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Paracervical block reduces pain with IUD placement
Clinical Question
Does the use of a paracervical block for analgesia reduce the pain associated with intrauterine device placement?
Bottom line
Nulliparous women who underwent intrauterine device (IUD) placement after a paracervical block of 20 mL buffered 1% lidocaine rated pain significantly lower on a visual analog scale (VAS) compared with women who did not receive it. Although there was pain associated with the administration of the block itself, women in the group that received the block rated overall pain associated with the procedure as lower. 1b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Self-funded or unfunded
Setting: Outpatient (any)
Synopsis
Prior studies have suggested that a paracervical block using 10 mL buffered 1% lidocaine for placement of a 52-mg levonorgestrel IUD and copper T IUD is not sufficient for satisfactory analgesia. Since a 20-mL dose has been shown to be effective for other gynecological procedures, these authors conducted a randomized controlled trial using the larger dose to assess pain perception with IUD placement as compared with minimal analgesia only at the site of tenaculum placement (2 mL at 12 o'clock). Nulliparous women aged 18 to 45 years were eligible if presenting for IUD placement for either contraception or control of uterine bleeding. Women were excluded if they had any diagnosis of a chronic pain condition, had any history of prior IUD placement, used an oral analgesic within 6 hours prior to the procedure, or had misoprostol administered within 24 hours prior to the procedure. Randomization was concealed, and 64 women were masked, but it was not feasible to mask the clinicians. Outcomes were measured using a VAS: from 0 (no pain) to 100 mm (worst pain imaginable). The scores were significantly lower in the cervical block group for pain with IUD placement (mean 33 mm vs 47 mm, P = .002) and for overall pain perception (30 mm vs 51 mm; P = .015), though perceived pain at the time corresponding to block administration was greater (30 mm vs 8 mm; P = .003). Differences of 15 mm on the VAS are generally accepted as clinically meaningful. No adverse events were observed among women who received the block, though the study was not powered to detect relatively rare events.
Reviewer
Linda Speer, MD
Professor and Chair, Department of Family Medicine
University of Toledo
Toledo, OH
Comments
So we don’t know if this is better than misoprostil. Why not use both?
In my experience of placing IUDs over 35-40 years as a famiy doc, and from my point of view, the discomfort of tenaculum placement and subsequent cervical traction, appeared to be brief and well-tolerated. A paracervical block is another welcome tool to offer my patients but I am not convinced it should be a routine procedure, again, from my point of view, ie, the administrator, not the recipient of sharp, pointy instruments being used in my pelvic geography. I’m also unclear as to why the clinician cannot be blinded, with a ‘dummy’ injection. RM
Excellent
Question is placing IUD is painful procedure or not ? I know some patient tolerate it some do not . So we have to find patient who really need to use paracervical block to reduces pain with IUD. Pain is subjective perception and not universal sensation.
Paracervical block???
I too am a family doc with experience of inserting IUDs for more than 35yrs. The tenaculum goes on quickly, the sound goes in and the iud is then placed...all this takes a few minutes. Is it worth giving a needle with a stinging sensation, waiting to let this work and then continuing for minimal gain. The procedure is then much longer and in my experience, the patient is not at ease. She is lying there more anxious and still in some discomfort. I find that what has been more advantageous than a needle with stinging sensation is to warn my patient that the tenaculum is going on and they are going to feel a sharp prick NOW...then using a sound and telling them they are going to feel a very strong painful menstrual cramp NOW and then quickly exchanging the sound for the iud and telling them you are going to get one more strong menstrual cramp NOW...and I'm done. Stay lying down and just breathe slowly and gently. I then turn around and wash my hands and dispose of the packaging in the recycle bin and then back to the patient and say, OK, if when I put it in that was a 10 out of 10 bad pain, where are you now? a few say 7 or 8, 80% say a 3 , a few say 2 and a few say they have no pain now...it was really strong when you put it in and now I feel nothing...So, having done many thousands, I do not feel it worth it for me to use the local block....I do not think it should be routine.
As for misoprostil, the literature does not support it any more. I used to use it in nullips but the severe cramping and diarrhoea side effects were usually much worse than the supposed benefits. After the literature did not support it any more, I asked a gyne for advice...he said not to use so I switched to not using it and have found no difference in the insertion...I can get them in as easily and the patient is more comfortable without the misoprostil.
The biggest problem with this study is that it did not follow current practice. This includes use of NSAID analgesia and misoprostol the night before to facilitate insertion of the device. As a result I feel that the data is flawed and does not meet common practice. I would like to see data where the analgesia was given.
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