Clinical Review

2015 Update on minimally invasive gynecologic surgery

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How to reduce patient anxiety and pain during in-office hysteroscopy

In this Article
— Innervation of the uterus
— Pain scores associated with specific hysteroscopic procedures



Office hysteroscopy offers many benefits and is becoming more acceptable among patients and gynecologists for both diagnostic and operative procedures (TABLE 1). Despite its clear advantages, however, many gynecologists remain hesitant to perform in-office procedures out of fear that the patient, who is generally awake, will experience significant discomfort.

Certainly, pain and low patient tolerance of discomfort have been the primary limitations to widespread use of office hysteroscopy without anesthesia.1 Data on the use of anesthesia for office hysteroscopy—especially diagnostic procedures—historically have been inconsistent in regard to the reduction of patient discomfort.2

Bettocchi and Selvaggi first reported a vaginoscopic approach to diagnostic hysteroscopy to reduce the discomfort of the procedure, compared with the conventional approach. They did not place a vaginal speculum or tenaculum and, therefore, avoided placing local anesthetic into the cervix.3

A randomized controlled trial by Sagiv and colleagues found reduced pain during diagnostic hysteroscopy with vaginoscopy (VIDEO).4

Vidyard Video

In 2004, Bettocchi and colleagues reported nearly 5,000 operative hysteroscopic procedures performed with this technique (the “no-touch” technique) in an outpatient setting, demonstrating very high patient tolerance and a low degree of procedural pain. More than 90% of patients experienced little to no pain, except for those undergoing ­polypectomy when the polyps were larger than the diameter of the cervical os, as well as those who had anatomic abnormalities, with moderate discomfort reported by 33.2% and 12.7% of these women, respectively.5 These few patients may have benefited from anesthetic intervention for the procedure.

In a 2010 review of the literature on hysteroscopy without anesthesia, Cicinelli found that diagnostic hysteroscopy was more successful, with less patient discomfort, when smaller hysteroscopes were used (3.5 mm or smaller, including flexible lenses) and when the approach was vaginoscopic.1 Reduced pain with operative procedures was associated with a number of variables, including:

  • increased surgeon experience
  • smaller instrument size
  • shorter duration of the procedure
  • premenopausal status.

Variables associated with increased pain during operative procedures included:

  • chronic pelvic pain
  • menopausal status
  • previous cesarean delivery
  • significant anxiety.

In the review, Cicinelli noted that not all patients are likely to have a successful hysteroscopic procedure without the use of anesthesia or analgesia, regardless of the approach used.1

Only 1 randomized controlled trial explored the use of anesthesia (versus placebo) during operative hysteroscopy, and the authors found a benefit for preprocedural paracervical block using local anesthetic to reduce cervical pain.6

The success of diagnostic and operative hysteroscopic procedures with minimal and acceptable levels of patient discomfort in the office depends, therefore, on multiple factors. Procedural factors affecting the outcome of hysteroscopy include the size of the instrument used, the type and length of the procedure, the use of preprocedure anesthesia or analgesia, and a vaginoscopic approach. The skill of the surgeon also affects the hysteroscopic experience and outcome. In addition, patient variables such as menopausal status, anatomic distortion (eg, cervical stenosis), and anxiety may adversely affect the patient’s experience.

In summary, it is possible for the gynecologist to appropriately accommodate any given patient and clinical scenario, keeping in mind that many patients will require a customized approach for ultimate success. In this article, I review 3 recent studies on office hysteroscopy, focusing on the reduction of procedural pain and anxiety. Because of the protective effect of a high degree of surgeon experience, it is important that we offer adequate education in hysteroscopy during residency and postgraduate courses.

Placement of local anesthetic at multiple anatomic sites facilitates patient comfort during hysteroscopy

Keyhan S, Munro MG. Office diagnostic and operative hysteroscopy using local anesthesia only: an analysis of patient reported pain and other procedural outcomes. J Minim Invasive Gynecol. 2014;21(5):791–798.

In a 2010 review of randomized controlled trials of the use of local anesthesia versus placebo during hysteroscopy, data from several studies indicated a significant decrease in procedural pain when local anesthesia was given, while other studies found no difference.2 Most of the studies in that review evaluated a single site of anesthesia placement and focused on diagnostic hysteroscopy. The findings of that review, as well as the differential innervation of the uterine cervix and fundus (FIGURE), prompted Keyhan and Munro to evaluate the efficacy of multimodal local anesthetic for office diagnostic and operative hysteroscopy without the use of any systemic agents except for preprocedural cyclooxygenase (COX) inhibitors (TABLE 2). Accordingly, they placed local anesthetic at multiple anatomic sites to alleviate patient pain and improve procedural success in a spectrum of office-based hysteroscopic procedures.

Details of the trial
Procedures generally were performed using a continuous-flow sheath with an outside diameter of 5.5 mm and a 5 French operative channel for placement of operative instruments such as scissors, graspers, and sterilization microinserts. Normal saline or sterile water was used as the uterine distention medium, with gravity inflow assisted by pressure cuff, when necessary. Occasionally, a sheath system with an outside diameter of 6.5 mm was used, or an outside diameter of 9 mm for resectoscopic procedures using a bipolar radiofrequency resectoscope. When needed, cervical dilation was performed to accommodate the specific instrument used.

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Local anesthesia for uterine procedures

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