UCSF Essentials of Primary Care Conference Outline Squaw Creek, CA August 8, 2019 • Pain relief for office procedures • Endometrial biopsy Maximizing Skills in Office • Vulvar biopsy GYN Procedures • Bartholin duct and vulvar abscesses • Vaso-vagal syncope • IUD challenges Michael S. Policar, MD, MPH Professor Emeritus of Ob, Gyn, and Repro Sci • Contraceptive implant challenges UCSF School of Medicine [email protected]

Outpatient Procedure Pain Relief Mary 18 Year Old G0 P0 “I Am So Afraid to Have This Done!” Principles And Application

• Pre-insertion NSAIDs • Verbicaine (aka: vocal local) • Slow technique • Tenaculum site local anesthetic • Tenaculum and sound technique • Paracervical and intracervical block Non-Steroidal Anti-inflammatory Drugs Verbicaine Cochrane review, 2015 • Keep her talking! - Tramadol and naproxen had some effect on • Calm, soothing vocal tone reducing IUD placement pain in specific groups • Slow, easy pace - Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain • Utilize whatever works for the patient ASK • Conventional wisdom • Breathing techniques –Rx naproxen sodium 550 mg or Ibuprofen 800 mg • Mindful mediation –Helps mainly with post-placement cramping • Guided imagery Lopez LM et al. Interventions for pain with IUD insertion. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD007373

Distraction Language Considerations

“Most patients are worried about pain, and they are often surprised Blending when it is easier than they had compassion, expected. As we proceed, let us medical fact, and know how you are feeling so that positive suggestion we can make adjustments. We want this to go well for you.” Language Considerations… Language Considerations…

Instead of: Try: Instead of: Try: “Try taking a deep breath” • I’m going to put a “Relax” grasper on your cervix “It’s a natural reaction to lift up. See “You may notice three if you can let your hips be heavy on cramps, then we’ll be done” the table.” • Now I’m going to sound your uterus You might feel “a pinch” “You might feel a sensation or ”a stick and a burn” or “a twinge” • Here comes the Let me know if you want me to “I can see you’ve had practice with “You’re doing great” inserter tell you before each one relaxation”

Tenaculum Choose Site for Placement Tenaculum: Size of Bite

• Anterior lip • 1-1.5 cm wide • Posterior lip • 1 cm deep • Not too shallow- may tear through • Typically a horizontal bite, some prefer vertical • Not too deep- unnecessary Tenaculum Pain Reduction Tenaculum Pain Reduction

• Once the teeth are in contact with the cervix, • Some providers recommend injection of 1cc local press into the tissue anesthetic at the tenaculum site • Close the tenaculum very, very slowly – Have patient cough or use other distraction – Only to the first or second stop • Don’t move the tenaculum inadvertently – Silently • Hook fingers thru rings to place tenaculum • Once the ratchet is closed, test your application • During sounding and IUD placement, don’t hook gently to be sure it is secure your fingers through the rings…hold the shank

Palm Up Palm Up Middle finger in ring Ring Finger in Ring 1-2 Clicks Still with Palm Up – Ring Finger

Ring Finger Still Palm Up So You Can See Above Your Hand!

Tenaculum Use When Sounding

• Change hands; hold the tenaculum with the non- dominant hand while sounding and for placement Fingers NOT in rings • OK to let tenaculum lay on speculum when picking up the sound or IUD • Thumb on one side of ratchet; fingers on the other – Avoid the rings – Avoid inadvertent movements Uterine Sound: Purpose

• Ensure that you can pass through the internal os Can “Choke up” • Direction and pathway through the os to the fundus • Measures depth/distance from external os to fundus – Appropriate for IUD placement not <5.5 cm – 10 cm or more in some cases – Tells you where to set the flange – So you don’t waste the IUD

Like a Dart Or Like Pencil Uterine Sound Pain Reduction

• If metal; bend sound to mimic uterine flexion • Hold it like a pencil or dart • Use wrist action – Not elbow – Not shoulder • Brace fingertips on speculum to achieve control of force while advancing the sound

Uterine Sound Pain Reduction Uterine Sound Pain Reduction

• Touch the fundus once S-l-o-w Progression – Repeated tapping is unnecessarily • Through the internal os uncomfortable for the patient • Move slowly and intentionally • Pause once when through the internal os – Moving too quickly increases discomfort • Slow intentional progression to the fundus • If difficulty sounding, consider • Avoid momentum – EMB sampler Still Unable To Pass Through Internal Os Os Finder Device

