The effect of preemptive pudendal nerve block on pain after anterior and posterior vaginal repair
Safoura Rouholamin1, Mitra Jabalameli2, Mostafa Abedi3
1 Department of Obstetrics and Gynecology, Isfahan University of Medical sciences, Isfahan, Iran
2 Department of Anesthesiology, Isfahan University of Medical sciences, Isfahan, Iran
3 School of Medicine, Isfahan University of Medical sciences, Isfahan, Iran
|Date of Submission||27-Feb-2013|
|Date of Acceptance||15-May-2013|
|Date of Web Publication||27-Jul-2015|
Dr. Safoura Rouholamin
Shahid Beheshti Hospital, Isfahan University of Medical sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: Anterior and posterior vaginal repair (APR) is a common surgery for women with prolapse of pelvic organs which creates post-operative pain because of damage of tissues that we should manage and control this pain. For this purpose, this study was conducted in order to evaluate the effect of preemptive pudendal nerve block on post-operative pain in anterior and posterior vaginal wall repair.
Materials and Methods: In a double-blinded clinical trial study, 60 women candidates of APR were randomly divided to two groups. In both of them was injected 0.3 cc/kg bupivacaine 0.25% for the intervention group or normal saline for the control group in pudendal nerve tract with the guide of nerve stimulator. A visual analog scale was used to measure pain during the first 48 h after the surgery. Data were analyzed by repeated measures analysis of variance (ANOVA).
Results: Compared with the intervention group, the control group experienced greater pain during rest and walking. There were significant differences between the two groups from the first post-operative hour (P = 0.003) until 48 h after the operation (P = 0.021). Furthermore, the mean ± SD values of pain in the sitting position was not significantly different between control and intervention groups at the same time (P = 0.340).
Conclusion: Preemptive pudendal nerve block can reduce post-operative pain score in anterior and posterior vaginal wall repair and this method was suggested in anterior and posterior vaginal wall repair.
Keywords: Anterior and posterior vaginal repair, pelvic organ prolapse, post-operative pain, pudendal nerve block
|How to cite this article:|
Rouholamin S, Jabalameli M, Abedi M. The effect of preemptive pudendal nerve block on pain after anterior and posterior vaginal repair. Adv Biomed Res 2015;4:153
|How to cite this URL:|
Rouholamin S, Jabalameli M, Abedi M. The effect of preemptive pudendal nerve block on pain after anterior and posterior vaginal repair. Adv Biomed Res [serial online] 2015 [cited 2019 Oct 16];4:153. Available from: http://www.advbiores.net/text.asp?2015/4/1/153/161580
| Introduction|| |
The surgery causes releasing of painful chemical mediators such as prostaglandin, histamine, bradykinin, serotonin, hydroxytryptophan and substance P. These mediators make pain impulses and transmit them to central nervous system by C and A delta neuron fibers. Body responses to pain are increasing of tonicity and spasm in skeletal muscles, rising of O 2 consumption and lactic acid production, rising of heart rate (HR) and cardiac output by stimulation of autonomic systems. ,
Pelvic organ prolapse (pop) is a bulge or protrusion of pelvic organs and their associated vaginal segments into or through the vagina. Anterior and posterior vaginal repair (APR) is a surgical method that apply to treatment of patients with pelvic organs prolapse. Pop is a pelvic disorder that often need to surgery. Annually, approximately 200,000 American women undergo surgery due to pop. ,, 1.1% of women undergo surgery due to pop until 80 years.  The annual direct cost of treating pop, was estimated more than 1 billion dollars. With the aging population, this disorder has become a problem with increasing prevalence. It has been estimated that treatment of this disorder will increase until 45%, over the next 30 years, commensurate with the increase in the female population over 50 years old. ,,
Methods of treatment are non-surgical and surgical. Non-surgical treatment includes pelvic floor muscle training and usage of vaginal devices. The primary aims of surgery are to relieve symptoms, which may be caused by prolapse and in most cases, to restore vaginal anatomy so that sexual function may be maintained or improved without significant adverse effects. Approaches to surgery include vaginal surgery, laparotomy, laparoscopy routes or a combination of approaches. ,,
