Maximizing Skills in Office Bartholin duct and vulvar abscesses GYN - PowerPoint PPT Presentation

Outline UCSF Essentials of Primary Care Conference Squaw Creek, CA • Pain relief for office procedures August 8, 2019 • Endometrial biopsy • Vulvar biopsy Maximizing Skills in Office • Bartholin duct and vulvar abscesses GYN Procedures • Vaso-vagal syncope • IUD challenges Michael S. Policar, MD, MPH • Contraceptive implant challenges Professor Emeritus of Ob, Gyn, and Repro Sci UCSF School of Medicine michael.policar@ucsf.edu Outpatient Procedure Pain Relief Mary 18 Year Old G 0 P 0 Principles And Application “I Am So Afraid to Have This Done!” • Pre-insertion NSAIDs • Verbicaine (aka: vocal local) • Slow technique • Tenaculum site local anesthetic • Tenaculum and sound technique • Paracervical and intracervical block

Non-Steroidal Anti-inflammatory Drugs Verbicaine Cochrane review, 2015 • Keep her talking! - Tramadol and naproxen had some effect on • Calm, soothing vocal tone reducing IUD placement pain in specific groups • Slow, easy pace - Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain • Utilize whatever works for the patient ASK • Conventional wisdom • Breathing techniques – Rx naproxen sodium 550 mg or Ibuprofen 800 mg • Mindful mediation – Helps mainly with post-placement cramping • Guided imagery Lopez LM et al. Interventions for pain with IUD insertion. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD007373 Distraction Language Considerations “ Most patients are worried about Blending pain, and they are often surprised compassion, when it is easier than they had expected. As we proceed, let us medical fact, and know how you are feeling so that positive suggestion we can make adjustments. We want this to go well for you.”

Language Considerations… Language Considerations… Instead of: Try: Try: Instead of: • I’m going to put a “ Try taking a deep breath” “Relax” grasper on your cervix “You may notice three “ It’s a natural reaction to lift up. See “ It’s a natural reaction to lift up. See cramps, then we’ll be done” if you can let your hips be heavy on the table.” the table.” • Now I’m going to sound your uterus You might feel “a pinch” “You might feel a sensation “You might feel a sensation or ”a stick and a burn” or “a twinge” or “a twinge” • Here comes the Let me know if you want me to “I can see you’ve had practice with inserter tell you before each one “You’re doing great” relaxation” Tenaculum Choose Site for Placement Tenaculum: Size of Bite • Anterior lip • 1-1.5 cm wide • 1 cm deep • Posterior lip • Not too shallow- may tear through • Typically a horizontal bite, some prefer vertical • Not too deep- unnecessary

Tenaculum Pain Reduction Tenaculum Pain Reduction • Once the teeth are in contact with the cervix, • Some providers recommend injection of 1cc local anesthetic at the tenaculum site press into the tissue • Close the tenaculum very, very slowly – Have patient cough or use other distraction – Only to the first or second stop • Don’t move the tenaculum inadvertently – Silently • Hook fingers thru rings to place tenaculum • Once the ratchet is closed, test your application • During sounding and IUD placement, don’t hook gently to be sure it is secure your fingers through the rings…hold the shank Palm Up Palm Up Ring Finger in Ring Middle finger in ring

1-2 Clicks Still with Palm Up – Ring Finger Ring Finger Still Palm Up So You Can See Above Your Hand! Tenaculum Use When Sounding • Change hands; hold the tenaculum with the non- dominant hand while sounding and for placement Fingers NOT in rings • OK to let tenaculum lay on speculum when picking up the sound or IUD • Thumb on one side of ratchet; fingers on the other – Avoid the rings – Avoid inadvertent movements

Uterine Sound: Purpose • Ensure that you can pass through the internal os Can “Choke up” • Direction and pathway through the os to the fundus • Measures depth/distance from external os to fundus – Appropriate for IUD placement not <5.5 cm – 10 cm or more in some cases – Tells you where to set the flange – So you don’t waste the IUD Like a Dart

Or Like Pencil Uterine Sound Pain Reduction • If metal; bend sound to mimic uterine flexion • Hold it like a pencil or dart • Use wrist action – Not elbow – Not shoulder • Brace fingertips on speculum to achieve control of force while advancing the sound Uterine Sound Pain Reduction Uterine Sound Pain Reduction • Touch the fundus once S-l-o-w Progression – Repeated tapping is unnecessarily uncomfortable for the patient • Through the internal os • Move slowly and intentionally • Pause once when through the internal os – Moving too quickly increases discomfort • Slow intentional progression to the fundus • If difficulty sounding, consider • Avoid momentum – EMB sampler

