QUESTION: Hi - there is an unusual case. Pt.with postmenopausal spotting as well as long history vaginismus needs an exam under anesthesia+hysteroscopy and D&C.
Considering epidural+ conscious sedation(pt.also has a phobia of general anesth).
What are your thoughts? I cannot find any literature other than treatment by botox for younger women(Pacik et.al)
Also will having the conscious sedation plus the epidural increase the risk of pt's bp dropping?
thanks so much,Ofe
ANSWER: Hi there and thanks for the question!
Well, these cases can be in three ways. Deep sedation (Mac), General Anesthesia and Spinal/Epidural. I have done many of these cases and in my experience they are often done either with sedation or general anesthesia but if a patient wanted regional I would certainly do mild sedation with a spinal. An epidural would not really be needed as these cases do not generally last longer than a spinal.
It sounds like you have done your research! Generally a spinal or epidural will cause a mild BP drop but it is never really an issue even under sedation. We have medicines which reverse that BP drop rapidly.
So from my perspective the best choice for a patient with an GA phobia would be sedation with a spinal anesthetic ;)
---------- FOLLOW-UP ----------
QUESTION: Thank you. When you say you have done "many of these cases" are you referring to EUA in vaginismus pts?
Also if so did you find even the severest level of vaginismus may still only require propofol, versed& fentanyl( or similar opiod)?
Even Pacik's pts moaned, retreated, etc under anesthesia.:( do note, of course, these pts are not undergoing tge more invasive h-scope, D&C, etc procedures)...
"-It is for all these reasons that all our patients are examined in the surgicenter so they can receive sedation and then anesthesia for the Botox injections and progressive dilation. Any patient that has the more severe forms of vaginismus will not allow a GYN exam to be performed. Any attempt is accompanied by considerable fear and retreat. We even find this to be true when the patient is under anesthesia, and often notice elevation of the buttocks and retreat even after the anesthetic has been given and the patient remembers nothing about the exam. In these cases, the anesthesia is deepened before doing an exam and introducing the intravaginal Botox injections and dilators"
Thanks again!! Ofe
Ive done a few vaginismus patients but multiple procedures similar in intensity to this. A severe vaginismus is generally done under general anesthesia with an LMA where as the much less severe cases are done with sedation. If a spinal anesthetic was used then nothing can be felt at all so it would be mild sedation just to get you through the case no matter the severity.
As for the statement "We even find this to be true when the patient is under anesthesia, and often notice elevation of the buttocks and retreat even after the anesthetic has been given and the patient remembers nothing about the exam. ". This can only be referring to sedation NOT general anesthesia. Sedation is when a patient can move with extreme stimulus but that is very rare under general and impossible under spinal.
Hope that helps!