Post-operative pain managements are pain control (PC), narcotic, cryoanalgesia, non-steroidal anti-inflammatory drugs local anesthesia, glucocorticoids, preemptive pudendal nerve block. Post-operative pain has been treated with systemic analgesia and oral or intravenous (IV) opioids as well as epidural opioids and local anesthetics. Because of post-operative pain after APR is commonly localized to the perineum and discomfort may also originate from the sacrospinous ligament and pelvic floor, pudendal nerve block provides adequate and effective analgesia of the perineum. ,,,,,,,,, Preemptive pudendal nerve block have some benefits safe and simple compared with other methods and without any systemic side-effects. A peripheral nerve stimulator, which is an excellent teaching method for regional anesthesia, helps the physition in this type of blockade due to location monitored by peripheral muscle contraction. , Complications are intravascular injection may cause severe systemic toxicity, there are risk of hematoma if patient has clotting disorder, infection at the injection site. ,
Various studies on post-operative PC by preemptive analgesia, have conflicting results. ,,,,,,,,, Someone have suggested that the effect of preemptive analgesia may vary and depends on the kind of surgery.  Because the so far studies on the effect of preemptive pudendal nerve block was not performed on women candidates for APR. This study was performed to determine the effect of preemptive pudendal nerve block on post-operative pain in APR and compare with the control group.
| Materials and methods|| |
This is a randomized, double-blinded, clinical trial study that conducted in Shahid Beheshti Hospital in Isfahan at during the period from October 2011 to August 2012. Sixteen women who were schooled to undergo APR under spinal anesthesia were invited to enroll in the study. Inclusion criteria included women candidate APR under spinal anesthesia, American Society of Anesthesiology physical status Class I and II and consent to participate in the study, no history of allergy to local anesthetic agents and narcotics, no history of clotting problems, no history of major psychological disorders, no history of chronic pain syndrome, lack of long-term use of painkillers, no recent use of opioids, lake of diabetes mellitus type 1 and 2. Exclusion criteria included need to change the type of anesthesia during surgery (due to prolongation of the operation or failure to block).
A sample size of 60 patients was calculated to be required with standard errors 0.05, a power of 0.95 and d = 1.2 based on previous relevant clinical data.
All included participants were asked to participate in the study by the study personnel soon after admission to the ward and a written consent was obtained from each women. 60 women candidates APR in Beheshti Hospital were divided into two groups randomly.
Both groups received the same pre-operative care and same anesthesia too (spinal). All subjects received antibiotic prophylaxis with cephasolin 2 g intravenously within an hour before surgery. In the operating room, standard monitoring was applied (the lead II electrocardiogram, pulse oximetry and non-invasive blood pressure monitor). During the 15 min preceeding the spinal block, subjects were administered 10 cc/kg ringer lactate solution via an 18-gauge IV cannula. Spinal anesthesia was performed in all patients at L 3 -L 4 interspace with patients in the sitting position using a 25-gauge quincke needle. The block was done with 3 cc bupivacaine 0.25% in 10-15 s. After 5 min, patient was placed in lithotomy position and surgery was performed on all patients with the same technique by Gynecologist. Vital sign was controlled before spinal anesthesia and after that in 15 min interval to end of surgery. A solution was injected in the pudendal nerve passage way by nerve stimulator in both groups at the same period of anesthesia. The solution was included 0.3 cc/kg bupivacaine 0.25% for the intervention group and 0.3 cc/kg normal saline for the control group. , Both groups received the same post-operative care and were monitored for up to 48 h. Each patient visit at 0, 1, 2, 4, 6, 12, 24 and 48 h after surgery and data were recorded. On arrival in recovery room, pain intensity was educated to patients by visual analogs scale (VAS) ranging from 0 (no pain) to 10 (worst pain imaginable). If analgesia was considered inadequate at any stage, the anesthesiologist could give additional IV bulous of morphine 0.08 mg/kg until VAS was <3. The frequency of nausea and vomiting evaluated at the same time and at the ongoing visited. Nausea and vomiting was managed with metoclopramide 0.15 mg/kg as necessary.
