant pain relief compared to no anesthesia during saline ultrasound evaluation of
uterine cavity and tubal patency.