I have no disclosures Sa ra Whe tsto ne , MD, MHS Unive rsity o f - PDF document

Gynecology Office Procedures: Maximizing Efficacy and Pain Control I have no disclosures Sa ra Whe tsto ne , MD, MHS Unive rsity o f Ca lifo rnia , Sa n F ra nc isc o A day in the office… A day in the office…  Utilize 2 e vide nc e -b a se d stra te g ie s fo r pa in re duc tio n during o ffic e g yne c o lo g ic D AILY S CHEDULE pro c e d ure s Tuesday Date: 7/3/18 T ime Visit Objectives 8:00 AM Fo llo w-up - Pe lvic pa in  De sc rib e the ste ps fo r 2 8:30 AM Ce rvic a l po lyp re mo va l c o mmo n g yne c o lo g ic 8:45 AM IUD re mo va l pro c e d ure s (so tha t yo u c a n d o 9:00 AM E nd o me tria l b io psy the m in yo ur pra c tic e 9:30 AM IUD inse rtio n E to no g e stre l impla nt inse rtio n & suc c e ssfully a nd pa inle ssly) 10:00 AM re mo va l 10:30 AM Ma nua l ute rine a spira tio n

Innervation of the pelvis Innervation of the pelvis 8AM –  Sympathetic fibers (T10-L2)  Sympathetic fibers (T10-L2) innervate the fundus innervate the fundus Follow-up -  E  E nte r ute ro sa c ra l lig a me nts via infe rio r nte r ute ro sa c ra l lig a me nts via infe rio r hypo g a stric ple xus hypo g a stric ple xus  E  E nte r via ne rve s fro m o va ria n ple xuse s a t the nte r via ne rve s fro m o va ria n ple xuse s a t the c o rnua c o rnua Pelvic pain  Parasympathetic fibers (S2-S4)  Parasympathetic fibers (S2-S4) innervate the lower uterine innervate the lower uterine segment, cervix, and upper segment, cervix, and upper vagina vagina  Prima rily fro m the F  Prima rily fro m the F ra nke nha use r ple xus ra nke nha use r ple xus  T  T ra ve l to the ute rus a nd c e rvix via the c a rd ina l ra ve l to the ute rus a nd c e rvix via the c a rd ina l lig a me nts lig a me nts Nociception ≠ Pain Nociception ≠ Pain  Myo me tria l inne rva tio n fo llo ws b ra nc he s o f  Myo me tria l inne rva tio n fo llo ws b ra nc he s o f Additional Additional the ute rine a rte ry the ute rine a rte ry  Ne rve s e xte nd thro ug h myo me trium to  Ne rve s e xte nd thro ug h myo me trium to innervation innervation e ndo me tria l-myo me tria l inte rfa c e e ndo me tria l-myo me tria l inte rfa c e  Ba sa l third o f the e ndo me trium is inne rva te d  Ba sa l third o f the e ndo me trium is inne rva te d

Measuring pain Measuring pain Strategies for acute pain Strategies for acute pain o Satisfaction o Satisfaction M ULTIMODAL PAIN MANAGEMENT M ULTIMODAL PAIN MANAGEMENT P REEMPTIVE ANALGESIA P REEMPTIVE ANALGESIA o Recommend to a friend o Recommend to a friend o Choose again o Choose again Definition: Definition: Definition: Definition: o % with severe pain o % with severe pain Using more than 1 class of meds or Using more than 1 class of meds or Intervention more effective PRIOR to Intervention more effective PRIOR to o Pain scales o Pain scales analgesic technique analgesic technique tissue injury tissue injury Example: Example: Rationale : Rationale : Local anesthesia + NSAID + Local anesthesia + NSAID + Increased pain response to Increased pain response to benzodiazepine + nonpharmacologic benzodiazepine + nonpharmacologic subsequent stimulation (“wind-up ” subsequent stimulation (“wind-up ” strategies strategies or “hyperanalgesia”) or “hyperanalgesia”) Crews JC. JAMA 2002 Comparison of local anesthetics Comparison of local anesthetics Local anesthetic Potency Onset Duration Types of Types of Bupivic a ine Stro ng Mo de ra te (up to 20 L o ng (3-6h) min) local local Me pivic a ine Me dium F a st (4-7 min) Mo de ra te (3 h) anesthesia anesthesia L ido c a ine Me dium F a st (4-7 min) Mo de ra te (1-2h) (~3 h with e pi) Chlo ro pro c a ine We a ke r F a ste st Sho rt (30-60 min) Cooper NA et al. BMJ, 2010

