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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