LAUSR

Minor gynaecological procedures are increasingly moving from day case operating theatres to the outpatient setting. Procedures that are performed in the outpatient setting include diagnostic and operative hysteroscopy (polypectomy or morcellation of small fibroids), cystoscopy (injection of Botulinum Toxin A or urethral bulking) and colposcopy (large loop excision of transition zone). Technique is essential tominimise all movementswithin the patient so as to reduce discomfort and, at times, local anaesthesia is considered. Pain is rare but is still the commonest adverse event and reason for procedure abandonment [1]. There are no published guidelines for the optimal method of pain relief in these procedures. It is common practice, however, to administer chlorhexidine and lidocaine gel prior to cystoscopy, whereas hysteroscopy and colposcopy do not usually require this. If dilatation of the cervix or excision of the cervix is required, then a local anaesthetic with a vasoconstrictor is commonly injected at 2 to 4 points on the cervical face. The vasoconstrictor is usually pre-mixed with the anaesthetic to maintain local anaesthesia in the desired area. It also has the benefit of reducing blood loss. The commonest vasoconstrictor utilised is adrenaline but with the palpitations, anxiety and other vasomotor symptoms which can arise secondary to it alongside the limited support available in the outpatient setting, some gynaecologists are moving to alternate vasoconstrictors such as vasopressin analogues (eg. felypressin) which have fewer side-effects, particularly cardiac and metabolic. There are substantial health and economic benefits to be gained from operating without general or regional anaesthesia, such as avoidance of anaesthetic complications, shorter recovery time and reduced overall costs. Placement of a single-toothed tenaculum on the anterior lip of the cervix precedes many of these uterine procedures, to facilitate stabilisation and traction of the uterus. This alone is known to cause pain [2]. Different methods of reducing this pain have been studied and found to be effective. The commonest is paracervical block [2] and others include lidocaine-prilocaine cream applied via cervical cup 30 min before procedure [3] or 10% lidocaine spray to the cervix [4]. Strategies developed to reduce pain include conducting hysteroscopy utilising a ‘vaginoscopic approach’, performed without a speculum or tenaculum and using normal saline as a distension medium instead of carbon dioxide. [5] Pain during hysteroscopy, once the hysteroscope has entered the uterus, is secondary to passage of the hysteroscope through the cervical canal, uterine distension and possibly spill of distension fluid into the peritoneum, causing peritoneal irritation [6]. Endometrial destruction and release of prostaglandin from such endometrium may be responsible for the delayed pain 30 min after the procedure [6]. Greater pain is experienced if a procedure such as endometrial