BACKGROUND AND PURPOSE:

• There is no standard of care for pain management for nulliparous women undergoing IUD insertion
• Mody et al. (Obstetrics & Gynecology, 2018) assessed whether lidocaine paracervical block reduces pain during intrauterine device (IUD) placement

METHODS:

• Randomized single-blinded (to participants) placebo-controlled trial (RCT)
• Participants
  • Women receiving an IUD for contraception or abnormal bleeding
  • Ages 18-45
• Women received either
  • 20-mL buffered 1% lidocaine paracervical block
    • 8 mL of 1% lidocaine buffered with 2 mL 8.4% sodium bicarbonate
    • 2 mL: Tenaculum at 12 o’clock
    • 18 mL: Vaginal fornices equally at 4 and 8 o’clock
  • No block
• Blinding achieved using the following language
  • “You may or may not feel something”
  • Saline control not used because distention from saline can provide relief and not a true placebo
• Primary outcome
  • Pain with IUD placement measured on a 100-mm visual analog scale
• Secondary outcomes included
  • Pain with speculum placement, paracervical block administration and tenaculum placement at 5 minutes post procedure
  • Overall pain perception
• Statistics
  • Sample size had 80% power to detect a 20-mm difference in visual analog scale scores (α=0.05)

RESULTS:

• 64 women were enrolled and analyzed
  • 33 in the paracervical block arm | 31 in the no-block arm
• Women who received the paracervical block reported less pain with IUD placement (P=.002)
  • Paracervical block: 33 mm
  • No block: 54 mm
• Pain was significantly less in the block group for
  • Uterine sounding (30 mm vs 47 mm, P=.005)
  • 5 minutes after placement (12 mm vs 27 mm, P=.005)
  • Overall pain perception (30 mm vs 51 mm, P=.015)
• Participants who received the paracervical block experienced more pain (P=.003) with block administration
  • Paracervical block: 30 mm
  • No block: 8 mm
• There was no perceived pain difference for speculum insertion or tenaculum placement
• In the no block group, women reported more often that IUD pain was worse than expected
  • Paracervical block: 1.6%
  • No block: 14.1%
• In the paracervical group vs no block, women more often reported
  • No pain (10.9% vs 1.6%)
  • Pain not as bad as expected (29.7% vs 18.8%)

CONCLUSION:

• • 1% lidocaine (20mL) administered prior to IUD insertion lead to overall lower perceived pain
  • This study also provides valuable counseling information for those who opt for the lidocaine block

…the patient may be informed during counseling that the paracervical block typically does cause some pain (30 mm on a 100-mm scale), but that the paracervical block reduces pain with IUD placement, pain 5 minutes after the procedure, and perceived pain for the overall procedure.

Learn More – Primary Sources:

Paracervical Block for Intrauterine Device Placement Among Nulliparous Women: A Randomized Controlled Trial.

Related ObG Topics:

ACOG & SMFM Guidance on the Use of IUDs and Contraceptive Implants

IUDs and Implants: How to Manage Potential LARC Complications

Outcomes after Immediate Postpartum IUD Insertion