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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References
- Postoperative voiding dysfunction following posterior colporrhaphy.Female Pelvic Med Reconstr Surg. 2012; 18: 32-34
- Liposomal bupivacaine efficacy for postoperative pain following posterior vaginal surgery: a randomized, double-blind, placebo-controlled trial.Am J Obstet Gynecol. 2018; 219: 500.e1-500.e8
- Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials.Can J Anaesth. 2016; 63: 1184-1196
- Postoperative analgesia after total abdominal hysterectomy: is the transversus abdominis plane block effective?.Niger J Clin Pract. 2019; 22: 478-484
- The analgesic efficacy of ultrasound-guided transversus abdominis plane block with mid-axillary approach after gynecologic laparoscopic surgery: a randomized controlled trial.J Anaesthesiol Clin Pharmacol. 2015; 31: 67-71
- Pre-emptive digitally guided pudendal block after posterior vaginal repair.Int Urogynecol J. 2021; 32: 2265-2271
- Pre-emptive analgesia by nerve stimulator guided pudendal nerve block for posterior colpoperineorrhaphy.Eur J Obstet Gynecol Reprod Biol. 2012; 163: 200-203
- Preemptive analgesia in minimally invasive gynecologic surgery.J Minim Invasive Gynecol. 2019; 26: 198-218
Pacira Pharmaceuticals Inc. Exparel (bupivacaine liposome injectable suspension) [package insert]. U.S. Food and Drug Administration website. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/022496s035lbl.pdf. Accessed Aug. 8, 2021.
- Efficacy profile of liposome bupivacaine, a novel formulation of bupivacaine for postsurgical analgesia.J Pain Res. 2012; 5: 107-116
- Bupivacaine extended-release liposome injection for prolonged postsurgical analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial.Dis Colon Rectum. 2011; 54: 1552-1559
- Transversus abdominis plane block with liposomal bupivacaine for pain control after cesarean delivery: a retrospective chart review.J Pain Res. 2018; 11: 3109-3116
- Intra-incisional liposomal bupivacaine and its impact on postcesarean analgesia: a retrospective study.J Matern Fetal Neonatal Med. 2019; 32: 966-970
- Ultrasound guided subcostal transversus abdominis plane (TAP) infiltration with liposomal bupivacaine for patients undergoing robotic assisted hysterectomy: a prospective randomized controlled study.Gynecol Oncol. 2015; 138: 609-613
- Transversus abdominis plane block versus surgical site infiltration for pain management after open total abdominal hysterectomy.Anesth Analg. 2015; 121: 1383-1388
- Liposomal bupivacaine decreases pain following retropubic sling placement: a randomized placebo-controlled trial.Am J Obstet Gynecol. 2017; 217: 598.e1-598.e11
- Liposomal bupivacaine versus bupivacaine hydrochloride with lidocaine during midurethral sling placement: a randomized controlled trial.J Minim Invasive Gynecol. 2019; 26: 1133-1138
- A novel injection technique for extended-release local anesthetic after posterior colporrhaphy and perineorrhaphy: a randomized controlled study.Female Pelvic Med Reconstr Surg. 2021; 27: 344-350
- Liposomal bupivacaine during robotic colpopexy and posterior repair: a randomized controlled trial.Obstet Gynecol. 2018; 131: 39-46
- Randomized double-blind trial of short- versus long-acting analgesia at the sacrospinous ligament.Int Urogynecol J. 2019; 30: 123-130
- Psychometric testing of the Defense and Veterans Pain Rating Scale (DVPRS): a new pain scale for military population.Pain Med. 2016; 17: 1505-1519
- The effect of preemptive pudendal nerve blockade on pain after transvaginal pelvic reconstructive surgery.Obstet Gynecol. 2005; 106: 782-788
- Regional anesthesia guided by ultrasound in the pudendal nerve territory.Rev Colomb Anesteiol. 2017; 45: 200-209
- A randomized controlled trial of liposomal bupivacaine for pain following obstetrical laceration.Am J Obstet Gynecol MFM. 2020; 2: 100115
- Gaining the patient perspective on pelvic floor disorders’ surgical adverse events.Am J Obstet Gynecol. 2019; 220: 185.e1-185.e10
- Pudendal block anaesthesia in obstetrics. A review of 510 operative deliveries.Br J Anaesth. 1959; 31: 538-542
- Local anaesthetic nerve block for pain management in labour.Cochrane Database Syst Rev. 2012; : CD009200
- The anatomical distribution of the pudendal nerve block injection: a cadaveric study.Female Pelvic Med Reconstr Surg. 2021; 27: e306-e308
- Preoperative percutaneous ilioinguinal and iliohypogastric nerve block with 0.5% bupivacaine for post-herniorrhaphy pain management in adults.Reg Anesth. 1990; 15: 130-133
- Blockade of peripheral neuronal barrage reduces postoperative pain.Pain. 1997; 70: 209-215
- Postoperative pain after inguinal herniorrhaphy with different types of anesthesia.Anesth Analg. 1990; 70: 29-35
- Evidence for a central component of post-injury pain hypersensitivity.Nature. 1983; 306: 686-688
- Preemptive analgesia--treating postoperative pain by preventing the establishment of central sensitization.Anesth Analg. 1993; 77: 362-379
- Comparative perioperative pain and recovery in women undergoing vaginal reconstruction versus robotic sacrocolpopexy.Female Pelvic Med Reconstr Surg. 2017; 23: 95-100
- EXPAREL is a cost-effective option for postsurgical pain management in the hospital and ambulatory (outpatient) settings.Non-Opioid Exparel. 2021; (Available at:) (Accessed Aug. 8, 2021)
- The effect of a scheduled regimen of acetaminophen and ibuprofen on opioid use following cesarean delivery.J Perinat Med. 2020; 48: 153-156
- Ultrasound-guided pudendal nerve block in patients undergoing open hemorrhoidectomy: a double-blind randomized controlled trial.Int J Colorectal Dis. 2020; 35: 1741-1747
- The role of pudendal nerve block in colorectal surgery: a systematic review.J Invest Surg. 2020; ([Epub ahead of print])
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.
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