Surgical Techniques
Hysteroscopic myomectomy using a mechanical approach
Compared with resectoscopy, the mechanical approach offers improved visualization and requires fewer insertions of the hysteroscope, shortening...
The impact of the multimodal, multisite anesthetic protocol was evaluated using contemporaneous patient reporting of numeric pain scores (worst pain experienced) that included anesthesia-related pain, procedure-related pain, and overall pain.
A total of 478 women underwent 535 procedures. A patient verbal response scale (range, 0–10) was used to assess the worst pain experienced. The overall mean (SD) procedure pain score was 3.7 (2.5). The mean score for patients undergoing diagnostic hysteroscopy was 3.2 (2.5), and it was 4.1 (2.5) for operative hysteroscopy (P<.001).
TABLE 3 shows the procedures performed under the anesthetic protocol. Pain associated with placement of anesthesia was similar for diagnostic and operative procedures (mean score, 2.7), but the mean overall pain scores for diagnostic procedures were about 1 unit less than for operative procedures, regardless of age or delivery history.
Complications were limited to 3 transient vasovagal episodes. Five procedures could not be completed because of intolerable pain or inability to access the uterine cavity. There was no difference in pain scores between menopausal and premeno-pausal women.
Malcolm G. Munro, MD, offers a protocol for pain relief during hysteroscopy
In this video, Malcolm G. Munro, MD, makes use of both topical and injectable lidocaine at 5 anatomic sites
Dr. Munro is Professor of Obstetrics and Gynecology at the David Geffen School of Medicine at UCLA and Director of Gynecologic Services at Kaiser Permanente, Los Angeles Medical Center, in Los Angeles, California.
When placing anesthesia at multiple sites, allow time for onset of action
Keyhan and Munro demonstrated that successful completion of hysteroscopic procedures in the office environment can be achieved with acceptable levels of patient discomfort using a multimodal, multisite approach for preemptive placement of local anesthetic in the vagina, cervix, and endometrial cavity. They emphasize that the waiting time allotted for the onset of anesthesia is critical to the success of this approach. They also stress that no preprocedure oral sedative or narcotic is used with their approach. In addition, they note that the minimal discomfort experienced during placement of local anesthetic was overshadowed by general comfort during the wide spectrum of procedures performed.
What this EVIDENCE means for practice
The placement of preemptive local anesthesia at multiple anatomic sites facilitates diagnostic and operative hysteroscopy with an acceptable degree of patient comfort and successful completion of office procedures.
Music may reduce patient anxiety during hysteroscopy
Angioli R, De Cicco Nardone C, Plotti F, et al. Use of music to reduce anxiety during office hysteroscopy: prospective randomized trial. J Minim Invasive Gynecol. 2014;21(3):454–459.
Angioli and colleagues set out to address another factor that can impede patient comfort during office hysteroscopy—anxiety. Their randomized prospective trial is the only such trial evaluating the use of music to establish a calm and relaxing environment prior to office hysteroscopy for patients who are awake. Music supports an environment that “stimulates and maintains relaxation, well-being, and comfort and can be used as a self-management technique to reduce or control distress,” Angioli and colleagues write. The theory is that music distracts the patient by drawing her attention away from negative stimuli, thereby reducing pain, anxiety, and stress.
Details of the trial
A standardized visual analog scale (range, 0–10) was used to assess patient discomfort, and a State-Trait Anxiety Inventory (STAI; range, 20–80) also was given. Both tools were administered at baseline. The visual analog scale was measured again during the procedure, and the STAI was administered again after the procedure.
A hysteroscopic sheath with an outside diameter of 5 mm was used with a 5 French operative channel, and a vaginoscopic approach was used for each hysteroscopic procedure. A total of 372 women were enrolled and randomly allocated to either:
- music group (n = 185)
- no-music group (n = 187).
The surgical procedure was not completed in 15 patients (9 in the music group and 6 in the no-music group) because of stenosis of the cervix and/or excessive pain.
Women in the music group were allowed to select a playlist of classical, pop, jazz, or rock music that was played through a speaker system in the room. Of these patients, 50% preferred classical, 45% preferred pop, 5% chose jazz, and none selected rock music.
There were no statistically significant differences between the 2 groups in terms of preprocedure wait time, preprocedure scores on the visual analog scale or STAI, preprocedure vital signs, patient characteristics, type of procedure, or duration of the procedure. However, the music group had a lower visual analog score during the procedure and a lower postoperative STAI for diagnostic hysteroscopy than the no-music group did. The music group also had a statistically significant lower visual analog score for operative hysteroscopy than the no-music group did. In addition, the music group had a lower postoperative STAI score than the no-music group, but this difference was not statistically significant (TABLE 4).
