Controlling Pain During Tubal Sterilization Using Hysteroscopy

According to the findings of a new intervention review and meta-analysis, neither paracervical block with lidocaine nor conscious sedation significantly reduced overall pain scores for tubal sterilization with hysteroscopy.¹

Performing tubal sterilization using hysteroscopy has significant advantages over using laparoscopy or mini-laparotomy, such as avoiding abdominal incisions and the convenience of having the procedure in an office-based setting versus an outpatient or hospital setting, explain the authors. The procedure involves a small metal microinsert that is placed into each fallopian tube under hysteroscopic guidance using a special catheter inserted through the vagina and into the uterus. The device has an inner coil made of stainless steel and polyethylene terephthalate fibers and an outer coil made of nickel-titanium. It works by “inducing” scar tissue to form over the implant, blocking the fallopian tube and thereby preventing fertilization of the egg by sperm. The fallopian tube typically is completely blocked after 3 months.

Because this procedure is office-based, one concern for many patients is pain management. To study the effectiveness of pain-reducing interventions, researchers analyzed 2 trials involving 167 participants in which the overall pain score or a summation of pain scores was the primary outcome. When comparing pain control using paracervical block with lidocaine versus normal saline, there was no difference in overall pain. In addition, the authors reported no differences for pain control between lidocaine and normal saline for the time of injection of the study solution to the anterior lip of the cervix, placement of the microimplant in the tubal ostia, and postprocedure. The procedure time and the rate of successful bilateral placement of the device were similar between study groups.

The use of paracervical block with lidocaine resulted in lower pain scores during certain portions of the procedure, which were placement of the tenaculum, administration of the paracervical block, and passage of the hysteroscope through the external and internal os. When conscious sedation and oral analgesia were compared, lower pain scores were reported by women who received conscious sedation at the time of insertion of the second tubal implant. However, the overall pain scores reported by women who received conscious sedation versus oral analgesia were not significantly different.

Pertinent Points:
- Although tubal sterilization is less invasive using hysteroscopy than when performed using abdominal surgery, women may experience more pain during hysteroscopy when it is performed in an office setting.
- The available data is insufficient to determine which form of analgesia or anesthesia provides the best pain control during tubal sterilization using hysteroscopy.
- Paracervical block with lidocaine and conscious sedation were associated with reduced pain during certain portions of the procedure.
- Neither paracervical block with lidocaine nor conscious sedation significantly reduced overall pain scores for hysteroscopy-guided tubal sterilization.

References:

1. Kaneshiro B, Grimes DA, Lopez LM. Pain management for tubal sterilization by hysteroscopy. Cochrane Database System Rev. 2012;8:CD009251.