What is an agent which can be used to numb the cervix prior to colposcopy or IUD insertions, and sometimes spraying on the skin when doing an I&D of a vaginal cyst, etc.?

Comment by InpharmD Researcher

Available literature suggests that lidocaine spray can be beneficial for pain control during colposcopy, intrauterine device (IUD) insertion, and vaginal cystic incision and drainage (I&D) procedures, though data is mixed (Tables 1-8). Topical lidocaine spray has shown variable results for pain control during colposcopy, while cocaine spray has been notably effective in reducing both pain and blood loss compared to placebo. For IUD insertion, lidocaine 10% spray has been reported to significantly reduce pain in some studies, although results are again inconsistent. In the management of Barthalin’s duct cyst and gland abscesses, lidocaine 1% or 2% solution is recommended following I&D, although evidence is limited and primarily based on observational data that did not assess pain scores.

Background

A 2016 Cochrane meta-analysis found that both lignocaine and cocaine sprays were effective in reducing pain compared to a placebo when administered prior to colposcopy treatment for cervical intraepithelial neoplasia. A total of 19 randomized controlled trials (RCTs; N= 1720 women) were included for analysis. One study compared the use of 40 mg 10% lignocaine spray alone versus 1.8 ml of 2% lignocaine plus 1:100,000 adrenaline injection for pain relief during gynecological procedures. Pain scores during the procedure were reported as medians on a 10 cm visual analog scale (VAS), with the median score being 3.0 (interquartile range [IQR] 0.0 to 9.5) for the lignocaine spray group and 4.0 (IQR 0.0 to 8.2) for the lignocaine plus adrenaline injection group (p= 0.11). Thirty minutes after the procedure, the median pain scores were 2.6 (IQR 0.0 to 7.8) for the spray group and 1.9 (IQR 0.0 to 8.5) for the injection group (p= 0.84). However, the pain scores during the application of the spray versus injection were significantly different, with a median of 0.0 (IQR 25.7 to 3.0) for the spray and 1.9 (IQR 23.5 to 7.6) for the injection (p<0.01). Another study compared 0.5 ml of 10% lignocaine spray plus standard cervical infiltration versus placebo. The results showed no significant effect of the lignocaine spray on pain scores, with a median VAS of 40.0 (IQR 21.25 to 63.25) for the spray group and 36.0 (IQR 17.5 to 49.5) for the placebo group (p= 0.38). Cocaine spray was associated with significantly less reported pain on a visual analog scale compared to placebo, with a mean difference of 28 (95% confidence interval [CI] -37.86 to -18.14; 50 women). The cocaine spray also resulted in less measured blood loss during the procedure. Overall, the findings indicate that brief administration of topical anesthetics like lignocaine and cocaine sprays can help minimize the discomfort experienced by patients undergoing colposcopy procedures to treat precancerous lesions of the cervix. [1]

A 2024 scoping review investigated different techniques for reducing pain during intrauterine device (IUD) insertion, which includes lidocaine cervical spray. A total of 19 studies that described pain management protocols for pain amelioration were included, with 12 evaluating pharmacologic management. Lidocaine cervical spray and cervical spray were assessed in 2 individual trials. In the first study, a 10% lidocaine spray was reported to be successful in decreasing pain with IUD insertion compared to placebo among 200 patients. However, the second study of 420 patients dividing lidocaine spray, gel, and placebo into groups of 140 found no significant benefit with the lidocaine spray or gel versus placebo. Further analysis regarding the spray is limited, and the authors’ general conclusions were that more research was needed to develop and refine a standardized pain protocol management. [2]

A 2003 review described the management of Bartholin’s Duct cyst and gland abscess in women of reproductive age. In cases where treatment is required (e.g., symptomatic Bartholin’s duct cysts), incision and drainage may be necessary, preceded by preparation and administration of a local anesthetic, such as lidocaine 1% or 2% solution. [3]

References:

[1] Gajjar K, Martin-Hirsch PP, Bryant A, Owens GL. Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment. Cochrane Database Syst Rev. 2016;7(7):CD006120. Published 2016 Jul 18. doi:10.1002/14651858.CD006120.pub4
[2] Rahman M, King C, Saikaly R, et al. Differing Approaches to Pain Management for Intrauterine Device Insertion and Maintenance: A Scoping Review. Cureus. 2024;16(3):e55785. Published 2024 Mar 8. doi:10.7759/cureus.55785
[3] Omole F, Simmons BJ, Hacker Y. Management of Bartholin's duct cyst and gland abscess. Am Fam Physician. 2003;68(1):135-140.
Literature Review

A search of the published medical literature revealed 8 studies investigating the researchable question:

What is an agent which can be used to numb the cervix prior to colposcopy or IUD insertions, and sometimes spraying on the skin when doing an I&D of a vaginal cyst, etc.?

Level of evidence

B - One high-quality study or multiple studies with limitations  Read more→


Please see Tables 1-8 for your response.

