Pain during diagnostic hysteroscopy: what is the role of the cervical canal? A pilot study

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Abstract

Objective

To evaluate whether a correlation exists between the pain perceived during diagnostic anesthesia-free hysteroscopy and the characteristics of the cervical canal.

Study design

Prospective observational pilot study of 255 women undergoing diagnostic hysteroscopy. Data analysis included characteristics of the patient and the cervical canal, and the pain experience during the procedure, assessed by visual analog score (VAS). A multiple logistic regression was then carried out in order to exclude confounding factors.

Results

The degree of pain during hysteroscopy was equal to a median VAS score of 2 (range 0–10). Bivariate analysis between patients with VAS > 3 and patients with VAS  3 demonstrated a significant correlation between pain and the presence of synechiae in the cervical canal (P = 0.022), the patient's age (P = 0.003) and parity (P = 0.001). Multivariate analysis revealed that the presence of cervical synechiae (P = 0.0001) [OR = 4.99 (95% CI 2.13–11.70)] and parity (P = 0.014) [OR = 0.42 (95% CI 0.21–0.83)] were significantly correlated with pain. There was no significant correlation with the different angles of the cervical canal.

Conclusion

Cervical synechiae appear as a major factor influencing pain during hysteroscopy. While parity acts as a protective factor, the angle of the cervical canal does not seem to play an important role for pain during diagnostic hysteroscopy.

Introduction

Diagnostic hysteroscopy is the gold standard in the study of uterine cavity morphology and in diagnosis of endocavitary pathologies [1], as it offers elevated sensitivity and specificity, a high feasibility and a low complication rate [2]. Nonetheless, hysteroscopy is often considered a painful procedure that is poorly tolerated by patients [3], with difficulties in reaching the uterine cavity [4]. For this reason, numerous studies have evaluated the effectiveness of alternative solutions in an attempt to make the investigation less painful. These include the use of normal saline instead of carbon dioxide (CO2) [5], the use of small-calibre [6] or flexible [7] hysteroscopes, a vaginoscopic approach [8], the administration of prostaglandins to induce cervical dilation [9], and recourse to analgesia [10] or local anaesthesia [11]. Some studies have sought to identify the variables responsible for pain during diagnostic hysteroscopy [12], [13], [14], but none of them has studied the correlation between pain and the characteristics of the cervix, particularly the morphology of the cervical canal. The aim of our study is to evaluate whether a correlation exists between the pain perceived while the procedure is being carried out and the characteristics of the cervix, the angle and the morphology of the cervical canal.

Section snippets

Materials and methods

This prospective observational study was conducted at “Arbor Vitae” Endoscopic Center, Rome from October 2012 to April 2013. The study population consisted of 255 women who were consecutively subjected to diagnostic hysteroscopy. The findings and implications were all discussed with the patient and verbal consent was obtained. Institutional Review Board approval was obtained for data collection.

The patients were all Caucasian and able to communicate the perceived pain. Indications for

Results

Out of a total of 255 women, the uterine cavity was reached and visualized in 100% of cases. The main characteristics of the population under examination are summarized in Table 1. The main characteristics of the cervix are also described (Table 2). The median duration of the investigation was 89 s (range 38–338). The pain degree at the end of the hysteroscopy was equal to a median VAS score of 2 (range 0–10). The number of patients who reported a VAS > 3 was 89 (34.9%), of which 26 (10.2%) felt

Comment

The results show that only the presence of cervical synechiae directly correlates with the perception of significant pain, while parity, on the other hand, demonstrates an inverse correlation. The angle of the cervical canal does not seem to play a role.

The pain perceived during the performance of diagnostic hysteroscopy has been the subject of study in numerous clinical analyses [3], [12], [13], [14], but for the first time we focused on the characteristics of the cervical canal as the cause

Condensation

Cervical synechiae appear as a major factor influencing pain during hysteroscopy. The angle of the cervical canal does not seem to play an important role.

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