Data were analyzed by SPSS version 20. Analysis of variance (ANOVA) with repeated measures was used to compare the changes in VAS, systolic blood pressure (SBP), diastolic blood pressure (DBP), HR and respiratory rate (RR). Chi-square test was used to assess the relationship between qualitative variables such as frequency of nausea, consumption of metoclopramide and morphine. A value of P < 0.05 was considered statistically significant.
| Results|| |
In this study, 60 women candidates APR were selected and were divided into two groups randomly. Thirty patients were in the intervention group and 30 patients were in the control group. During the study, two patients were excluded due to prolonged surgical procedure (1 patient from each group). A solution was injected in the pudendal nerve passage way by nerve stimulator in both groups at the same period of anesthesia. The solution was included 0.3 cc/kg bupivacaine 0.25% for the intervention group and 0.3 cc/kg normal saline for the control group.
The mean age of the patients in the intervention and control groups, respectively, were 41.9 ± 7.1 and 41.6 ± 10 that there was no significant difference between the two groups according to t-test (P = 0.92).
Mean systolic and DBP in both groups of patients from 0 h to 48 h after surgery are shown in [Table 1]. According to this table, changes in systolic and DBP were equal in the intervention and control groups and there was no significant differences between two groups according to ANOVA with repeated measures (P = 0.2) and (P = 0.15).
Mean changes in HR and RR in both groups of patients from 0 h to 48 h after surgery are shown in [Table 2]. According to this table, changes in HR and RR were equal in the intervention and control groups and there was no significant differences between two groups according to ANOVA with repeated measures (P = 0.47) and (P = 0.81).
Mean changes in pain intensity at rest; sitting and walking in both groups of patients from 0 h to 48 h after surgery are shown in [Table 3]. According to this table, changes in pain intensity at rest in the control group were more than intervention group and this difference was significant according to ANOVA with repeated measures (P = 0. 003). Changes in pain intensity at sitting and walking were analyzed at 12, 24 and 48 h after surgery. According to ANOVA with repeated measures, there was no significant differences between two group at sitting position (P = 0.34) while the difference was significant at walking (P = 0.021).
The frequency distribution of incidence of nausea and consumption of metoclopramide and morphine has been shown in [Table 4]. According to this table, morphine consumption had significant difference between two groups at 4 and 12 h after surgery and it was higher in the control group. It had no significant difference between two groups at other times. There was no significant difference between two groups in the frequency distribution of incidence of nausea and thus metoclopramide consumption.
|Table 4: The frequency distribution of incidence of nausea and consumption of metoclopramid and morphin in both groups|
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The incidence of complication was shown in [Table 5]. According to this table, there was no significant difference between the two groups in complication for 48 h post-operatively.
|Table 5: The frequency distribution of incidence of complications in both groups|
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The mean of sedation score in patient at 0 up to 48 h after surgery in both groups has been shown in [Table 6]. According to this table, there was no significant differences in changes of sedation score between two groups (P = 0.41).
| Discussion|| |
The general objective of this study was to determine the effect of preemptive pudendal nerve block on post-operative pain in APR and comparison with the control group.
According to results of this study, preemptive pudendal nerve block had no effect on unexpected changes in the intervention group. Vital variables (SBP, DBP, HR and RR) were not different in both groups at 0 up to 48 h after surgery. Therefore, this method can be used to APR. Post-operative pain was significantly lower in the intervention group than the control group. Morphine consumption in the intervention group was less than the control group at all mentioned times. However, this different was significant at 4 and 12 h after surgery according to statistical tests and there were no significant differencesbetween two groups at other times.