Os Finder Device Still Unable To Pass Through Internal Os • Place paracervical or intracervical block at any point • Use a thinner sound (endometrial sampler) • Use os finder device • Dilate internal os with small metal or plastic dilator • Try a shorter wider speculum • Reposition the tenaculum onto a different place • If unsuccessful, return after misoprostol 200 mg per vagina 10 hours and 4 hours prior to placement Cervical Os Finders (Disposable Box/25) Cervical Os Finder Set (Reusable Set of 3) Dilators Passed Through with Sound …But not the inserter! • Dilate internal os with metal dilators • #13 french • Choke up on the handle – Divide by 3.16 to get mm (4.1 mm) • Sterile lubricant on tip • Double ended • Leave the (small) sound in the canal and come alongside the sound with the inserter • Tapered ends ease passage through os

Pain with IUD Placement Cervical Lidocaine Block vs. Sham Block Anesthesia Median Pain Scores w/ 20 mL 1% Lidocaine 70 60 50 40 10-20 ml of 1% lidocaine 30 (NO epinephrine) 20 10 0 No PCB PCB Mody et al. ObGyn 2018 Carrie Cwiak, MD, MPH Pain with IUD Insertion, Nulliparas Paracervical Block 10 mL • Target is uterosacral ligaments, which contain the cervical and uterine nerves • Use spinal needle OR 25g, 1 ½” needle + extender • Inject at reflection of cervico-vaginal epithelium Akers et al. ObGyn 2017

Paracervical Block • 5-10 cc 1% lidocaine (no epinephrine) each side • Submucosal injection 5mm-1cm deep • Short speculum allows more movement • WAIT 1-2 minutes after placing block Paracervical Block Paracervical Block X X X 8 o’clock 4 o’clock

Paracervical Block Intracervical Block • Targets the paracervical nerve plexus X • 1 ½ inch 25g needle with 12 cc “finger lock” syringe • Inject ½- 1 cc. at 12 o’clock, then apply tenaculum X X X X 8 o’clock 4 o’clock 6 o’clock Intracervical Block • Angulate needle at the hub to 45 o lateral direction • At 3 o’clock, insert needle into cervix to the hub 1 cm lateral to external os, then aspirate – Inject 4 cc of local, then 1 cc while withdrawing • Rotate barrel 180 o , then inject at 9 o’clock

Intracervical Block Lidocaine Safety • Inject in correct spot • X Aspirate to avoid intravascular injection • Metallic taste is a common side effect X X 9 o’clock 3 o’clock 4 o’clock 8 o’clock 6 o’clock Maximum Local Anesthetic Dosing Local Anesthetic Onset Max Dose (mg/kg) Max Dose (mg) 55kg pt dose (mins) without/with epi without/with epi without/with Lidocaine 4-7 4.5/7 mg/kg 300/500 mg 25/38 mL Endometrial Biopsy Bupivacaine 10-20 2.5 mg/kg 175 mg 55 mL Chloroprocaine fast 11/14 mg/kg 800/1000 mg 60/77 mL • Rough estimates that are not evidence-based • Lower peak levels and slower absorption with vasoconstrictor • Adding bicarb (to lidocaine) speeds onset of action • Bupivacaine with less difference since med is vasoconstrictive

Who Needs an EMB? Who Needs an EMB? • Purpose: detect endometrial hyperplasia or cancer Premenopausal Women • Menopausal woman • Prolonged metro rrhagia – Any postmenopausal bleeding, if not using HT • Unexplained post-coital or intermenstrual bleeding – Unscheduled bleeding on continuous-sequential hormone • Endometrial cells on cytology in an anovulatory therapy premenopausal woman – Bleeding > 3 mo after start of continuous-combined • Atypical Glandular Cells (AGC) cervical cytology hormone therapy – Abnormal endometrial cells, or – Endometrial stripe > 5 mm (applies to postmenopausal – Older than 35 years old woman only) – Under 35 yo with abnormal bleeding – Pap smear: any endometrial cells or AGC Pap Technique of EMB • Bimanual exam to evaluate uterine axis, size • Cleanse cervix with antiseptic • S-l-o-w-l-y apply tenaculum ( + local anesthetic) • Use of the sampling device – Choose correct type (rigidity) of sampler – “Crack” stylet to ensure easy movement – Gently advance to fundus; expect resistance at internal os – Note depth of sounding with side markings – Pull back stylet to establish vacuum