 

Lidocaine 10% spray to the cervix reduces pain during intrauterine device insertion: a double-blind randomised controlled trial
Design

Randomized, double-blind, placebo-controlled trial (Turkey)

N= 200
Objective To determine the effectiveness of topical 10% lidocaine spray for pain control during intrauterine device (IUD) insertion
Study Groups

Lidocaine spray group (n=100)

Placebo spray group (n=100)
Inclusion Criteria Aged 18-49 years, accepting IUD as the method of contraception, no known previous allergic reaction or sensitivity to lidocaine or placebo spray, no accompanying extraordinary medical or surgical conditions necessitating special attention, no specific request for anesthesia, no history of chronic pelvic pain or dysmenorrhoea
Exclusion Criteria Currently pregnant or within 2 weeks of the conclusion of a pregnancy, presence of a known uterine anomaly or fibroid distorting the uterine cavity, contraindication to a copper IUD, untreated acute cervicitis or pelvic inflammatory disease, known cervical stenosis or extraordinary surgical conditions necessitating cervical dilators, any systemic diseases or medications that would affect the perception of pain, current or past history of illegal drug or narcotic use, inability to understand how to score a 10-cm Visual Analogue Scale (VAS) for pain, a VAS pain score other than 0 just before IUD insertion
Methods Participants received either four pumps of 10% lidocaine spray or four pumps of isotonic saline solution spray. No cervical ripening agents were used. Three puffs were applied to the cervical surface, with one directed toward the external os, followed by a 3-minute wait as per the manufacturer's guidance for the anesthetic to take effect. The cervix was then grasped with a tenaculum, straightened to the uterine axis, and the IUD was inserted following standard uterine sounding. Patients rated their pain on a 10-cm VAS, from 0 cm (no pain) to 10 cm (worst pain). Pain was assessed before speculum placement and after insertion. Procedures were performed by the same gynecologist and team.
Duration From December 2013 to January 2014
Outcome Measures Primary: IUD insertion pain score measured by 10-cm VAS
Baseline Characteristics Characteristic Lidocaine spray group (n=100) Placebo spray group (n=100) p-value
Age 30.19±7.51 29.62±7.42 0.590
Body mass index (BMI) 26 (22–29) 26 (23–29) 0.437
Gravidity 3 (2–3) 3 (2–3) 0.865
Parity 2 (2–3) 2 (2–3) 0.595
Results Pain score Lidocaine spray group (n=100) Placebo spray group (n=100) p-value
VAS during the procedure, cm 1.00 (0–6) 3.00 (0–7) <0.001
Frequency of VAS ≥4 6.0% 41.0% <0.001
A significantly lower score for overall pain during the procedure was found in the treatment group compared to controls (p<0.001).
Adverse Events Five mild complications associated with vasovagal reaction such as nausea, vomiting, and dizziness; no systemic side effects associated with 10% lidocaine spray were observed
Study Author Conclusions Lidocaine spray can be effective in controlling procedure-related pain during IUD insertion when compared with placebo. More, larger-scale, prospective, and homogeneous studies are needed to determine the effectiveness, safety, and optimal dosage of lidocaine spray.
Critique This study has some limitations, including the absence of a no-treatment group. Pain was not measured at different stages of IUD insertion, and a post-insertion assessment at 10 minutes could have captured cramping often associated with prostaglandin release. While immediate somatic pain, likely tenaculum-related, was assessed—where lidocaine might be most effective—the exclusion of nulliparous women limits the generalizability of the findings, reflecting the specific patient population at this family planning center.
References:

Aksoy H, Aksoy Ü, Ozyurt S, Açmaz G, Babayigit M. Lidocaine 10% spray to the cervix reduces pain during intrauterine device insertion: a double-blind randomised controlled trial. J Fam Plann Reprod Health Care. 2016;42(2):83-87. doi:10.1136/jfprhc-2014-100917

 

Effect of lidocaine spray during colposcopy-directed cervical biopsy: A randomized controlled trial
Design

Randomized controlled trial (Thailand)

N= 200 participants
Objective To examine the effect of lidocaine spray in reducing pain during colposcopy-directed cervical biopsy (CDB)
Study Groups

Lidocaine spray (n = 100)

No anesthesia (n = 100)
Inclusion Criteria Women with abnormal cervical screening test results and abnormal colposcopic findings requiring a CDB
Exclusion Criteria Known hypersensitivity to lidocaine or other components, pregnancy, post-hysterectomy, bleeding disorders, drug abuse, cervical and vaginal infection, inability to communicate in Thai
Methods Participants were randomly assigned to receive either 10% lidocaine spray (4 puffs, 40 mg) applied to the ectocervix or no anesthesia. Pain scores were measured at baseline, immediately after biopsy, and 10 minutes post-procedure using a 10-point Likert scale. 
Duration April to December 2015
Outcome Measures Primary: Biopsy pain score
Baseline Characteristics Characteristic Lidocaine spray (n = 100) No anesthesia (n = 100) p-value
Median age, years 42 (20–62) 47 (19–61) 0.01
Nulliparous 25 (25) 15 (15) 0.08
Postmenopausal 17 (17) 27 (27) 0.09
History of previous LEEP 3 (3) 4 (4) 0.61
HIV-positive 8 (8) 0 0.01
Dysmenorrhea 35 (35) 35 (35) 1.00

