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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 50-55

Pharmacologic pain management in outpatient uterine fibroid embolization


1 Department of Medical Imaging, King Abdulaziz Medical City, Jeddah, Saudi Arabia
2 Department of Radiology, Umm Al-Qura University, Makkah, Saudi Arabia
3 Department of Radiology, King Fahd Hospital, Jeddah, Saudi Arabia
4 Department of Diagnostic Radiology, McGill University Health Center, Montreal, Canada

Date of Web Publication4-Sep-2018

Correspondence Address:
Dr. Azzam A Khankan
Department of Medical Imaging, King Abdulaziz Medical City, P.O. Box. 9515, Jeddah 214 23
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIR.AJIR_27_18

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  Abstract 

The key for successful uterine fibroid embolization in outpatient setting is good management of pain and other postembolization symptoms. Although several different protocols with different medication regimens have been used successfully in multiple institutions, it is still a challenge for interventional radiologists who should be prepared to provide detailed follow-up plans, continuous staff availability, and an oral medication regimen sufficient to alleviate these symptoms. Moreover, the interventional radiologist should be able to educate the patient about this postprocedural pain and available treatments.

Keywords: Outpatient setting, pain, uterine fibroid embolization


How to cite this article:
Khankan AA, Al-Habli IA, Alhazmi T, Feteih I, Valenti DA. Pharmacologic pain management in outpatient uterine fibroid embolization. Arab J Intervent Radiol 2018;2:50-5

How to cite this URL:
Khankan AA, Al-Habli IA, Alhazmi T, Feteih I, Valenti DA. Pharmacologic pain management in outpatient uterine fibroid embolization. Arab J Intervent Radiol [serial online] 2018 [cited 2018 Dec 10];2:50-5. Available from: http://www.arabjir.com/text.asp?2018/2/2/50/240490


  Introduction Top


Uterine fibroid embolization (UFE) is an effective treatment for symptomatic uterine fibroid and an alternative to traditional surgical therapies. It successfully controls symptoms in 85%–95% of patients for a median of 24 months.[1],[2],[3],[4] It was recognized and listed by the American College of Obstetricians and Gynecologists in the Level A treatment category in the management of uterine fibroids as a safe and effective treatment option based on long- and short-term outcomes.[5]

UFE is accomplished with bilateral occlusion of the uterine artery, with the end point being stasis or near stasis in the artery and with no large uterine artery branches remaining patent. As the fibroid tissue is more vulnerable to embolization than the myometrium, UFE will result in irreversible ischemia and complete infarction of fibroids with gradual reversible ischemia of myometrium.[6],[7] These myometrial ischemic changes most likely cause significant pelvic pain with variable degrees of intensity within the first 24 h. Although such pain should not be considered a complication of UFE but an expected aspect of recovery,[6] it continues to be a challenge for interventional radiologists to treat especially in outpatient setting of UFE as it is the most common reason for readmission.[8]


  Pain after Uterine Fibroid Embolization Top


Post-UFE pain is both variable and unpredictable. It is most commonly described as menstrual-type cramps within the first 24 h after the procedure. Although there is little or no pain during the procedure, the pain starts when embolization is completed. It peaks at 7 h after the procedure and it starts to improve gradually over time.[9] Its intensity is variable and ranges from mild cramps to cramps comparable with childbirth.[10] Interpatient variations occur,[11] and pain degree and experience are unpredictable in general as they are unrelated to the patient age, fibroid size and location, uterine size, and has no significant association with the size of embolic material used.[9],[12] However, the use of a large volume of embolic agents is associated with severe post-UFE pain,[13] while limited or incomplete embolization with polyvinyl alcohol particles or gelatin-coated tris-acryl polymer microspheres may produce significant effective infarction of fibroids with less severe pain.[14]

Racial difference in pain perception levels has been noted as a sole predictive factor prior to UFE as Black women recorded greater pain than White women.[9],[15] However, White women who had a greater mean volume of dominant fibroid in the reported studies are more likely to have severe nausea and emesis associated with pain than Black women.

Pain and other postembolization symptom management is the clinical challenge to perform UFE as an outpatient procedure.[16] It is the responsibility of the interventional radiologist to manage the symptoms experienced by these patients immediately after embolization.


