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Minimizing Pain During Vasectomy: The Mini-Needle
Grace Shih, Merlin Njoya, Marylène Lessard and Michel Labrecque* From the Department of Family and Community Medicine, University of California-San Francisco (GS), San Francisco, California, andResearch Centre of the Centre Hospitalier Universitaire de Québec (MN, ML) and Department of Family and Emergency Medicine, LavalUniversity, Québec City (ML), Québec, Canada Purpose: We describe pain scores for a modified anesthesia technique for no-
scalpel vasectomy using a 1-inch 30 gauge mini-needle.
Materials and Methods: A prospective study was performed in 277 patients who
received anesthesia using a 3 cc syringe filled with approximately 2 cc 2% lidocaine without epinephrine and a 1-inch 30 gauge needle. Local anesthesia was given directly to the vas at the expected surgical site on each side.
Results: Mean Ϯ SD pain intensity score on the 10 cm visual analog scale was
1.5 Ϯ 1.6 (95% CI 1.3–1.7) during the anesthesia and 0.6 Ϯ 1.0 (95% CI 0.5– 0.7)
during the procedure. Patients experienced less pain during anesthesia and the procedure than they expected before vasectomy (average 3.1 Ϯ 1.8, 95% CI2.8 –3.3).
Submitted for publication September 6, 2009.
Conclusions: The mini-needle technique provides excellent anesthesia for no-
Study received hospital medical director ap- scalpel vasectomy. It compares favorably to the standard vasal block and other Supplementary material for this article can be anesthetic alternatives with the additional benefit of minimal equipment and less * Correspondence: Hôpital Saint-François d’Assise D6-728, 10 rue de l’Espinay, Québec, Canada, G1L 3L5 Key Words: testis; vasectomy; anesthesia, local; pain; pain measurement
(telephone: 418-525-4444 ext. 52419; FAX: 418-525-4194; e-mail: adjunct to infiltration anesthesia, buffer- 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
1-inch needle. The mini-needle technique should Data Collection
be an acceptable alternative to the standard vasal Patients were asked to complete a preoperative question- block. It uses commonly available materials and naire in the waiting room while waiting for surgery. The requires a smaller quantity of anesthesia to pro- questionnaire included a 10 cm VAS on expected painintensity (score 0 —no pain to 10 —worst possible pain) and a 5-item VDS of overall pain expected (score 0 —no,1—mild, 2— discomforting, 3— distressing, 4 —intenseand 5— excruciating pain) during vasectomy. The ques- MATERIALS AND METHODS
tionnaire was given to a nurse after completion.
Immediately after vasectomy patients were asked to Participants
complete a postoperative questionnaire. They had no ac- Patients were recruited between January and February cess to the preoperative questionnaire. The postoperative 2007, and May and June 2009 at 2 primary care private questionnaire included assessment of actual pain related clinics and 1 family planning clinic in a tertiary care to anesthesia and actual pain related to vasectomy. Pain teaching hospital. Patients scheduled to undergo the first assessment of anesthesia and vasectomy included 3 ques- vasectomy entered the study after verbally agreeing to tions, including a 10 cm VAS of pain intensity, a 10 cm answer a preoperative and postoperative pain question- VAS of unpleasantness and a 5 item VDS of pain. VDS naire. Patients were recruited in consecutive fashion and descriptors were identical to those described. Preoperative none refused study participation. The study was reviewed and postoperative questionnaires were matched based on and accepted as an evaluation of the quality of care by the Analysis
The same ruler was used to measure VAS results in all The mini-needle technique was introduced in late 2006 at patients. All measurements and data entry were done by all 3 participating clinics. This technique replaced the an independent research assistant. The mean is with the vasal block that had been in use since NSV was SD and 95% CI. The Student t test was used to evaluate differences between surgical sites (private clinics vs hos- To perform the mini-needle technique a 3 cc syringe is pital clinic) and years (2007 vs 2009). The Pearson corre- filled with approximately 2 cc 2% lidocaine without epi- lation coefficient was calculated to evaluate the correla- nephrine. A 1-inch 30 gauge needle is attached before tion between scores reported on different pain scales.
injection. With the surgeon on the right side of the patientthe left vas deferens is secured using the traditional 3finger technique of NSV. As in the standard vas block the needle entry site is over the vas deferens, A total of 277 patients were recruited to participate midway between the top of the testes and the base of the in the study, including 84 in 2007 and 193 in 2009.
penis over the median raphe. Using the needle tip a su- Average patient age was 38 Ϯ 6 years (range 26 to perficial skin wheal is raised with approximately 0.5 cc.