Cervical cytology results

  
ASC-US 44 (44) 44 (44) 0.22
ASC-H 3 (3) 2 (2)  
LSIL 48 (48) 39 (39)  
AGC NOS 1 (1) 2 (2)  
Cytology negative (HPV-positive) 4 (4) 10 (10)  
HPV status  
Positive 35 (35) 49 (49) 0.13
Negative 8 (8) 7 (7)  
Unknown 57 (57) 44 (44)  
Final histology  
No epithelial lesion or cervicitis 50 (50) 52 (52) 0.53
LSIL 33 (33) 37 (37)  
HSIL 16 (16) 11 (11)  
AIS 1 (1) 0  

Values are given as n (%), or median (range).

Abbreviations: AGC NOS, atypical glandular cells not otherwise specified; AIS, adenocarcinoma in situ; ASC-H, atypical squamous cells cannot exclude HSIL; ASCUS, atypical squamous cells of undetermined significance; HIV, human immunodeficiency virus; HPV, human papilloma virus; HSIL, high-grade squamous intraepithelial lesions; LEEP, loop electrosurgical excision procedure; LSIL, low-grade squamous intraepithelial lesions.

Median number of cervical biopsy was one (range, 1–3) for both groups. The median duration of the colposcopy procedure was approximately 7 min for both groups. 

  
Results Pain scores Lidocaine spray (n = 100) No anesthesia (n = 100) p-value
Baseline 1.71 ± 1.95 1.41 ± 1.82 0.26
Biopsy 1.43 ± 1.75 1.92 ± 2.09 0.07
Biopsy to baseline difference -0.28 ± 2.22 0.51 ± 2.07 0.01
Postprocedure 1.05 ± 1.55 1.40 ± 1.68 0.13
Postprocedure to baseline difference -0.66 ± 1.93 -0.01 ± 2.04 0.02
Adverse Events No complications observed in any participants.
Study Author Conclusions Lidocaine spray reduces pain during colposcopy-directed cervical biopsy; however, the clinically meaningful effect of such a procedure cannot be demonstrated in this study. The pain associated with this procedure was generally minimal.
Critique The study's strengths include its prospective randomized controlled design with allocation concealment, uniform technique, and no dropouts. However, limitations exist, such as the lack of a placebo, which could have improved methodological rigor, and the inability to fully blind participants and colposcopists due to the procedure's nature. Despite these factors, the study found no significant benefit from using 10% lidocaine spray for reducing pain during colposcopy-directed cervical biopsy, as the pain was generally minimal.
References:

Wongluecha T, Tantipalakorn C, Charoenkwan K, Srisomboon J. Effect of lidocaine spray during colposcopy-directed cervical biopsy: A randomized controlled trial. J Obstet Gynaecol Res. 2017;43(9):1460-1464. doi:10.1111/jog.13380

 

10% lidocaine spray for pain control during intrauterine device insertion: a randomised, double-blind, placebo-controlled trial

Design

Randomized, double-blind, placebo-controlled trial

N= 124

Objective

To investigate the efficacy of 10% lidocaine spray in reducing pain during copper-containing intrauterine device (Cu-IUD) insertion

Study Groups

10% lidocaine spray (n= 62)

Placebo spray (n= 62)

Inclusion Criteria

Women age 18 to 45 years with body mass index (BMI) of 18.5 to 30 kg/m2, who requested Cu-IUD for contraception and were new Cu-IUD users

Exclusion Criteria

Contradition(s) to Cu-IUD use, inability to comprehend use of 10 cm visual analogue scale (VAS), local anesthetic allergy or sensitivity to lidocaine, and analgesic use within 24 hours of study participation

Methods

Patients were randomized (1:1) to receive either 4 puffs of 10% lidocaine spray (10 mg/mL/puff; 40 mg total) or 4 puffs of sterile water placebo; three puffs were applied to the cervical surface and one puff applied to the cervical os. For blinding purposes, treatments were supplied in identical spray bottles. During Cu-IUD insertion procedure, the study medications were administered to cervical region and given 3 minutes for lidocaine to take effect, per manufacturer recommendation, before Cu-IUD placement.

Patients indicated their level of pain using the 10 cm VAS at 6 different points during and after the procedure: immediately after speculum placement following 3 minutes of study medication application, immediately after tenaculum placement, immediately after uterine sound, immediately after Cu-IUD insertion, and both 5- and 20-minutes post-IUD insertion.

