After hysterectomy, 5 – 32% of women report chronic pain. In most women, the pain was present pre-operatively; 1-15% reported the pain as a new symptom at a 1-2 year follow-up. The origin and risk factors for persisting pain after hysterectomy are not clear. For pain reported after 1 year, risk factors were pre-operative pelvic pain, non-pelvic pain and previous Caesarean section, there were no differences between vaginal or abdominal hysterectomy. Some specific early anaesthetic and/or analgesic interventions may reduce the incidence of chronic pain after hysterectomy, e.g. spinal as opposed to general anaesthesia. ANZCA chapter 1.3, p 10; ANZAC chapter 9.1.3, ‘Post hysterectomy pain syndrome’, p 237-238.

Evidence-based treatment recommendations specific to the condition

For overview of recommended treatments and those NOT recommended see PROSPECT/abdominal hysterectomy/OVERALL Prospect recommendations

Preoperative

See PROSPECT/abdominal hysterectomy/Summary recommendations/ Prospect recommendations/pre-operative

• Systemic analgesics (e.g. IV COX-2 inhibitors, conventional NSAIDs, strong opioids), to secure sufficient analgesia when the patient wakes up.
• Low-risk patients: general anaesthesia or single shot spinal anaesthesia with or without light general anaesthesia.
• High-risk ¹ patients: epidural anaesthesia combined with light general anaesthesia or combined spinal-epidural anaesthesia.
  (¹ Patients at high risk of adverse effects from inhalation anaesthetics and high-dose opioids, e.g. at risk of organ dysfunction or undergoing extensive surgery for malignancy.)

Intraoperative

See PROSPECT/abdominal hysterectomy/Summary recommendations/ Prospect recommendations/intra-operative

• Strong opioids administered in time to secure analgesia when the patient wakes.

• Wound infiltration before closure.
• Continuous wound infiltration of bupivacaine below the superior abdominal fascia rather than above. This reduced pain scores (rest & movement), opioid consumption, PONV, hospital stay, increased satisfaction and no increase in incidence of infection at the wound site ANZCA chapter 7.5.3, p 200.
• Laparoscopically AssistedVaginal HysterectomyorVaginal hysterectomyrather than abdominal hysterectomy
• In open hysterectomy, a transverse incision is less painful than a vertical incision.
• Diathermy incision
• Active patient warming in high-risk patients
• Intra-operative music

Postoperative

See PROSPECT/abdominal hysterectomy/Summary recommendations/ Prospect recommendations/intra-operative

• Gabapentin, specifically after spinal anaesthesia, improved pain relief, was opioid sparing, reduced nausea, with no difference in sedation compared to controls. ANZCA, chapter 4.3.4 p.89.

• Whenever possible, patients should be given multimodal pain management.

  • COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
  • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs , or paracetamol. ASA section V Multimodal techniques for Pain Management, p 253-254.

Summary

Patients after hysterectomy are at risk of developing persistent pain. Use a multimodal pain management strategy. High risk patients may benefit from regional anaesthesia.

Supplementary reading

1. Allen TK, Jones CA, Habib AS.Dexamethasone for the prophylaxis of postoperative nausea and vomiting associated with neuraxial morphine administration: a systematic review and meta-analysis. Anesth Analg. 2012 Apr;114(4):813-22. Review.
2. Petersen PL, Mathiesen O, Torup H, Dahl JB. The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review. Acta Anaesthesiol Scand. 2010 May;54(5):529-35.