Trainee’s Corner
Management of Postprocedural Uterine Artery
Embolization Pain
Johannes L. du Pisanie, MD1
Clayton W. Commander, MD, PhD1
1 Department of Radiology, University of North Carolina, Chapel Hill,
North Carolina
Charles T. Burke, MD, FSIR, FACR1
Address for correspondence Charles T. Burke, MD, FSIR, FACR, 101
Manning Drive, CB 7510 Chapel Hill, NC, 27599
(e-mail: charles_burke@med.unc.edu).
Semin Intervent Radiol 2021;38:588–594
Since the first uterine artery embolization (UAE) procedures
were performed by Ravina in 1995, UAE has become
accepted as a safe and effective alternate method for the
treatment of uterine fibroids.1–4 UAE is a minimally invasive
method for treating fibroids and adenomyosis with shorter
postoperative recovery times and faster returns to normal
daily activities compared with hysterectomy.5 Even with a
growth in its popularity, the number of UAEs performed to
treat uterine fibroids compared with hysterectomies
remains low.3,4 It has been postulated that one barrier to
wider acceptance of UAE among providers and patients is
the perception that post-UAE pain is severe and difficult to
control.6 Pain is the most reported symptom associated
with UAE with approximately 90% of patients experiencing
some level of postoperative pain compared with 30% intraoperatively.3,7 Post-UAE pain can be accompanied by other
symptoms including fever, nausea, vomiting, and malaise
which has been termed “postembolization syndrome” (PES)
and can be seen in up to 30 to 40% of patients postprocedurally.3,8,9 Both post-UAE pain and PES stem from inflammatory mediators released secondary to ischemia.3,8,9 The
foundation of pain management for UAE involves managing
pain at its various physiologic sites including the following:
the reception/transmission of painful stimuli (local anesthesia, intrauterine arterial anesthesia, and nerve blocks),
the production of inflammatory mediators (steroidal
and nonsteroidal anti-inflammatory medications), and the
recognition of pain by the central nervous system
(opiate analgesia).10 Although many periprocedural UAE
pain management approaches and interventions have
been proposed and studied, no consensus guidelines exist
to date.11 Management styles between providers differ
considerably and as such this article aims to serve as a
guide for trainees through the various multimodal noninvasive and invasive approaches employed to prevent and
treat peri-UAE pain.
Issue Theme Advances in IR; Guest
Editor, Charles T. Burke, MD, FSIR
Preoperative Management
Managing Expectations
Preoperative pain management employs both patient periprocedural counseling and pharmaceutical prophylaxis.
Post-UAE pain, which is centered in the lower abdominal
and pelvic regions, is most severe within the first few hours
postoperatively and usually peaks within the first 6 to
8 hours. This pain then slowly decreases over several hours
before more rapidly decreasing within the next 24 hours.
Over the next 2 to 3 days, the pain is usually of low level
finally subsiding by 7 to 10 days.11–13 There have been
attempts to predict a patient’s postprocedural pain severity
using baseline uterine or fibroid volume; however, the
results have not been significant.14 Managing patient expectations through preprocedural counseling on the time course
and management of post-UAE pain can help better shape a
patient’s understanding of their experience and may allay
anxieties associated with the unexpected.6
Pharmaceutical Prophylaxis
Pre-UAE pharmaceutical prophylaxis is aimed at prophylactically combating pain and nausea. Preprocedural prophylactic doses of long-acting antiemetics, anti-inflammatories,
and steroids have been utilized to reduce periprocedural
pain and nausea (►Table 1).6,15–17 Preprocedural regimens
range from minimal to aggressive. A study published on the
performance of UAE in the outpatient setting describes a
more aggressive preprocedural regimen as follows: two
doses of oral anti-inflammatory (naproxen: 1,000 mg), acid
suppression (omeprazole: 20 mg to protect the gastric mucosa), antihistamine (hydroxyzine: 25 mg), and a stool softener medications the day before the procedure followed by
IV analgesics (tramadol: 100 mg, metamizole: 2 g), IV acid
suppressors (omeprazole: 20 mg), IV antiemetics (metoclopramide: 25 mg, droperidol: 0.10 mg), and an IV anti-inflammatory (piroxicam: 20 mg) medications just before the
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588
Management of Postprocedural Uterine Artery Embolization Pain
dural sedation with the goals of pain reduction, sedation,
anxiolysis, amnesia, and motion control.18 Moderate sedation aims to safely generate a depression of consciousness
with maintenance of response to verbal instruction, arousal
upon tactile stimulation, patency of the airway, ventilatory
drive, and cardiovascular function.19 Moderate sedation is
commonly achieved with titrated IV doses of fentanyl and
midazolam.18 In some patients, general anesthesia may be
required; however, appropriate patient counseling, anesthesia evaluation, and patient selection are warranted.
