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#Grand Rounds

Reducing Pain During Office Hysteroscopy: Voltaren vs Buscopan

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BACKGROUND AND PURPOSE:

  • A recent Cochrane review found the NSAIDs did not reduce pain associated with hysteroscopy although still recommended by some professional organizations to be taken 1 hour prior to procedure  
  • Buscopan (hyoscine-N-butyl bromide [HBB]) is an antispasmodic and could potentially reduce uterine spasms associated with the procedure
  • Abbas et al. (Journal of Minimally Invasive Gynecology, 2019) compared the efficacy of oral the NSAID diclofenac potassium (Voltaren) vs HBB for pain management during hysteroscopy

METHODS:

  • Randomized double-blind placebo-controlled trial (RCT)
    • Outpatient setting
  • Participants
    • 18 to 50 years
    • BMI between 18 and 30 kg/m 2
    • American Society of Anesthesiologists physical status I to II
    • Clear indication for the procedure (e.g., AUB)
  • Intervention groups (All tablets were taken orally 1 hour before procedure)
    • Diclofenac group: 50mg diclofenac potassium tablets
    • HBB group: 20mg HBB tablets
    • Placebo group: Placebo tablets
  • Primary outcome
    • Participant’s self-rated pain perception during the procedure using 10-point visual analog scale (10 equals worst imaginable pain)  
  • Secondary outcomes
    • Visual analog scale score immediately and 30 minutes after procedure
    • Ease of procedure (clinician assessment where 10 equals terribly difficult procedure)
    • Duration of procedure
    • Adverse medication effects

RESULTS:

  • 129 patients | 43 in each group

Pain During Procedure

  • Both the diclofenac and HBB groups showed significant pain score reduction compared with the placebo group (p = 0.001)
  • Diclofenac group mean pain scores were significantly less than HBB group (p = 0.002)
    • Diclofenac group:  2.12 ± 1.03
    • HBB group: 3.02 ± 1.55  

Pain Immediately After Procedure

  • Both the diclofenac and HBB groups showed significant pain score reduction compared with the placebo group (p = 0.001)
  • Diclofenac group mean pain scores were significantly less than HBB group (p = 0.024)
    • Diclofenac group:  1.23 ± 0.57
    • HBB group: 1.56 ± 0.73
  • No statistical differences noted 30 minutes after the procedure    

Ease of Procedure

  • Clinicians reported significantly better ease of procedure vs placebo in both the diclofenac (p = 0.003) and HBB groups (p = 0.005)

Mean Duration of Procedure

  • Longer in the placebo group (6.88 minutes), but no significant difference noted between diclofenac (4.65 minutes) and HBB group (5.23 minutes)

Adverse Effects of Medication

  • HBB group
    • 14 women (32.6%) experienced dizziness and 2 women (4.6%) had nausea
  • Diclofenac group
    • 4 women (9.3%) in the diclofenac group had dizziness and 2 women (4.6%) had vomiting

CONCLUSION:

  • Diclofenac improved patient perceived pain during and immediately after hysteroscopy and reduced procedure time

Learn More – Primary Sources:

Oral Diclofenac Potassium Versus Hyoscine-N-Butyl Bromide in Reducing Pain Perception during Office Hysteroscopy: A Randomized Double-blind Placebo-controlled Trial

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Related ObG Topics:

Hysteroscopy Guidelines
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Does Self-Administered Lidocaine Gel Reduce Pain During IUD Insertion?
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