IUD Insertion Pain Control

IUD insertion causes pain at three points: tenaculum placement, passage of the sound and inserter through the cervix, and the uterine cramping after release. Pain is moderate on average and greater in nulliparous patients, adolescents, patients with a history of dysmenorrhoea, and patients who are anxious. Good analgesia makes the procedure easier for patient and provider and prevents patients from declining the method.

Principles.

• Ask every patient about previous pain and fear, and offer analgesia before starting.

• Use a combination of measures: counselling, oral analgesia, local anaesthetic and gentle technique.

• Never withhold analgesia because the procedure is brief.

Preparation.

• Explain each step and the sensations to expect, and agree a signal to pause.

• Give ibuprofen 400 to 800 mg orally 30 to 60 minutes before, or naproxen 500 mg orally; check for allergy, asthma triggered by NSAIDs, kidney disease and gastric ulcer.

• Allow a support person if the patient wishes.

• Empty the bladder and position comfortably.

Paracervical block.

• Draw up 10 mL of lidocaine 1% (100 mg) with a long fine needle; use buffered lidocaine if available.

• After cleaning the cervix, inject a small amount at the 12 o'clock tenaculum site, then place the tenaculum.

• Inject 5 mL at 4 o'clock and 5 mL at 8 o'clock, 1 to 3 cm deep into the cervix, aspirating before injecting.

• Wait 2 to 3 minutes before sounding.

• The maximum dose of plain lidocaine is 4.5 mg/kg (about 300 mg in a 70 kg adult); with adrenaline 7 mg/kg.

Topical measures.

• Lidocaine 2% gel 5 mL into the cervical canal or lidocaine spray 10% to the cervix for 1 to 2 minutes before the tenaculum, which reduces pain at tenaculum placement.

• Lidocaine and prilocaine cream applied to the cervix may reduce pain at tenaculum placement.

Technique.

• Avoid sudden traction; apply the tenaculum gently and release traction when possible.

• Work slowly and keep talking to the patient.

• Minimise the number of passes of the sound and inserter.

Other options. Nitrous oxide 50% with oxygen where available; a heat pack for the lower abdomen after the procedure; relaxation breathing and distraction.

Not routinely useful. Misoprostol does not reduce pain and increases side effects; routine antispasmodics and general anaesthesia are not needed in usual cases, but general anaesthesia or sedation is used for patients who cannot tolerate the procedure and for difficult insertions in theatre.

Lidocaine toxicity. Perioral numbness, metallic taste, tinnitus, agitation, seizures, arrhythmia. Stop injecting, give oxygen, treat seizures with diazepam 5 to 10 mg intravenously, and give lipid emulsion 20% 1.5 mL/kg intravenously as a bolus for severe toxicity.

Allergy to local anaesthetic. Adrenaline 0.5 mg (0.5 mL of 1 in 1,000) intramuscularly into the anterolateral thigh, repeated after 5 minutes if needed; oxygen, intravenous fluids and help.

Vasovagal reaction. Stop, lay the patient flat with legs raised, give oxygen, monitor pulse and blood pressure; atropine 0.5 mg intravenously for persistent symptomatic bradycardia.

Severe pain during insertion. Stop and assess for perforation, cervical injury or an anomaly; do not continue.

Cramping after insertion. Common for hours to days; treat with ibuprofen 400 mg orally every 8 hours for up to 3 days with food, or naproxen 500 mg orally twice daily; heat pack; rest.

Observation. Keep the patient resting for 15 to 30 minutes, check vital signs and confirm she can walk.

Analgesia at home. Ibuprofen 400 mg orally every 8 hours as needed for up to 3 days, with food, or paracetamol 1 g orally every 6 hours (maximum 4 g daily) if NSAIDs are not suitable.

Return instructions. Return if pain is severe or worsens after the first day, or with fever, heavy bleeding or missing strings.

Special groups. Nulliparous patients, adolescents and those with a history of severe dysmenorrhoea or previous painful insertion benefit most from a paracervical block. Patients with a history of sexual trauma need trauma-informed care, a chosen pace and the right to stop. Postpartum insertion is usually less painful and needs less analgesia.

Referral and escalation. Refer patients who cannot tolerate an awake procedure for insertion under sedation or anaesthesia, and refer severe or persistent pain after insertion for assessment of perforation or malposition.