Duration

July 2018 to December 2019

Outcome Measures

Primary: VAS immediately after Cu-IUD placement

Secondary: VAS at the other different points of the procedure, difference in VAS from baseline at each time point, side effects of study medication

Baseline Characteristics

  

10% lidocaine spray (n= 62)

Placebo spray (n= 62)

  

Age, years

 31.2 ± 6.7 30.6 ± 6.3  

Weight, kg

 60.2 ± 8.5 60.3 ± 11.1  

BMI, kg/m2

 24 ± 3.1 23.7 ± 3.6  

History of vaginal delivery

Normal delivery with most recent child

Cesarean delivery with most recent child

39 (62.9%)

37 (63.8%)

21 (36.2%)

37 (59.7%)

37 (61.7%)

23 (38.3%)

  

Timing of IUD insertion

Delayed postpartum insertion

Interval insertion

 

31 (50%)

31 (50%)

 

29 (46.8%)

33 (53.2%)

  

Currently breastfeeding

 33 (53.2%) 30 (48.4%)  

Dysmenorrhea VAS≥4

 16 (25.8%) 21 (33.9%)  

Results

Endpoint

10% lidocaine spray (n= 62)

Placebo spray (n= 62)

p-value

VAS (IQR)

Speculum placement

Tenaculum placement

Uterine sound

IUD insertion

5 minutes after IUD insertion

20 minutes after IUD insertion

 

0 (0 to 1.53)

0.75 (0 to 2.2)

2.3 (1.08 to 4.6)

2.95 (1 to 5.63)

0 (0 to 2.03)

0 (0 to 2)

 

0.75 (0 to 1.68)

2.4 (1.2 to 3.85)

4.1 (2.9 to 6)

5 (3.35 to 7)

0.95 (0 to 2.93)

0.55 (0 to 1.9)

 

0.165

<0.001

<0.001

0.002

0.078

0.688

VAS change from baseline (IQR)

Tenaculum placement

Uterine sound

IUD insertion

5 minutes after IUD insertion

20 minutes after IUD insertion

 

0 (0 to 1.38)

1.6 (0 to 3.05)

1.85 (0.08 to 4.03)

0 (-0.03 to 1)

0 (-0.2 to 1.23)

 

1.4 (0.2 to 2.13)

2.9 (2.18 to 4.5)

3.6 (2.4 to 5.8)

0 (-0.83 to 2.03)

0 (-0.93 to 0.83)

 

<0.001

<0.001

0.004

0.784

0.3

Adverse drug effect

Vaginal irritation

 

34 (54.8%)

 

1 (1.6%)

 

<0.001

Abbreviations: IQR, interquartile range

Adverse Events

No serious adverse events were reported in either treatment group. 

Study Author Conclusions

10% lidocaine spray was found to be an effective local anaesthetic method for reducing pain during insertion of Cu-IUD.

InpharmD Researcher Critique

Study strengths include evaluation of lidocaine spray in women with and without previous history of vaginal delivery and use of VAS assessment during and after Cu-IUD procedure; lack of anticipated pain or altered pain tolerances between patients, as well as the use of one form of IUD potentially limit the results of this study. Study authors concluded that the use of 10% lidocaine spray is beneficial for pain reduction during Cu-IUD insertion, particularly during the tenaculum placement, uterine sounding, and immediately following IUD placement. 



References:

Panichyawat N, Mongkornthong T, Wongwananuruk T, Sirimai K. 10% lidocaine spray for pain control during intrauterine device insertion: a randomised, double-blind, placebo-controlled trial. BMJ Sex Reprod Health. 2021;47(3):159-165. doi:10.1136/bmjsrh-2020-200670

 

Lidocaine for pain control during intrauterine device insertion

Design

Prospective randomized study

N= 200

Objective

To compare the effects of topical lidocaine spray, cream and injection on pain perception during intrauterine device (IUD) insertion

Study Groups

Control (n= 49)

Lidocaine spray (n= 51)

Lidocaine cream (n= 53)

Lidocaine injection (n= 47)

Inclusion Criteria

Multiparous women, age > 18 years, eligible for IUD insertion 

Exclusion Criteria

Heavy menstrual bleeding, IUD contraindicated, unable to comprehend visual analog scale (VAS)

Methods

Patients were randomized to treatment with lidocaine cream, spray, or injection or control. Patients in the control group received no additional medication prior to insertion of IUD, while those in the lidocaine spray group received 4 puffs (50 mL, 10 mg/puff) to the cervical canal and cervix, those receiving lidocaine cream were administered 2 g to the cervical canal and cervix via cotton swab, and those receiving injection were administered 10 mL (20 mg/mL) at two sites in the cervicovaginal junction and 2 mL to the area to be grasped with the tenaculum. Pain levels were assessed using a 10-point VAS after the speculum insertion and analgesic administration (baseline) as well as a second time after the cervix was grasped with the tenaculum and third time after hysterometry and insertion of the IUD. In all patients, a Copper T IUD was inserted on day 3 to 5 of menstrual bleeding. 