The surgeon then redirects the needle directly to the vas 58). Of the 277 patients 50 (18%) were recruited at at the expected surgical site and infiltrates 0.5 to 0.75 cc the tertiary care hospital family planning clinic and anesthesia as close as possible to and even into the vas 227 (82%) were recruited at private clinics. Three deferens. The procedure is repeated for the right vas de- patients left at least 1 item of the questionnaire ferens except the superficial skin wheal is not repeated unanswered. Six of the total of 2,216 items (0.3%) since the needle reenters through the previously used site.
were unanswered, including 1 on VAS expected Vasectomy is started immediately on the left side after pain, 2 on VDS expected pain, 1 on VAS vasectomy finishing anesthesia on the right side.
pain intensity, 1 on VAS vasectomy unpleasantness In all cases the NSV technique was used to secure and and 1 on VDS vasectomy pain. These missing items extract the vas from the Vasal occlusion was achieved using thermal cautery of the prostatic end of the The lists pain outcome results. An average vas, fascial interposition with a medium Hemoclip® over of almost no pain was perceived during vasectomy, the prostatic end and excision of approximately 5 mm of mild pain was perceived during anesthesia and dis- the testicular end, which remained open In 17 comforting pain was expected before surgery. The 10 consecutive patients average total operative time from cm VAS and the 5-item VDS results for expected anesthetic injection to skin dressing was 5.0 Ϯ 1.1 min- pain correlated highly (r ϭ 0.72, p Ͻ0.0001), as did the 3 scales to measure pain during anesthesia (r ϭ A verbal announcement was made at the beginning and end of anesthesia, and at the start of vasectomy to delin- 0.71 to 0.82, each p Ͻ0.0001) and during vasectomy eate these time points for the patient. Anesthesia and (r ϭ 0.67 to 0.91, each p Ͻ0.0001). Pain scores dur- vasectomy were done by a single surgeon (ML), who per- ing anesthesia and during vasectomy correlated forms more than 1,000 cases per year. No mention or moderately (r ϭ 0.44 to 0.55, each p Ͻ0.0001). How- discussion about pain was done during or after the proce- ever, although they were statistically significant, correlations of expected pain scores with pain scores Pain outcome with mini needle anesthesia during vasectomy lower. Using the mini-needle technique the average VAS pain score for vasectomy was 0.6. In studies using a traditional vasal block that measured pain on a 10 cm VAS scale the mean pain score was 1.9 to 3.3. There are limitations to these comparisons.
These studies done at various sites and in various clinical contexts used different anesthetic prepara- tions and needle gauges, and surgeons with varying skill levels. In our study all procedures were done by 1 experienced surgeon, which may have contributed to our low pain scores. Also, given the different back- grounds of the patients in these studies, cultural or other differences in pain perception may not makethe VAS scale universally comparable. Due to theseveral variables that may influence pain perceived during anesthesia or during vasectomy were low and reported by patients comparisons across studies must be made while considering these limitations.
We compared pain intensity, unpleasantness and Our technique also compares favorably with vari- overall pain scores by surgical site and by year. There ations of the traditional vasal block. Recently SCB were no statistically significant differences among the was suggested as an alternative vasectomy anesthe- sites in any pain measure. When analyzing pain scores A 30 gauge 0.5-inch needle was used for SCB, by year, we found a statistical difference only in ex- which is similar to our mini-needle but shorter (0.5 pected pain scores. Patients in 2007 had a higher av- vs 1 inch). SCB uses an equal mixture of 1% lido- erage expected VAS score than those in 2009 (3.4 Ϯ 1.8 caine with epinephrine and 0.5% bupivacaine. Ap- vs 2.9 Ϯ 1.8, p ϭ 0.02). There were no statistically proximately 4 cc anesthesia were infiltrated in each significant differences between the 2 periods in all spermatic cord. An additional 1 to 2 cc were used for other pain measures. No adverse events were noted local anesthesia on the scrotal skin for a total of 10 except occasional perivasal ecchymosis, which did not cc compared to 2 cc for our technique. The average pain scores of 1.7 and 0.6 on a 10 cm VAS for SCBwith local anesthesia during anesthesia and vasec-tomy, respectively, were similar to those of our tech- DISCUSSION
Given the efficacy, cost-effectiveness and safety of Other variations of the traditional block include vasectomy, we must make advancements in tech- EMLA cream and anesthetic buffering. These tech- nique so that vasectomy is more used by couples who niques showed higher pain scores. EMLA cream have completed childbearing or do not want chil- combined with local anesthesia had an average VAS dren. The development of the no-scalpel technique pain score during vasectomy of 2.211 vs 0.6 for the shows that improvements in technique and social mini-needle and a VDS score of 0.612 vs 0.4 for the marketing can dramatically increase the selection of mini-needle. Buffered anesthesia had an average anesthetic VAS pain score of 1.7 vs 1.5 for the mini- propose a method that may make vasectomy a more needle and an average VAS vasectomy pain score of acceptable option by using a smaller gauge needle while minimizing the equipment needed to perform improved pain scores achieved by the mini-needle technique, no extra preparation is needed. EMLA Overall our patients reported mild pain during cream is applied to the scrotal skin 1 hour before the anesthesia and virtually no pain during vasectomy.