Monitor patient Aspirate for blood symptoms. Stop Monitor total dose prior to injection after partial dose to check symptoms. Lidocaine toxicity Prepare for toxic Use larger volume Inject multiple sites and allergic of more dilute soln reactions Prevent local anesthetic toxicity Prevent local anesthetic toxicity Carin MA et al. Neoreviews, 2008 Pain and the pelvic exam Pain and the pelvic exam Pa tie nt c o ntro l: pa rtic ipa tio n in de c isio ns He a t Non- Non- Co unse ling te c hniq ue s pharmacologic pharmacologic 10-80% o f wo me n pain pain 11-60% o f wo me n 3.2 is me a n pa in 17% o f wo me n Po sitive sug g e stio n, g uide d ima g e ry re po rt fe a r, re po rt pa in o r sc o re fo r re po rte d a pa in management management e mb a rra ssme nt, o r disc o mfo rt during disc o mfo rt with sc o re o f 6-10/ 10 Music a nxie ty during pe lvic e xa m pe lvic e xa m with pe lvic e xa m pe lvic e xa m Ac upunc ture Hypno sis Risk factors for higher pain scores: “Vo c a l lo c a l” • Ag e < 26 Akin MD et al. Obstet Gynecol, 2001 • Pre se nc e o f 1+ me nta l he a lth issue s Cepeda MS et al. Cochrane Database Syst Review, 2006 • Histo ry o f se xua l a b use Faymonville ME et al. Pain, 1997 Keogh SC et al. BMC Womens Health, 2014 • Ne g a tive e mo tio na l c o nta c t with pro vide r Blo o mfie ld HE e t a l. Ann o f Int Me d , 2014 Hild e n M e t a l. Ac ta Ob ste t Gyne c o l Sc a nd , 2003 Kotani N et al. Anesth, 2001

8:30AM – Power of Power of Cervical language language polyp (“verbocaine”) (“verbocaine”) removal Nic ho la s MD e t a l. Pa in ma na g e me nt. I n Pa ul M e t a l. Manage me nt of U ninte nde d and Abnormal Pre gnanc y . Ho b o kne , NJ: Wile y-Bla c kwe ll; 2009 Polyp Removal Polyp Removal Cervical Polyp Removal Cervical Polyp Removal  If yo u a re n’ t c urre ntly d o ing this, yo u sho uld ! Ca n  If yo u a re n’ t c urre ntly d o ing this, yo u sho uld ! Ca n  Cle a n with b e ta dine  Cle a n with b e ta dine re mo ve c e rvic a l po lyps a nd sma ll (<2c m) re mo ve c e rvic a l po lyps a nd sma ll (<2c m)  I  I f po lyp o n a sta lk, g ra sp a s hig h a s po ssib le with ring f po lyp o n a sta lk, g ra sp a s hig h a s po ssib le with ring e nd o me tria l po lyps e nd o me tria l po lyps fo rc e ps a nd b e g in to twist in o ne dire c tio n. Whe n fo rc e ps a nd b e g in to twist in o ne dire c tio n. Whe n me e t re sista nc e in tha t dire c tio n, twist o the r wa y. Do me e t re sista nc e in tha t dire c tio n, twist o the r wa y. Do  Equipment:  Equipment: not pull . Co ntinue twisting pro c e ss until po lyp ha s not pull . Co ntinue twisting pro c e ss until po lyp ha s 1. Ring fo rc e ps. 1. Ring fo rc e ps. b e e n re mo ve d. Ca ute rize b a se with silve r nitra te b e e n re mo ve d. Ca ute rize b a se with silve r nitra te (he lps kill re ma ining c e lls) (he lps kill re ma ining c e lls) 2. Silve r nitra te stic ks. 2. Silve r nitra te stic ks.  I  I f po lyp no t o n a sta lk: Unlike ly tha t ring fo rc e ps will f po lyp no t o n a sta lk: Unlike ly tha t ring fo rc e ps will 3. Optio na l: a llis c la mp 3. Optio na l: a llis c la mp g ra sp it. T g ra sp it. T ry a llis c la mp to “c ho mp it o ff”. Ca ute rize ry a llis c la mp to “c ho mp it o ff”. Ca ute rize b a se with silve r nitra te b a se with silve r nitra te  T  T ypic a lly we ll to le ra te d witho ut a ne sthe sia . ypic a lly we ll to le ra te d witho ut a ne sthe sia .  Se nd to pa tho lo g y.  Se nd to pa tho lo g y.  Ba c k

IUD Removal IUD Removal 8:45AM – IUD  No tra ining ne c e ssa ry!  No tra ining ne c e ssa ry! Removal  Equipment:  Equipment:  Ring fo rc e ps.  Ring fo rc e ps.  Cyto lo g y b rush.  Cyto lo g y b rush. If strings visible If strings not visible IUD IUD 9:00 AM Removal Removal Endometrial Ask pt to c o ug h T ry to te a se the m a nd pull q uic kly o n o ut b y twisting biopsy (EMB) string s a s she c yto lo g y b rush c o ug hs (this he lps within the Complications : ve ry with the visc e ra l e ndo c e rvix. fe e ling pt will ha ve ra re . String c a n b re a k o ff o r if I UD yo u re mo ve it) e mb e dde d yo u wo n’ t b e a b le to re mo ve it. Oc c a sio na lly it hurts to re mo ve (usua lly no t).