Duration

Trial: February 2015 to September 2015

Outcome Measures

Pain scores with IUD insertion

Baseline Characteristics

  

Control (n= 49)

Lidocaine spray (n= 51)

Lidocaine cream (n= 53)

 Lidocaine injection (n= 47)  

Age, years

 29.2 30.6 30.2 28.8  

Body mass index, kg/m2

 25.2 25.6  24.6 26.4  

Gravidity

 3 3 2 2  

Parity

 2  2  2 2  

Abortion

 0  0  0 0  

Curettage

 0 0 0 0  

Baseline demographics were comparable between groups.

Results

VAS Scores

Control (n= 49)

Lidocaine spray (n= 51)

Lidocaine cream (n= 53)

 Lidocaine injection (n= 47)

p-Value

Baseline

0 (none)

1-3 (mild)

4-6 (moderate)

7-10 (severe)

 

44 (89.8%)

4 (8.2%)

1 (2.0%)

0 

 

49 (96.1%)

2 (3.9%)

0

0 

 

49 (92.5%)

4 (7.5%)

0

0 

 

1 (2.1%)

12 (25.5%)

33 (70.2%)

1 (2.1%)

 < 0.001 

Tenaculum

0 (none)

1-3 (mild)

4-6 (moderate)

7-10 (severe)

 

2 (4.1%)

26 (53.1%)

21 (42.9%)

0 

 

20 (39.2%)

22 (43.1%)

8 (15.7%)

1 (2.0%)

 

4 (7.5%)

28 (52.8%)

20 (37.7%)

1 (1.0%) 

 

3 (6.4%)

26 (55.3%)

18 (38.3%)

0 

 < 0.001

Insertion

0 (none)

1-3 (mild)

4-6 (moderate)

7-10 (severe)

 

1 (2.0%)

14 (28.6%)

31 (63.3%)

3 (6.1%) 

 

13 (25.5%)

16 (31.4%)

19 (37.4%)

3 (5.9%) 

 

1 (1.9%)

13 (24.5%)

37 (69.8%)

2 (3.8%)

 

1 (2.1%)

28 (59.6%)

18 (38.3%)

0

 < 0.001 

All p-test results per chi-squared test.

Adverse Events

 N/A

Study Author Conclusions

To conclude, we believe that lidocaine spray is a good option for reducing pain during IUD insertion, which is a common method of contraception around the world. Spray application is both easy and rapid. While paracervical lidocaine injection also reduces pain during IUD insertion, the injection itself is painful. Therefore, this option is not seen as a plausible method for reducing pain during IUD insertion.

InpharmD Researcher Critique

Dosing for lidocaine varied between the three formulations utilized. This study was conducted in Turkey, where standards of care may vary compared to the United States. 



References:

Karasu Y, Cömert DK, Karadağ B, Ergün Y. Lidocaine for pain control during intrauterine device insertion. J Obstet Gynaecol Res. 2017;43(6):1061-1066. doi:10.1111/jog.13308

 

Comparison of topical lidocaine spray with forced coughing in pain relief during colposcopic biopsy procedure: a randomised trial

Design

Prospective randomised study

N= 86

Objective

To evaluate the effectiveness of local lidocaine spray (LS) compared to forced coughing (FC) for relieving the pain during colposcopically guided cervical biopsies (CGBs)

Study Groups

Lidocaine spray (n= 44)

Forced coughing (n= 42)

Inclusion Criteria

Presence of abnormal cervical cytology requiring a colposcopy, an age ≥ 18 years old, the presence of cervix

Exclusion Criteria

Patients who were pregnant, those with a heart block disease, advanced liver or kidney disease, had any gross invasive cancer appearance and any known allergy to lidocaine

Methods

Eligible patients in Turkey were randomised in a 1:1 ratio to receive a local anesthesia spray (10% pump spray) or instructed to have an FC during their colposcopic guided biopsies. The pain was assessed using a 10 cm visual analogue scale (VAS), with scores ranging from 1 to 10 (1 indicating no pain and 10 representing the worst unbearable pain).

Duration

March 2017 to March 2018

Outcome Measures

Primary: Differences in pain perceived at four different consecutive steps during the CGB procedure

Secondary: Adverse effects related to the local anesthetic spray and bleeding associated with the biopsy procedure

Baseline Characteristics

  

Lidocaine spray (n= 44)

Forced coughing (n= 42)

  

Age, years

 42.1 ± 11.4  41.6 ± 10.9  

Parity

 2.3 ± 1.2  2.4 ± 1.1   

BMI, kg/m2

 27.62 ± 3.2  26.9 ± 4.2   

History of previous curettage

 14.2% 12.5%  

History of vaginal delivery

 72.7% 71.4%  

Cervical cytologic results

AS-CUS

L-SIL

H-SIL

Other

 

31.8%

45.4%

13.6%

4.5%

 

30.9%

47.6%

14.2%

7.1%

  

Patients with ECC

26%

23.8%

  

Biopsy number

Single biopsy

Multiple biopsy

 

73.9%

26%

 

76.1%

23.8%

  

Abbreviations: ASC-US: atypical squamous cells of undetermined significance; L-SIL: low-grade squamous intraepithelial lesion; H-SIL: high-grade squamous intraepithelial lesion; n: number; SD: standard deviation; BMI: body mass index; ECC: endocervical curettage

There were no statistical differences between the two groups.