  Mcgill University Health Center Protocol Top


At our institution, McGill University Health Center, we use a simplified protocol for pain management after UFE [Table 1]. The protocol was designed and assessed in close cooperation with the departments of anesthesiology and gynecology. It includes acetaminophen, codeine, and nonsteroidal anti-inflammatory drugs naproxen in addition to mepiridine and fentanyl, when necessary. Based on a previous study by Pisco et al[17], we started medications the night before and the day of the procedure to reduce the severity of postembolization symptoms, especially in regards to pain. After the procedure, the patient is transferred to the recovery room and aggressive treatment of pain is started until achieving the desired level of pain control. Pain is assessed on a regular basis to enable the administration of analgesics before progression to a level where pain control is virtually impossible. Switching to oral medication starts usually after 4 h. We believe that oral medication if works in hospital, will work at home. The patient will be discharged home after 6–8 h and given appropriate instructions. In general, patients are recommended to take 1 week off from work. All patients are given appropriate contact numbers for the interventional radiology service, should any problems arise, and informed to return to the emergency department in case of severe pelvic pain which is unresponsive to the treatment. Patient follow-up consists of initial telephone contact during the first few days after UFE and a clinic visit at a 3- to 4-month interval. A magnetic resonance imaging scan is obtained at the 3-month follow-up visit. Nearly 81% of patients are discharged on the day of procedure and 19% of patients are admitted for pain control and/or fever control.[16]
Table 1: McGill University Health Center protocol for outpatient uterine fibroid embolization

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  Reported Protocols Top


Although a fixed pain medication protocol cannot be recommended,[15] several different protocols with different medication regimens have been published in the literatures.[18],[19],[20],[21],[22] They have been used attempting to control the pain and manage the nausea and vomiting associated with UFE in outpatient setting. No consensus regarding the best pain management method after UFE has been achieved,[23] and most of the protocols use a combination of opioid analgesics and nonsteroidal anti-inflammatory drugs to control post-UFE pain in addition to antiemetics for the associated nausea.

In addition, the use of superior hypogastric nerve block may significantly reduce pain and the need for narcotics.[24]

The reported medication protocols in outpatient UFE are summarized in [Table 2].
Table 2: Reported medication protocols for UFE in outpatient settings

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  Patient Education Top


Most UFE patients are otherwise well and are able to communicate their experience and needs regarding pain and other symptoms. To achieve such needs, it is important to inform the patients during the initial consultation and on the morning of the procedure about the expected symptoms during the post-UFE recovery period and the medication regimen that will be used to manage these symptoms, especially the pain and vomiting. Moreover, the patient must receive a written form about all these symptoms with clear instructions regarding the adjustment in their medications, especially those prescribed for pain.

In summary, post-UFE pain in outpatient setting poses unique challenges to the interventional radiologists, who must be fully knowledgeable of the available methods and medications to provide safe and reliable pain relief, tailored for each individual patient. Both the education of patients regarding expected symptoms and the interventionalists' experience with a spectrum of medications in each category prove helpful in optimizing each patient's care and achieving individual satisfactions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Marret H, Alonso AM, Cottier JP, Tranquart F, Herbreteau D, Body G, et al. Leiomyoma recurrence after uterine artery embolization. J Vasc Interv Radiol 2003;14:1395-9.  Back to cited text no. 1
    
2.
Ravina JH, Aymard A, Ciraru-Vigneron N, Clerissi J, Merland JJ. Uterine fibroids embolization: Results about 454 cases. Gynecol Obstet Fertil 2003;31:597-605.  Back to cited text no. 2
    
3.
Spies JB, Ascher SA, Roth AR, Kim J, Levy EB, Gomez-Jorge J, et al. Uterine artery embolization for leiomyomata. Obstet Gynecol 2001;98:29-34.  Back to cited text no. 3
    
4.
Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids: Clinical results in 400 women with imaging follow up. BJOG 2002;109:1262-72.  Back to cited text no. 4
    
5.
American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol 2008;112:387-400.  Back to cited text no. 5
    
6.
Hovsepian DM, Siskin GP, Bonn J, Cardella JF, Clark TW, Lampmann LE, et al. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol 2004;15:535-41.  Back to cited text no. 6
    
7.
Ruuskanen A, Sipola P, Hippeläinen M, Wüstefeld M, Manninen H. Pain after uterine fibroid embolisation is associated with the severity of myometrial ischaemia on magnetic resonance imaging. Eur Radiol 2009;19:2977-85.  Back to cited text no. 7
    
8.
Walker WJ, Pelage JP, Sutton C. Fibroid embolization. Clin Radiol 2002;57:325-31.  Back to cited text no. 8
    
9.
Kim HS, Czuczman GJ, Nicholson WK, Pham LD, Richman JM. Pain levels within 24 hours after UFE: A comparison of morphine and fentanyl patient-controlled analgesia. Cardiovasc Intervent Radiol 2008;31:1100-7.  Back to cited text no. 9
    