In another study, in 2003, in a randomized, double-blind clinical trial study, O'Neal et al. were injected 20 mL bupivacaine 0.5% or 20 mL normal saline paracervical into intervention and control groups and obtained results similar to our results. They found that post-operative pain in the intervention group was less than the control group.  In 2005, in a randomized, double blind clinical trial study, Abramov et al. have studied the effect of preemptive pudendal nerve block on post-operative pain on 102 women candidate trans vaginal pelvic repair under spinal anesthesia. They were injected 10 mL bupivacaine 0.25% or normal saline in each side of pudendal nerve passageway and found that there were no significant differences between two groups in PC and narcotic consumption.  In 2008, in a randomized, double-blind study, Aissaoui et al. were found that preemptive pudendal nerve block can decrease post-operative pain at rest and during activity and need for additional analgesics. They were injected 15 mL ropivacaine 7.5 mg/mL or normal saline after repair of episiotomy in 40 women. Their result was similar to our results.  In 2009, in a randomized, double-blind clinical trial study, Long et al. were injected 20 mL bupivacaine 0.5% into 45 women of the intervention group from 90 women candidate vaginal hysterectomy under general anesthesia and found that post-operative pain and use of additional narcotic in the intervention group were less than the control group.  Ismail et al.  found that preemptive analgesia by bilateral nerve stimulator with 10 ml of 0.25% bupivacaine, reduce post-operative pain and shorten the time to return to normal activity.
Although the fewer patients in the intervention group were nausea and received metoclopramide, there was no significant difference between two groups in incidence of nausea and metoclopramide consumption after surgery according to statistical tests. Also, there were no significant difference between two groups in the frequency distribution of incidence of complications and changes of sedation score after surgery. Therefore, preemptive pudendal nerve block is a relatively safe and simple method for providing analgesia after surgery. The lack of systemic side-effects is another benefit for this method. , Complications of this method are similar to other methods of local anesthesia. Intravascular injection may cause severe systemic toxicity. There is a risk of hematoma if patient has clotting disorder infection at the injection site. However, we did not have any complication in this study. Preemptive pudendal nerve block can reduce post-operative pain and need to additional narcotic in patients undergoing APR. Therefore, this method is suggested for reducing of post-operative pain in APR.
Some limitations and problems of our study is that this study was conducted on women undergoing APR who received spinal anesthesia. Therefore, suggestion of this method for other methods of surgery and anesthesia need to further studied. This study was prolonged due to less patients with inclusion criteria. Data collection at different times required cooperation of personnel in the operation room and section. Therefore, we suggest altering of the study design and further investigation.
| References|| |
Hurley RW, Wu CL. Acute postoperative pain. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, editors. Miller's Anesthesia. 7 th
ed. Philadelphia, PA: Elsevier; 2010. p. 2757-67.
Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, editors. Williams Obstetrics. 23 rd
ed. New York: McGraw-Hill; 2010. p. 444-63.
Richter HE, Varner RE. Pelvic organ prolapsed. In: Berek JS, Rinehart RD, Hengst TC, editors. Berek and Novak's Gynecology. 15 th
ed. Philadelphia, PA: LWW; 2012. p. 906-30.
Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and Gynecology. 10 th
ed. Philadelphia, PA: LWW; 2008. p. 818-65.
Rock JA, Jones HW, editors. TeLinde's Operative Gynecology. 10 th
ed. Philadelphia, PA: LWW; 2008. p. 854-935.
Minassian VA, Jazayeri A, Prien SD, Timmons RL, Stumbo K. Randomized trial of lidocaine ointment versus placebo for the treatment of postpartum perineal pain. Obstet Gynecol 2002;100:1239-43.