Since this is a descriptive study without an inherent Comparing our technique to the no-needle jet in- comparison group, we performed a literature search jector anesthesia, our VAS scores were similar to using the key words vasectomy and anesthesia in those in the study by Weiss and Li that was done in MEDLINE® in July 2009 to provide some comparison for our results. From 197 titles and abstracts we iden- pain score during anesthesia with the 30 gauge nee- tified 10 articles providing pain scores associated with dle was 1.5 vs 1.7 for the jet injector anesthetic.
Average pain score during vasectomy with the 30 additional article was found in the personal database gauge needle was 0.6 vs 0.7 for the jet injector an- esthetic. In the single group, randomized trial by When comparing the mini-needle technique with White and Maatman the average pain score during the traditional vasal block, our pain scores are anesthesia with the jet injector was 1.6, similar to our results, but during vasectomy it was higher at In the study by Aggarwal et al average pain This website was updated with mini-needle scores during anesthesia and procedure were higher information in the interim between the 2 study re- cruitment periods. The website describes the mini- These data show that the jet injector is an appro- needle technique and states that vasectomy will be priate option for vasectomy anesthesia. Known as without pain and most men describe vasectomy as the no-needle technique, it may have marketing ap- less painful than going to the dentist. This state- peal. However, it appears to have varying results ment did not appear to influence any other pain depending on provider. It may also not be suitable for all settings. The estimated cost of a jet injector is Surprisingly there was only a weak correlation $56216 and the device requires regular maintenance between expected pain and anesthesia pain scores and inspection. These factors may restrict its use in (r ϭ 0.18, p Ͻ0.001), and between expected pain and low resource settings and at clinics with low vasec- vasectomy pain scores (r ϭ 0.26, p ϭ 0.003). Never- tomy volume. Based on our study results equivalent theless, patients can be reassured that the average or improved pain control could be achieved with the pain of the procedure is less than expected.
This is a descriptive study of a modified technique The mini-needle technique uses only 2 cc 2% lido- for vasectomy anesthesia that warrants further in- caine compared to the conventional vasal block, vestigation. The next step includes a randomized, controlled trial comparing pain control with the cost of $0.10 to $0.20/cc lidocaine this has the possi- mini-needle technique vs that of the standard vasal bility for significant savings in settings with a large block and/or jet injector technique.
number of vasectomies. The small anesthetic vol-ume infiltrated directly into the surgical site did not CONCLUSIONS
alter performance of the standard NSV technique in The 30 gauge mini-needle technique is a promising any way. Minimizing the superficial wheal for the alternative to the standard vasal block, as evidenced standard vasal block is recommended to facilitate by our low pain scores. This technique may improve pain control during vasectomy and increase patient To our knowledge this is the first study to evalu- acceptability, given the smaller needle size. Since ate expected pain before vasectomy. Men expected the 30 gauge needle technique does not require extra an average of “discomforting” pain. VAS results equipment and it is done with a small volume of were significantly higher in patients operated on in anesthesia, it may be particularly suitable in low 2007 than in 2009 (3.4 vs 2.9). An explanation may resource settings and may make vasectomy even be the inclusion of a description of the mini-needle REFERENCES
1. No-Scalpel Vasectomy: An Illustrated Guide for 8. Duncan C: Pain during vasectomy: a prospective caine) in vasectomy. Ugeskr Laeger 1989; 151:
Surgeons, 3rd ed. New York: EngenderHealth audit. Br J Theatre Nurs 1999; 9: 79.
