Background
Pelvic reconstructive surgery may cause significant postoperative pain, especially
with posterior colporrhaphy, contributing to a longer hospital stay and increased
pain medication utilization. Regional blocks are being increasingly utilized in gynecologic
surgery to improve postoperative pain and decrease opioid usage, yet preoperative
pudendal blocks have not been used routinely during posterior colporrhaphy.
Objective
This study aimed to compare the effect of preoperative regional pudendal nerve block
using a combination of 1.3% liposomal and 0.25% plain bupivacaine vs 0.25% plain bupivacaine
alone on vaginal pain after posterior colporrhaphy on postoperative days 1, 2, and
3. We hypothesized that there would be a reduction in vaginal pain scores for the
study group vs the control group over the first 72 hours.
Study Design
This was a double-blinded, randomized controlled trial that included patients undergoing
a posterior colporrhaphy, either independently or in conjunction with other vaginal
or abdominal reconstructive procedures. Patients were block randomized to receive
20 mL of either a combination of 1.3% liposomal and 0.25% plain bupivacaine (study)
or 20 mL of 0.25% plain bupivacaine (control) in a regional pudendal block before
the start of surgery. Double blinding was achieved by covering four 5-mL syringes
containing the randomized local anesthetic. After induction of anesthesia, a pudendal
nerve block was performed per standard technique (5 mL superiorly and 5 mL inferiorly
each ischial spine) using a pudendal kit. The primary outcome was to evaluate postoperative
vaginal pain using a visual analog scale on postoperative days 1, 2, and 3. Secondary
outcomes included total analgesic medication usage through postoperative day 3, postoperative
voiding and defecatory dysfunction, and impact of vaginal pain on quality of life
factors.
Results
A total of 120 patients were enrolled (60 in each group). There were no significant
differences in demographic data, including baseline vaginal pain (P=.88). Postoperative vaginal pain scores were significantly lower in the combined
liposomal and bupivacaine group at all time points vs the plain bupivacaine group.
Median pain scores for the study and control groups, respectively, were 0 (0–2) and
2 (0–4) for postoperative day 1 (P=.03), 2 (1–4) and 3 (2–5) for postoperative day 2 (P=.05), and 2 (1–4) and 3 (2–5) for postoperative day 3 (P=.02). Vaginal pain scores increased from postoperative day 1 to postoperative days
2 and 3 in both groups. There was a significant decrease in ibuprofen (P=.01) and acetaminophen (P=.03) usage in the study group; however, there was no difference between groups in
total opioid consumption through postoperative day 3 (P=.82). There was no difference in successful voiding trials (study 72%, control 82%,
P=.30), return of bowel function (P>.99), or quality of life factors (sleep, stress, mood, and activity).
Conclusion
Preoperative regional pudendal block with a combination of liposomal and plain bupivacaine
provided more effective vaginal pain control than plain bupivacaine alone for reconstructive
surgery that included posterior colporrhaphy. Given the statistically significant
decrease in vaginal pain in the study group, this block may be considered as a potential
adjunct for multimodal pain reduction in this patient population.
Key words
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Article Info
Publication History
Published online: August 30, 2021
Accepted:
August 24,
2021
Received in revised form:
August 8,
2021
Received:
February 14,
2021
Footnotes
C.M.V. is on the medical advisory board for the Patty Brisben Foundation. The remaining authors report no conflict of interest.
The views expressed in this article are solely those of the authors and do not necessarily reflect the official policy or position of the US Air Force, US Army, the Department of Defense, or the US Government.
This research received no outside funding.
Clinical trial registration number: NCT04032327; date of registration: March 27, 2018; date of initial participant enrollment: July 1, 2018; available at: https://clinicaltrials.gov/ct2/show/NCT04032327.
Cite this article as: Dengler KL, Craig ER, DiCarlo-Meacham AM, et al. Preoperative pudendal block with liposomal and plain bupivacaine reduces pain associated with posterior colporrhaphy: a double-blinded, randomized controlled trial. Am J Obstet Gynecol 2021;225:556.e1-10.
Identification
Copyright
Published by Elsevier Inc.