Results

Endpoint

Lidocaine spray (n= 44)

Forced coughing (n= 42)

p-value

VAS pain scores

Speculum insertion

Cervical biopsy

5 min after the procedure

 

1.4 ± 0.8

3.25 ± 1.4

1.9 ± 0.4

 

1.2 ± 0.9

4.4 ± 1.3

2.1 ± 0.6

 

0.89

0.02

0.46

Patients with ECC at 5 min after colposcopy

 2.4 ± 1.2 2.6 ± 1.8 0.78

Time needed, min

 7.6 ± 1.4 5.2 ± 0.8 0.004

Adverse Events

No major complications including allergic reactions or persistent bleeding from the biopsy site or persistent pain were observed in the lidocaine and cough groups of the study.

Study Author Conclusions

The present study showed that LS use can be recommended for pain relief during colposcopically directed cervical biopsy procedure with a superiority to the FC in the terms of pain and absence of any adverse reactions.

InpharmD Researcher Critique

The study's limitations include the subjective nature of the VAS for pain assessment, which can be influenced by factors such as social and cultural differences. Additionally, the absence of a placebo group and the non-blinded design may impact the results. Despite these limitations, the study's strengths lie in its randomized prospective design and the lack of significant differences in baseline demographic characteristics between groups.
References:

Karaman E, Kolusarı A, Alkış İ, Çetin O. Comparison of topical lidocaine spray with forced coughing in pain relief during colposcopic biopsy procedure: a randomised trial. J Obstet Gynaecol. 2019;39(4):534-538. doi:10.1080/01443615.2018.1538329

 

Comparison of Topical Lidocaine Spray With Placebo for Pain Relief in Colposcopic Procedures: A Randomized, Placebo-Controlled, Double-Blind Study

Design

Randomized, placebo-controlled, double-blind study

N= 214

Objective

To compare the effectiveness of topical lidocaine spray to placebo for relieving pain during colposcopic cervical biopsies and endocervical curettage (ECC)

Study Groups

Lidocaine 10% spray (n= 104)

Placebo spray (n= 110)

Inclusion Criteria

Adult women with abnormal cytologic results requiring colposcopy and colposcopically directed cervical biopsy with or without ECC

Exclusion Criteria

Current pregnancy, allergy to lidocaine, or visible cervical lesion

Methods

Patients were randomized to receive either 5 pumps of lidocaine 10% spray (10 mg/pump; 50 mg total) or sterile saline placebo spray. Both products were sprayed on the ectocervix and followed by a 2 minute waiting period before acetic acid application by colposcopist. Patient pain scores were measured using the Wong-Baker FACES Pain Rating Scale, with pain levels immediately after the punch biopsy and ECC reported; if patient had multiple biopsies, only the first cervical biopsy pain score was recorded.

Duration

December 2013 to April 2014

Outcome Measures

 Pain scores following cervical biopsy and ECC

Baseline Characteristics

  

Lidocaine 10% spray (n= 104)

Placebo spray (n= 110)

  

Age, years

 41.5 ± 10.6 43 ± 11.3  

Parity

 2.1 ± 1.4  2.3 ± 1.4   

History of previous vaginal delivery

 1.9 ± 1.5  2.1 ± 1.5   

History of previous cervical biopsy

 0.2 ± 0.5 

0.2 ± 0.6 

  

Results

Endpoint

10% lidocaine spray (n= 104)

Placebo spray (n= 110)

p-value

Pain scores after cervical biopsy

 2.2 ± 1.7 2.3 ± 1.6 0.30

Pain scores after ECC

 3.7 ± 2.2 3.7 ± 2.2 0.80

Adverse Events

N/A

Study Author Conclusions

In our population, there is no evidence to recommend the use of routine locally sprayed lidocaine anesthesia before cervical punch biopsy or ECC.

InpharmD Researcher Critique

This study is limited by the unknown interference of the acetic acid use on lidocaine efficacy, as it is used as a diagnostic intervention and was applied post-lidocaine administration. From these findings, lidocaine 10% spray was not shown to be effective in the reduction of pain during a colposcopy procedure. 