9. Li PS, Li SQ, Schlegel PN et al: External spermatic 14. Cooper TP: Use of EMLA cream with vasectomy.
2. Labrecque M, Dufresne C, Barone MA et al: sheath injection for vasal nerve block. Urology Urology 2002; 60: 135.
Vasectomy surgical techniques: a systematic re- 1992; 39: 173.
view. BMC Med 2004; 2: 21.
15. Younis I and Bhutiani RP: Taking the ‘ouch’ out— 10. Paxton LD, Huss BK, Loughlin V et al: Intra-vas effect of buffering commercial xylocaine on infil- 3. Li SQ, Goldstein M, Zhu J et al: The no-scalpel deferens bupivacaine for prevention of acute pain tration and procedure pain—a prospective, ran- vasectomy. J Urol 1991; 145: 341.
and chronic discomfort after vasectomy. Br J domised, double-blind, controlled trial. Ann R Coll Anaesth 1995; 74: 612.
Surg Engl 2004; 86: 213.
4. Haws JM, Morgan GT, Pollack AE et al: Clinical aspects of vasectomies performed in the United 11. Thomas AA, Nguyen CT, Dhar NB et al: Topical 16. Weiss RS and Li PS: No-needle jet anesthetic States in 1995. Urology 1998; 52: 685.
anesthesia with EMLA does not decrease pain technique for no-scalpel vasectomy. J Urol 2005; during vasectomy. J Urol 2008; 180: 271.
5. Xu B, Feng H and Liu XZ: No-scalpel vasectomy training in China. Adv Contracept Deliv Syst 12. Honnens de Lichtenberg M, Krogh J, Rye B et al: 17. White MA and Maatman TJ: Comparative anal- 1993; 9: 1.
Topical anesthesia with eutetic mixture of local ysis of effectiveness of two local anesthetic tech- anesthetics cream in vasectomy: 2 randomized niques in men undergoing no-scalpel vasectomy.
6. Xu B and Huang WD: No-scalpel vasectomy out- trials. J Urol 1992; 147: 98.
Urology 2007; 70: 1187.
side China. Asian J Androl 2000; 2: 21.
13. Honnens de Lichtenberg M, Krogh J, Kjersgaard P 18. Flanagan T, Wahl MJ, Schmitt MM et al: Size 7. Mumford SD: The vasectomy decision-making et al: EMLA cream (lidocaine/prilocaine) versus doesn’t matter: needle gauge and injection pain.
process. Stud Fam Plann 1983; 14: 83.
infiltration analgesia with carbocaine (mepiva- Gen Dent 2007; 55: 216.
19. Brownbill JW, Walker PO, Bourcy BD et al: Com- 22. Watts AC and McEachan J: The use of a fine- 25. Weiss RS: Re: no-needle jet anesthetic technique parison of inferior dental nerve block injections in gauge needle to reduce pain in open carpal tun- for no-scalpel vasectomy. J Urol 2006; 176: 842.
child patients using 30-gauge and 25-gauge short nel decompression: a randomized controlled trial.
needles. Anesth Prog 1987; 34: 215.
J Hand Surg Br 2005; 30: 615.
26. Aggarwal H, Chiou RK, Siref LE et al: Compara- tive analysis of pain during anesthesia and no- 20. Ram D, Hermida BL and Amir E: Reaction of 23. Labrecque M, Nazerali H, Mondor M et al: Effec- scalpel vasectomy procedure among three differ- children to dental injection with 27- or 30-gauge tiveness and complications associated with 2 ent local anesthetic techniques. Urology 2009; needles. Int J Paediatr Dent 2007; 17: 383.
vasectomy occlusion techniques. J Urol 2002; 21. Palmon SC, Lloyd AT and Kirsch JR: The effect of 168: 2495.
needle gauge and lidocaine pH on pain during 27. Zambon JV, Barone MA, Pollack AE et al: Efficacy intradermal injection. Anesth Analg 1998; 86:
24. Liu X and Li S: Vasal sterilization in China. Con- of percutaneous vas occlusion compared with traception 1993; 48: 255.
conventional vasectomy. BJU Int 2000; 86: 699.
Tudományos közlemények listája Dr. Csabai Márta 2010 Csőry Angéla, Csabai Márta, Kırössy Judit: Amikor fájnak a szavak.Szülıi érzelmi bántalmazás lélektani háttere és kapcsolata gyermekek játékával valamint CAT-ban adott válaszaival In: Német D. Harsányi G. és Szokolszky Á. (szerk): Szegedi pszichológiai tanulmányok 2010. Juhász Gyula Felsıoktatási