10.
Siskin GP, Bonn J, Worthington-Kirsch RL, Smith SJ, Shlansky-Goldberg R, Machan LS, et al. III. Uterine fibroid embolization: Pain management. Tech Vasc Interv Radiol 2002;5:35-43.  Back to cited text no. 10
    
11.
Carr DB, Goudas LC. Acute pain. Lancet 1999;353:2051-8.  Back to cited text no. 11
    
12.
Roth AR, Spies JB, Walsh SM, Wood BJ, Gomez-Jorge J, Levy EB, et al. Pain after uterine artery embolization for leiomyomata: Can its severity be predicted and does severity predict outcome? J Vasc Interv Radiol 2000;11:1047-52.  Back to cited text no. 12
    
13.
Volkers NA, Hehenkamp WJ, Birnie E, de Vries C, Holt C, Ankum WM, et al. Uterine artery embolization in the treatment of symptomatic uterine fibroid tumors (EMMY trial): Periprocedural results and complications. J Vasc Interv Radiol 2006;17:471-80.  Back to cited text no. 13
    
14.
Spies JB. Recovery after uterine artery embolization: Understanding and managing short-term outcomes. J Vasc Interv Radiol 2003;14:1219-22.  Back to cited text no. 14
    
15.
Hehenkamp WJ, Volkers NA, Birnie E, Reekers JA, Ankum WM. Pain and return to daily activities after uterine artery embolization and hysterectomy in the treatment of symptomatic uterine fibroids: Results from the randomized EMMY trial. Cardiovasc Intervent Radiol 2006;29:179-87.  Back to cited text no. 15
    
16.
Al-Fozan H, Dufort J, Kaplow M, Valenti D, Tulandi T. Cost analysis of myomectomy, hysterectomy, and uterine artery embolization. Am J Obstet Gynecol 2002;187:1401-4.  Back to cited text no. 16
    
17.
Pisco J. How to reduce the severity of pain after uterine artery embolization of fibroid for leiomyomata. Cardiovascular and Interventional Radiological Society of Europe Annual Scientific and Postgraduate Educational Meeting 8-12 September, 2007. Athens, Greece: Springer; 2007. p. S317.  Back to cited text no. 17
    
18.
Goodwin SC, Walker WJ. Uterine artery embolization for the treatment of uterine fibroids. Curr Opin Obstet Gynecol 1998;10:315-20.  Back to cited text no. 18
    
19.
Baerlocher MO, Asch MR, Hayeems EB, Rajan DK. Uterine artery embolization – Inpatient and outpatient therapy: A comparison of cost, safety, and patient satisfaction. Can Assoc Radiol J 2006;57:95-105.  Back to cited text no. 19
    
20.
Klein A, Schwartz ML. Uterine artery embolization for the treatment of uterine fibroids: An outpatient procedure. Am J Obstet Gynecol 2001;184:1556-60.  Back to cited text no. 20
    
21.
Pisco JM, Bilhim T, Duarte M, Santos D. Management of uterine artery embolization for fibroids as an outpatient procedure. J Vasc Interv Radiol 2009;20:730-5.  Back to cited text no. 21
    
22.
Siskin GP, Stainken BF, Dowling K, Meo P, Ahn J, Dolen EG, et al. Outpatient uterine artery embolization for symptomatic uterine fibroids: Experience in 49 patients. J Vasc Interv Radiol 2000;11:305-11.  Back to cited text no. 22
    
23.
Andrews RT, Spies JB, Sacks D, Worthington-Kirsch RL, Niedzwiecki GA, Marx MV, et al. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol 2004;15:115-20.  Back to cited text no. 23
    
24.
Rasuli P, Jolly EE, Hammond I, French GJ, Preston R, Goulet S, et al. Superior hypogastric nerve block for pain control in outpatient uterine artery embolization. J Vasc Interv Radiol 2004;15:1423-9.  Back to cited text no. 24
    
25.
Rasuli P, Sabri A, Hammond I, French GJ, Gamache N, Jolly EE, et al. Outpatient uterine artery embolization for symptomatic fibroids: Short- and long-term single institution-based outcomes. J Obstet Gynaecol Can 2013;35:156-63.  Back to cited text no. 25
    
26.
Spencer EB, Stratil P, Mizones H. Clinical and periprocedural pain management for uterine artery embolization. Semin Intervent Radiol 2013;30:354-63.  Back to cited text no. 26
    



 
 
    Tables

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Introduction
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