• Place paracervical or intracervical block at any point • Use a thinner sound (endometrial sampler) • Use os finder device • Dilate internal os with small metal or plastic dilator • Try a shorter wider speculum • Reposition the tenaculum onto a different place • If unsuccessful, return after misoprostol 200 mg per vagina 10 hours and 4 hours prior to placement Cervical Os Finders (Disposable Box/25) Cervical Os Finder Set (Reusable Set of 3)

Dilators Passed Through with Sound …But not the inserter! • Dilate internal os with metal dilators • #13 french • Choke up on the handle – Divide by 3.16 to get mm (4.1 mm) • Sterile lubricant on tip • Double ended • Leave the (small) sound in the canal and come • Tapered ends ease passage through os alongside the sound with the inserter Pain with IUD Placement Cervical Lidocaine Block vs. Sham Block Anesthesia Median Pain Scores w/ 20 mL 1% Lidocaine 70 60 50 40 10-20 ml of 1% lidocaine 30 (NO epinephrine) 20 10 0

Carrie Cwiak, MD, MPH Mody et al. ObGyn 2018 No PCB PCB

Pain with IUD Insertion, Nulliparas Paracervical Block 10 mL

• Target is uterosacral ligaments, which contain the cervical and uterine nerves • Use spinal needle OR 25g, 1 ½” needle + extender • Inject at reflection of cervico-vaginal epithelium

Akers et al. ObGyn 2017 Paracervical Block

• 5-10 cc 1% lidocaine (no epinephrine) each side • Submucosal injection 5mm-1cm deep • Short speculum allows more movement • WAIT 1-2 minutes after placing block

Paracervical Block Paracervical Block

X

X X 8 o’clock 4 o’clock Paracervical Block Intracervical Block

• Targets the paracervical nerve plexus X • 1 ½ inch 25g needle with 12 cc “finger lock” syringe • Inject ½- 1 cc. at 12 o’clock, then apply tenaculum X X X X 8 o’clock 4 o’clock 6 o’clock

Intracervical Block

• Angulate needle at the hub to 45o lateral direction • At 3 o’clock, insert needle into cervix to the hub 1 cm lateral to external os, then aspirate –Inject 4 cc of local, then 1 cc while withdrawing • Rotate barrel 180o, then inject at 9 o’clock Intracervical Block Lidocaine Safety

• Inject in correct spot X • Aspirate to avoid intravascular injection • Metallic taste is a common side effect 9 o’clock X X 3 o’clock

8 o’clock 4 o’clock 6 o’clock

Maximum Local Anesthetic Dosing

Local Anesthetic Onset Max Dose (mg/kg) Max Dose (mg) 55kg pt dose (mins) without/with epi without/with epi without/with Lidocaine 4-7 4.5/7 mg/kg 300/500 mg 25/38 mL Bupivacaine 10-20 2.5 mg/kg 175 mg 55 mL Endometrial Biopsy Chloroprocaine fast 11/14 mg/kg 800/1000 mg 60/77 mL

• Rough estimates that are not evidence-based • Lower peak levels and slower absorption with vasoconstrictor • Adding bicarb (to lidocaine) speeds onset of action • Bupivacaine with less difference since med is vasoconstrictive Who Needs an EMB? Who Needs an EMB?

• Purpose: detect endometrial hyperplasia or cancer Premenopausal Women • Menopausal woman • Prolonged metrorrhagia – Any postmenopausal bleeding, if not using HT • Unexplained post-coital or intermenstrual bleeding – Unscheduled bleeding on continuous-sequential hormone • Endometrial cells on cytology in an anovulatory therapy premenopausal woman – Bleeding > 3 mo after start of continuous-combined • Atypical Glandular Cells (AGC) cervical cytology hormone therapy – Abnormal endometrial cells, or – Endometrial stripe > 5 mm (applies to postmenopausal – Older than 35 years old woman only) – Under 35 yo with abnormal bleeding – Pap smear: any endometrial cells or AGC Pap

Technique of EMB

• Bimanual exam to evaluate uterine axis, size • Cleanse cervix with antiseptic • S-l-o-w-l-y apply tenaculum ( + local anesthetic) • Use of the sampling device – Choose correct type (rigidity) of sampler – “Crack” stylet to ensure easy movement – Gently advance to fundus; expect resistance at internal os – Note depth of sounding with side markings – Pull back stylet to establish vacuum Technique of EMB Tips for Internal Os Stenosis