References:

Öz M, Korkmaz E, Cetinkaya N, et al. Comparison of Topical Lidocaine Spray With Placebo for Pain Relief in Colposcopic Procedures: A Randomized, Placebo-Controlled, Double-Blind Study. J Low Genit Tract Dis. 2015;19(3):212-214. doi:10.1097/LGT.0000000000000099

Efficacy of Lidocaine Spray for Pain Reduction during Colposcopy-Directed Cervical Biopsies: A Randomized Controlled Trial

Design

Randomized controlled trial

N= 312

Objective

To evaluate the efficacy of lidocaine spray in reducing pain during colposcopy-directed cervical biopsies (CDBs)

Study Groups

Lidocaine spray (n= 104)

Normal saline solution (NSS) spray (n= 104)

Control group (n= 104)

Inclusion Criteria

Women age 15-50 years with abnormal cervical screening results and abnormal colposcopic findings requiring a CDB

Exclusion Criteria

Patients with history of hypersensitivity to lidocaine or to other components of the solution; pregnancy; history of prior hysterectomy; bleeding disorders; drug abuse; cervical or vaginal infection

Methods

Patients in Thailand were randomized 1:1:1 to receive either 4 puffs of 10% lidocaine spray, 4 puffs of NSS spray, or no treatment. A cervical punch biopsy was performed two minutes after the respective treatments. The procedure was identical for all patients, including speculum insertion, cervical inspection, and biopsy, with additional procedures performed as needed. Pain was assessed using a 10 cm visual analog scale (VAS) at baseline, immediately after the biopsy, and 10 minutes post-procedure.

To conceal treatment assignments, numbered, sealed envelopes were used. All colposcopy procedures were performed by gynecologic oncology staff or trainees using the same standard method.

Duration

December 2017 to February 2019

Outcome Measures

Biopsy pain score

Baseline characteristics

 

Lidocaine
spray (n= 104)

NSS spray (n= 104)

Control (n= 104) 

 

Age, years (range)

42 (32–54)

40 (33–51)

42 (35–51) 

 

Parity

Nulliparous

Multiparous

 

23 (22.1%)

81 (77.9%)

 

28 (26.9%)

76 (73.1%)

 

26 (25.0%)

78 (75.0%)

 

Menopause

27 (26.0%) 

29 (27.9%) 

28 (26.9%)

 

Dysmenorrhea

44 (42.3%) 

46 (44.2%) 

40 (38.5%) 

 

Dyspareunia

26 (25%)

26 (25%)

21 (20.2%) 

 

HIV positive 

7 (6.7%)

9 (8.7%) 

8 (7.7%) 

 

HPV positive 

11 (10.6%)

18 (17.3%) 

16 (15.4%)

 

History of PID

23 (22.1%) 

28 (26.9%)

20 (19.2%)

 

Cervical cytology result

Negative/HPV+ve

AC-US

ASC-H

LSIL

HSIL

AGC-NOS

AGX-FN

AIS

Adenocarcinoma

 

7 (6.7%)

46 (44.3%)

2 (1.9%)

44 (42.3%)

2 (1.9%)

2 (1.9%)

1 (1.0%)

0

0

 

13 (12.5%)

39 (37.5%)

2 (1.9%)

40 (38.5%)

4 (3.8%)

3 (2.9%)

1 (1.0%)

1 (1.0%)

1 (1.0%)

 

10 (9.6%)

46 (44.3%)

2 (1.9%)

43 (41.3%)

3 (2.9%)

0

0

0

0

 

Procedure

CBD

CBD + ECB

CBD + ECC

CBD + Polypectomy

CDB + ECC + Endocel*

 

85 (81.7%)

12 (11.5%)

1 (1.0%)

5 (4.8%)

1 (1.0%) 

 

84 (80.8%)  

12 (11.5%)

4 (3.8%)

1 (1.0%)

3 (2.9%)

 

82 (78.8%)

16 (15.4%)

2 (1.9%) 

3 (2.9%)

1 (1.0%)

 

Colonoscopy diagnosis

Normal

LSIL

HSIL

 

8 (7.7%)

83 (79.8%) 

13 (12.5%) 

 

5 (4.8%) 

86 (82.7%)

13 (12.5%) 

 

2 (1.9%)

93 (89.4%)

9 (8.7%)

 

Abbreviations: AGC-NOSs, atypical glandular cells not otherwise specified; AIS, adenocarcinoma in situ; ASC-Hs, atypical squamous cells cannot exclude HSIL; ASCUS, atypical squamous cells of undetermined significance; CDB, colposcopy-directed biopsy; ECB, endocervical brushing; ECC, endocervical curettageHIV, human immunodeficiency virus; HPV, human papillomavirus; HSILs, high-grade squamous intraepithelial lesions; LSILs, low-grade squamous intraepithelial lesions; PID, pelvic inflammatory disease

*Endometrial sampling with Endocel® device    

Results 

Endpoint

Lidocaine spray (n= 104)

NSS spray (n= 104)

Control (n= 104) 

p-value

Pain scores (IQR)

Baseline

Biopsy

Biopsy to baseline change 

Post-procedure

Post-procedure to baseline change 

 

1.4 (0.3–3.5)

2.5 (1.2–4.9)

0.9 (0.0–2.3)

1.8 (0.5–3.1)

