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Grand Rounds

Pain Control During In-Office Hysteroscopy: Nitrous Oxide vs Lidocaine vs No Analgesic

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BACKGROUND AND PURPOSE:

  • Solano et al. (BOJG, 2021) compared inhaled nitrous oxide vs 1% lidocaine paracervical infiltration vs no analgesic for pain control during in-office hysteroscopy

METHODS:

  • Single-blind stratified randomized clinical trial
  • Participants
    • Women undergoing hysteroscopy
    • Performed with 4.3 mm inner sheath, with working channel for semirigid 5 Fr. operating instruments
  • Interventions
    • Nitrous oxide | Mask or a buconasal pipette with on-demand intermittent flow, self-controlled by patient
    • 1% lidocaine | 12 ml used for pericervical and paracervical blocks
    • No analgesic | Needle touching cervico-vaginal fold but no puncture
  • Study design
    • Participants were stratified into 3 groups depending on indication (biopsy, polypectomy or tubal sterilization)
    • Pain was assessed by a gynecologist blinded to procedures and treatments
    • Intention-to-treat approach
  • Primary outcome
    • Pain control: Visual analog scale (VAS) from 0 to 100 mm

RESULTS:

  • Participants per group
    • Nitrous oxide group: 105 women
    • 1% lidocaine group: 104 women
    • No analgesic: 105 women
  • Baseline characteristics were comparable between groups
  • Mean VAS scores after the procedure
    • Nitrous oxide: 34.7 mm
    • 1% lidocaine: 36.1 mm
    • No analgesic: 47.3 mm
  • Mean VAS scores were significantly lower in the nitrous oxide (p=0.001) and 1% lidocaine groups vs no analgesic (p=0.010)
  • There was no significant difference in VAS scores between nitrous oxide and 1% lidocaine groups (p = 1.0)
  • At least 1 adverse event reported
    • Nitrous oxide: 13.4% of patients
    • 1% lidocaine: 25.0% (most commonly bleeding and pain at the puncture site)
    • No analgesic: 20.0%
  • Rescue analgesia or atropine were required  
    • Nitrous oxide: 3.8%
    • 1% lidocaine: 7.7%
    • No-analgesic: 14.3% (p=0.010 vs nitrous oxide and p=0.13 vs 1% lidocaine)

CONCLUSION:

  • Nitrous oxide and 1% lidocaine were both similarly effective at controlling pain during in-office hysteroscopy
  • Nitrous oxide was associated with fewer adverse events
  • The authors concluded that nitrous oxide has a better safety profile, is easier to administer and has

…an equivalent analgesic efficacy as the one shown by paracervical block with

lidocaine-1%, widely recognised as the standard treatment, for all in-office hysteroscopic procedures assessed

Learn More – Primary Sources:

Nitrous Oxide vs Lidocaine vs No‐analgesic for In‐office Hysteroscopy: A Randomised Clinical Trial

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Related ObG Topics:

Reducing Pain During Office Hysteroscopy: Voltaren vs Buscopan
Reducing Hysteroscopy Pain with Transcutaneous Nerve Stimulation  
Does Self-Administered Lidocaine Gel Reduce Pain During IUD Insertion?

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