• Use of the sampling device (continued) • Pain relief — Rotate in a helical direction from the fundus to the os in order to use the lateral cutting edge of the port – Use para-cervical or intra-cervical block — If the sampler has filled, remove  place tissue in fixative – Intrauterine instillation of lidocaine — If the sampler did not fill, repeat 2-3 more passes • Cervical dilation — If a “curette check” for completeness is desired, perform in- – Freeze endometrial sampler to increase rigidity and-out motion in vertical strips to confirm a “gritty” feel – Grasp sampler with ring forceps 3-4 cm from tip — Cut tip of sampler and empty any remaining tissue – Use cervical “os finder” device • Remove the tenaculum; check for bleeding – Use small size Pratt or Hegar dilators • Remove the speculum – No evidence to support misoprostol priming • Move the patient to a supine position for a few minutes

Indications for Vulvar Biopsy

• Papular or exophtic lesions, except obvious condylomata • Thickened lesions (biopsy thickest region) to differentiate VIN vs. LSC Vulvar Biopsy • Hyperpigmented lesions (biopsy darkest area), unless obvious nevus or lentigo • Ulcerative lesions (biopsy at edge), unless obvious herpes, syphilis or chancroid • Lesions that do not respond or worsen during treatment • In summary: biopsy whenever diagnosis is uncertain Tools for Vulvar Biopsy Tips for Vulvar Biopsies • Insulin syringe • 1% lidocaine with or • Where to biopsy without epinephrine – Homogeneous : one biopsy in center of lesion • 2x2 or 4x4 gauze sponge – Heterogeneous: biopsy each different lesions • Unsterile exam gloves • Prep skin with antiseptic • Antiseptic solution (e.g, • Skin local anesthesia povidone-iodine or – Most lesions will require ½ cc. lidocaine or less chlorhexidine – Epinephrine will delay onset, but longer duration • Silver nitrate sticks or – Use smallest, sharpest needle: insulin syringe Monsel’s solution – Inject anesthetic s-l-o-w-l-y • Pathology container and • Alternative: 4% liposomal lidocaine (30 minutes) or EMLA label (60 minutes) pre-op Photo courtesy of Dr Hope Heafner

. Stretch skin; twist 3 or 4 mm Keyes punch back-and-forth Tips for Vulvar Biopsies until it “gives” into fat layer

• Lift circle with forceps or needle; snip base

• Hemostasis with AgNO3 stick or Monsel’s solution - Silver nitrate will not cause a tattoo - Suturing the vulva is almost never necessary • Separate pathology container for each area biopsied • LABEL the container!!! Bartholin Duct and Vulvar Abscess Management

from: Omole F, Am Fam Physician 2003

Bartholin’s Duct and Gland Conditions Bartholin Duct Cellulitis (aka: Bartholinitis, Bartholin adenitis)

• 2% lifetime risk of developing BD cyst or abscess, especially • Painful red induration of lateral perineum at 5 or 7 o’clock, during reproductive years but no palpable abscess • BD abscess is 3-times more common than BD cyst • Most commonly due to skin streptococcus • If duct becomes blocked or transected – No infection: BD cyst • Treatment – Primary infection: acute BD cellulitis or abscess – Cephalexin 500 mg PO QID or – Rarely, BD cyst is secondarily infected  abscess – Clindamycin 300-450 mg PO QID – All surgical treatments are designed to drain fluid and create a new duct – 5 day course, but extend if not improved (IDSA #15) • BG/BD carcinoma is rare; occurs in women > 40 yo – Moist heat: sitz baths, warm compresses Bartholin Duct Cellulitis Bartholin Duct Abscess

• Develops over 2-4 days; up to 8 cm diameter • Re-evaluate in 2-4 days • Tend to rupture and drain after 4-5 days – Cellulitis will either have improved or point as abscess • Pain may range from local discomfort to severe pain – If abscess develops, perform I&D – BD abscess can be so painful that the patient is • Admit immunocompromised women (especially diabetics) incapacitated; difficulty in walking or sitting for IV antibiotics and close observation • Physical exam – Risk of developing necrotizing fasciitis – Fever present in one-third of patients – Acutely tender swelling at posterior labium majora extending inwards into the base of labium minora – Occasionally track anteriorly up L majora (Rouzier, 2005)