0.1 (−0.8 to 1.8)

 

1.0 (0.2–2.7)

3.1 (1.2–5.6)

1.8 (0.2–3.8)

2.3 (0.8–4.8)

1.0 (−0.1 to 2.8)

 

1.2 (0.3–3.1)

3.3 (1.3–5.3)

1.4 (0.1–2.8)

1.8 (0.8–4.0)

0.3 (−0.7 to 1.9)

 

0.53

0.51

0.03

0.18

0.03

Abbreviations: IQR, interquartile range

Adverse Events

N/A     

Study Authors Conclusion

Lidocaine spray is a simple method that could provide small pain reductions during CDBs. Nevertheless, such a reduction is small and probably is not clinically significant. Accordingly, because CDBs, though a minor procedure, can result in significant biopsy pain, as noted in this study, there is still a need for other more effective modalities. Future randomized controlled trials comparing other local cream or spray analgesics should be encouraged. 

InpharmD Researcher Critique

While findings suggested that lidocaine spray might slightly reduce pain during cervical punch biopsies, the small sample size may limit generalizability and incomplete blinding, where the no-intervention group and clinicians could not be fully blinded, may have potentially introduced bias. Comparisons with other analgesics or local creams were not conducted.
References:

Mongkolmafai O, Jeerakornpassawat D, Tantipalakorn C, et al. Efficacy of Lidocaine Spray for Pain Reduction during Colposcopy-Directed Cervical Biopsies: A Randomized Controlled Trial. Medicina (Kaunas). 2024;60(4):630. Published 2024 Apr 13. doi:10.3390/medicina60040630

 

Approach to Bartholin's abscesses and recurrences under office conditions

Design

Retrospective, observational study

N= 155 

Objective

To investigate the various treatment methods and recurrence rates regarding Bartholin's gland abscesses under office conditions in the clinic

Study Groups

Incision and drainage (n= 111)

Marsupialization (n= 22)

Incision + silver nitrate (n= 22)

Inclusion Criteria

Symptomatic Bartholin's abscess or asymptomatic abscess >3 cm who underwent Bartholin's gland sparing surgery in the clinic

Exclusion Criteria

Patients who were treated due to Bartholin's abscess in an outer center, those who received medical treatment alone, and asymptomatic patients with an abscess <3 cm

Methods

The following factors were examined: patient age, pregnancy status and duration, gland infection site, white blood cells (WBC) and C-reactive protein (CRP) levels at admission, surgical procedure, recurrence presence and frequency, and additional treatments for recurrences. Gynecological exams were repeated 12 months after the last intervention.

For the incision drainage, after cleaning the skin with iodine-based antiseptic, 2% lidocaine was used for local anesthesia on the mucosal tissue over the abscess (unspecified method of application). For the marsupialization procedure, local anesthesia with 2% lidocaine was also applied for this procedure. Silver nitrate (AgNO3) was applied to some patients who underwent the incision technique in the same session to benefit from the ablation effect on the Bartholin surface epithelium.

Duration

January 2017 to November 2020

Outcome Measures

 Recurrence of first treatment 

Baseline Characteristics

  

Incision drainage (n= 111)

Marsupialization (n= 22)

 Incision + silver nitrate (n= 22)  

Age, years

 31.85 ± 10.90 33.59 ± 8.75 29.36 ± 9.46  

Number of recurrences

 1.80 ± 1.11  1.29 ± 0.49 1.50 ± 0.71  

Gestational week (n= 20)

 20.89 ± 11.49 28.50 ± 6.36 0  

Results

Endpoint

Incision drainage (n= 111)

Marsupialization (n= 22) 

Incision + silver nitrate (n= 22)

p-value
Recurrence of first treatment 44 (39.6%) 7 (31.8%) 2 (9.1%)

0.022

Success rates of methods in cases of recurrence

How many times in total

Success rate

 

69

21 (30.43%)

 

8

8 (100%)

 

24

22 (91.67%)

 -

Adverse Events

None

Study Author Conclusions

Although Bartholin's gland abscesses can be approach using various treatment methods, a standard approach has still not been identified, due to their high recurrence rates. Methods with high recurrence rates lead to increased cost and decreased comfort for the patient. Today, the most commonly used treatment methods are incision drainage, marsupialization, and incision-silver nitrate. Our study showed that silver nitrate administration was significantly associated with a lower recurrence rate. Because incision drainage has a high recurrence rate, it should be considered a temporary solution in conditions requiring immediate rapid intervention, and the patient should be informed about the risk of recurrence.

InpharmD Researcher Critique

This study has notable limitations, including its retrospective design, which may introduce bias, and the absence of microbiological examinations in recurrent patients, potentially missing key diagnostic information.
References:

Goklu MR, Tunc S, Andan C, Aksin S. Approach to Bartholin's abscesses and recurrences under office conditions. J Gynecol Obstet Hum Reprod. 2021;50(9):102186. doi:10.1016/j.jogoh.2021.102186