Pain Relief of Hysterosalpingography by Prior Uterine Cervical Application of Lidocaine/Prilocaine Cream

Abstract

Hysterosalpingography (HSG) is commonly a painful procedure. We sought to evaluate whether application of the local anesthetic lidocaine 25 mg, prilocaine 25 mg/G cream (EMLA® 5%) on the uterine cervix before performing HSG, relieves the pain associated with this procedure. A prospective cohort study to compare the perception of pain during HSG with no analgesia to the perception of pain following pre-operative application of EMLA® 5% to the uterine cervix. During a 1 yr study-period, 79 consecutive patients underwent HSG as part of infertility investigation. All patients were evaluated for the pain related to the procedure by a zero[=no pain] to ten[=worst pain imaginable] visual analogue scale (VAS). Pain was scored at five predefined steps: speculum application as baseline, at the cervical instrumentation by the tenaculum/canula, at the end of uterine filling, at the end of tubal spillage, and immediately following removal of instruments. In addition, on the next day, the patient was asked to score retrospectively the pain of the entire HSG procedure. The pain scoring method was designed by a ratio to the pain associated with that perceived during speculum application. In the first study period, 38 women underwent HSG without any analgesic treatment (control group). In the following period, 41 women were treated by topical application of 3 mL of EMLA® 5% cream on the uterine cervix using a cervical cup, 30 min before performing the HSG. The student’s t test was used to compare the pain scores at each step in the untreated-control group and the EMLA®-treated group, a P<0.05 was considered statistically significant. There was no difference in the baseline speculum application-pain in both study’s groups. Initial analysis of the procedure pain, enables us to define only two significant steps: 1.cervical instrumentation. 2.The following steps of HSG performance (uterine filling, tubal spillage and instruments removal). The cervical instrumentation was found to be more painful then the following steps, in both study groups (P<0.001). At this step the EMLA®-treated patients reported significantly less pain then the control group: 1.9 and 2.7 times the baseline pain, respectively (P=0.01). The score given retrospectively by the patient on the day after the HSG, correlated with the less painful step in the EMLA®-treated group (r=0.8, P=0.01) while in the untreated-control group it correlated with the more painful step (r=0.8, P=0.01). Topical application of EMLA® 5% cream on the cervix before HSG performance significantly reduces the pain associated with this procedure.