Pregnant, diabetic, or BD Abscess immunocompromised? BD Abscess: I&D Tools and Supplies Pre-treatment

Yes No • Povidone-iodine solution Large enough • Anesthetic solution (1-2% lidocaine) + insulin needle/syringe Admit to drain? • Word catheter (diameter: #10F Foley catheter)

Yes No – 22-25 gauge needle and 5 mL-syringe, plus water or gel, for inflation of catheter tip Tolerates Moist heat manipulation Abx if induration • No. 11 blade scalpel RTC in 48-72 hours • Hemostat (for breaking up loculations) No Yes • Saline solution for irrigation Abscess Resolved I&D Conscious sedation points • Collection kits for bacterial culture and GC/Ct NAAT Word catheter in ED or office Pus: C/S + GC/Ct if STD risks BD Abscess: Tips for Word Catheter

• Consider topical skin anesthetic with EMLA • Have assistant retract abscess laterally to select incision site…immediately external to the hymeneal ring • Inject skin with 1-2 cc. lidocaine • 5-10 mm. stab with # 11 blade perpendicular to abscess • Gently lyse loculations with clamp • Irrigate cavity with saline • Insert needle into Word port; then test the bulb • Insert Word catheter; inflate (3-5cc) until snug fit in cavity • Tuck nipple into vagina

Word Catheter: Correct Position BD Abscess: Post-Drainage Management • Sitz baths and warm compresses for 2-3 days • Antibiotics not needed routinely after I&D • If residual cellulitis, SIRS, or immunocompromise, recommended antibiotic regimens include Strep: Cephalosporin (cephalexin or cefixime) And for Staph: TMP/SMX 1-2 double strength tablets PO BID or Doxycycline 100 mg PO BID – If MRSA confirmed, replace doxycycline with TMP/SMX Treatment of Vulvar Abscess Incision & Drainage

• Abscess <2 cm with mild cellulitis – Moist heat: sitz-bath, warm compresses • Dome infiltration with local anesthetic – 1st line: TMP-SMX 1-2 DS tabs BID for 5-10 days – 2nd line: doxycycline (100 mg BID) or • in A-P axis, incise point with #11 blade • Clindamycin (300-450 mg TID) – Follow-up one week later • Send culture • Abscess >2 cm or less than 2 cm and present > 1 week • Break up loculations – I&D, with packing if possible • Irrigate – Aerobic c/s for MRSA • Pack as needed – Follow-up at 2 days and 2 weeks after treatment • Saline-soaked gauze replaced daily until the defect has closed

Vulvar Abscess: I&D, then Antibiotics Treatment of Vulvar Abscess With Cellulitis

• Extensive or rapidly progressing surrounding cellulitis • Abscess size ≥5 cm • I&D, then antibiotics and serial surveillance • Location makes abscess difficult to drain completely • Antibiotics • Infection extends into other anatomic compartments (e.g., – Staph: TMP/SMX or doxycycline abdominal wall or thigh) PLUS • High likelihood of MRSA – Strept: cephalosporin or clindamycin • Systemic signs of infection • 5-10 days of therapy is recommended • Immunocompromised patient – Duration of therapy guided by resolution of symptoms • Recurrent abscess

Chen K, UpToDate. 2016 Betsy 17 year old G0 Betsy 17 year old G0

• While having her LNg IUD placed, Betsy • She recalls after the fact that she had a says, “Is this going to take much longer? I fainting spell after her HPV immunization really need to go to the bathroom” • She had told her PCP about this • What’s going on here?? problem…heart auscultation and an ECG were normal.

Vasovagal Response, Episode Or Attack Presyncopal Signs AKA: Non-cardiogenic Syncope • Facial pallor (distinct green hue) • Mechanism • Yawning – Starts with peripheral vasodilation • Pupillary dilatation – Bradycardia + drop in B/P • More likely with • Nervousness •Pain with cervical manipulation • Diaphoresis •Previous episodes of vaso-vagal fainting • Slurred or confused speech •Dehydration or NPO

Grubb BP N Engl J Med 2005 Grubb BP N Engl J Med 2005 Presyncopal Symptoms Vasovagal Prevention