Hedayati H, Parsons J, Crowther CA. Rectal analgesia for pain from perineal trauma following childbirth. Cochrane Database Syst Rev 2003;3:CD003931.
Dodd JM, Hedayati H, Pearce E, Hotham N, Crowther CA. Rectal analgesia for the relief of perineal pain after childbirth: A randomised controlled trial of diclofenac suppositories. BJOG 2004;111:1059-64.
Urion L, Bayoumeu F, Jandard C, Fontaine B, Bouaziz H. Quality assurance program for pain management after obstetrical perineal injury. Ann Fr Anesth Reanim 2004;23:1050-6.
Bolandard F. Pudendal nerve block with nerve stimulation. In: Gaertner E, Al Nasser B, Choquet O, editors. Regional Anesthesia: Truncular and Plexus Anesthesia in Adults. WArnette; 2004. p. 213-7.
Facchinetti F, Casini ML, Costabile L, Malavasi B, Unfer V. Diclofenac pyrrolidine versus ketoprofen for the relief of pain from episiotomy: A randomized controlled trial. Acta Obstet Gynecol Scand 2005;84:951-5.
Goodman SR, Drachenberg AM, Johnson SA, Negron MA, Kim-Lo SH, Smiley RM. Decreased postpartum use of oral pain medication after a single dose of epidural morphine. Reg Anesth Pain Med 2005;30:134-9.
Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal pain after childbirth. Cochrane Database Syst Rev 2005;18:CD004223.
Saleh A, Fox G, Felemban A, Guerra C, Tulandi T. Effects of local bupivacaine instillation on pain after laparoscopy. J Am Assoc Gynecol Laparosc 2001;8:203-6.
Fong SY, Pavy TJ, Yeo ST, Paech MJ, Gurrin LC. Assessment of wound infiltration with bupivacaine in women undergoing day-case gynecological laparoscopy. Reg Anesth Pain Med 2001;26:131-6.
Einarsson JI, Sun J, Orav J, Young AE. Local analgesia in laparoscopy: A randomized trial. Obstet Gynecol 2004;104:1335-9.
Kwok RF, Lim J, Chan MT, Gin T, Chiu WK. Preoperative ketamine improves postoperative analgesia after gynecologic laparoscopic surgery. Anesth Analg 2004;98:1044-9, table of contents.
Genover E, Subira C, Iglesia M, Capo M, Martin A, Sole A, et al
. Infiltration of the uterosacral ligaments with a long-acting local anesthetic in patients undergoing vaginal hysterectomy. Prog Obstet Ginecol 2006;49:473-8.
Aida S, Baba H, Yamakura T, Taga K, Fukuda S, Shimoji K. The effectiveness of preemptive analgesia varies according to the type of surgery: A randomized, double-blind study. Anesth Analg 1999;89:711-6.
O'Neal MG, Beste T, Shackelford DP. Utility of preemptive local analgesia in vaginal hysterectomy. Am J Obstet Gynecol 2003;189:1539-41.
Abramov Y, Sand PK, Gandhi S, Botros SM, Miller JJ, Koh EK, et al
. The effect of preemptive pudendal nerve blockade on pain after transvaginal pelvic reconstructive surgery. Obstet Gynecol 2005;106:782-8.
Aissaoui Y, Bruyère R, Mustapha H, Bry D, Kamili ND, Miller C. A randomized controlled trial of pudendal nerve block for pain relief after episiotomy. Anesth Analg 2008;107:625-9.
Long JB, Eiland RJ, Hentz JG, Mergens PA, Magtibay PM, Kho RM, et al
. Randomized trial of preemptive local analgesia in vaginal surgery. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:5-10.
Ismail MT, Elshmaa NS. Pre-emptive analgesia by nerve stimulator guided pudendal nerve block for posterior colpoperineorrhaphy. Eur J Obstet Gynecol Reprod Biol 2012;163:200-3.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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