• Weakness/light-headedness • Visual blurring/tunnel vision • Good hydration (electrolyte/ sports drink) • Nausea • Eat before placement • Feeling warm or cold • Prophylactically contract muscles if known history • Sudden need to go to the bathroom • Tinnitus

Grubb BP N Engl J Med 2005 Grubb BP N Engl J Med 2005

How to Abort a Vasovagal

• Isometric contractions of the extremities • Intense gripping of the arm, hand, leg and foot muscles • No need to bring the legs together or change position– just tense the muscles • These contractions push blood back into the center of the body Missing strings • ….and abort the reflex Missing String…Possibilities Missing String…Possibilities

1. IUD in-situ Malpositioned IUD, following perforation or – String coiled in canal or endometrial incorrect placement cavity 4. Embedment into the myometrium – String short, broken, or severed 5. Translocation into the abdomen or pelvis 2. Unnoticed expulsion 3. Intrauterine pregnancy

Missing String: Office Ultrasound

Prevention of Perforation: Copper IUD • No IUD string in canal • Pregnancy test negative • Office ultrasound (UTZ)

Do not use the Present Absent white stabilizing Desires Desires KUB removal retention

rod as a plunger Present Absent Extract Leave during + guidance In Situ “Formal” UTZ Expelled placement of a Present copper IUD Absent Extracted Not found Translocated Embedded? Embedded Hysteroscopy Laparoscopy 3D-UTZ or or 3D-UTZ or CT CT with contrast with contrast Missing String: No Office Ultrasound Missing String: Desires Removal •No IUD string in canal •Pregnancy test negative Extraction of IUD in-situ Desires Desires removal retention 1. Consent for uterine instrumentation procedure 2. Bimanual exam OR Attempt Ultrasound KUB extraction 3. Probe for strings in cervical canal 4. Apply tenaculum 5. Administer cervical block Extracted In Situ Absent Absent Present 6. Choose extraction device KUB Ultrasound Embedded Not felt – Emmett Thread Retriever – Patterson alligator forceps Op hysteroscopy Present Absent In Situ Absent – Ring IUD: crochet hook or 3-5 mm suction curette Extracted Translocated Expelled Translocated

Emmett Thread Retriever Thread Retriever Missing String: Desires Removal Fulcrum 1 cm from the Extraction of IUD in-situ tip of the device 7. Intrauterine exploration for a T-shaped IUD Opened and closed – Real-time ultrasound guidance may help, if available completely within the – Gently open/ close/quarter turn forceps at progressive uterine cavity depths until “purchase” of stem or arm 8. Maneuver hook along anterior, then posterior, uterine wall No cervical dilation from fundus to canal necessary 9. If embedment suspected, consider evaluation with 3-D ultrasound or pelvic CT with contrast – Extract via operative hysteroscopy or laparoscopy

Prabhakaran S, Chuang A, Contraception 2011.

Why Do CT or 3-D Ultrasound? Missing String: Desires Removal

Additional measures, as indicated • Pain management – Cervical block + oral NSAIDs for pain Answer: – Conscious sedation To decide whether to • Cervical dilation start the extraction with – Osmotic dilator laparoscopy or – Rigid dilators hysteroscopy! – Misoprostol may facilitate IUD extraction Identify the Insertion Site Implant Location After Insertion

• This location is intended • Inner side of non-dominant upper arm to avoid the large blood vessels and nerves lying within and surrounding • Overlying the triceps muscle about 8-10 the sulcus. cm (3-4 inches) from the medial Old site • If it is not possible to epicondyle of the humerus insert the implant in this location (e.g., in women with thin arms), it should • 3-5 cm (1.25-2 inches) posterior to the New site be inserted as far sulcus (groove) between the biceps and posterior from the sulcus triceps muscles as possible.

Implant Insertion Troubleshooting Implant Removal Tips • If you pierce the skin, retract and re-insert subdermally • Only attempt removal if you have localized it • If the implant protrudes from the insertion site, remove it and perform a new procedure with a new implant – Identify radiologist who can identify it on u/s • If the rod is not palpable… – Obtain u/s in your clinic – Check the applicator (purple tip of the obturator should – Can also obtain etonogestrel level if not radio-opaque be visible) • If you can feel it, you can often remove it – Use imaging (x-ray, CT, ultrasound, MRI) – Fine mosquito clamps are key – Until location is confirmed, counsel to use other method • Identify referral center for deep removals • Deep implants need to be removed to prevent migration – It takes special expertise if below the muscle fascia