Local Anesthesia
Injection of lidocaine at the vascular access site is essential to
the management of localized pain, but it is often painful
upon injection. Various injection techniques which have
been shown to reduce pain associated with local lidocaine
injection include pinching the skin at the injection site
during injection, perpendicular needle entry, prioritizing
slow subdermal and not intradermal injection, and preventing reinsertion of the needle in un-anesthetized regions
when blocking a large area.20,21 The use of bicarbonate
buffered lidocaine has also been shown to decrease the
pain associated with the intradermal injection.6,22 Ultrasound-guided injection of tumescent anesthesia around
the planned arteriotomy site is also important for reducing
pain.6
procedure.16 Another study explored the use of a single dose
of steroid (dexamethasone: 10 mg) compared with a control
(normal saline) 1 hour before UAE along with a standard
fentanyl patient-controlled analgesia (PCA) postprocedural
pain control regimen. The two groups showed similar postprocedural pain medication use; however, serum inflammatory marker concentrations and pain scores at 12 and
24 hours were significantly lower in the dexamethasone
group.15 Some providers advocate the use of preprocedural
PCA (hydromorphone) with additional loading doses of
analgesia shortly before the procedure along with preprocedural anti-inflammatories and antiemetics.6 Finally, managing preprocedural anxiety can also be aided with the use of
oral benzodiazepines such as diazepam.
Intraoperative Management
Sedation
Intraprocedural Management
Moderate Sedation
In the interventional radiology setting, moderate or conscious sedation is the mainstay method of achieving proce-
589
Intra-arterial Lidocaine
Intra-arterial lidocaine has long been used for pain reduction in hepatic chemoembolization and peripheral arteriography and has since been applied to UAE with some
efficacy.23 It is postulated that intra-arterial lidocaine has
a local analgesic effect rather than a systemic effect. Due to
lidocaine’s rapid onset and low toxicity, it has proven very
useful and safe in this application.23 Although effective at
controlling pain, a profound local vasospasm lasting approximately 10 to 20 minutes can occur.23,24 One prospective randomized controlled trial found that pain scores at
4 hours and narcotic use were significantly lower in the
lidocaine groups injected during and after embolization
compared with the control; however, the rate of complete
infarction was decreased from 75 to 38.9% when lidocaine
was injected during embolization (►Table 2).24 Similar
findings were noted in another prospective control trial
at 2 hours, but no significant difference was found beyond
2 hours (►Table 2).25 There is some heterogeneity in the
literature concerning postembolization intra-arterial lidocaine injection with one prospective randomized control
trial finding minimal to no significant difference between
lidocaine and control groups (►Table 2).26 A recent systematic review of various articles studying the use of intraarterial anesthesia in hepatic embolization and UAE showed
that it may slightly reduce the intensity of pain and amount
of postprocedural opiates used, but their results were not
significant prompting the call for further study on its
efficacy (►Table 2).27 This technique is often favored by
providers as it does not involve a second procedure and
adds minimal time to the overall procedure.
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Table 1 Pre-procedure medications that can be used to reduce
peri-procedure discomfort
Pisanie et al.
Management of Postprocedural Uterine Artery Embolization Pain
Pisanie et al.
Table 2 Comparison of study outcomes related to intraprocedural pain management techniques/protocols
Study (study type)
Comparison (group
designation)
Outcome
Pain or opiate value comparison
(no. of patients (n), p-value)
Noel-Lamy et al24
(prospective randomized)
Intra-arterial lidocaine
during UAE (A)
vs.
Intra-arterial lidocaine
after UAE (B)
vs.
Control (C)
Postprocedural pain at
4 h and opiate use were
decreased in groups A
and B.
More incomplete fibroid
necrosis in A
Mean pain at 4 h
A: 28.6
B: 35.8
C: 59.4
(n ¼ 60, p ¼ 0.001)
Duvnjak and Andersen25
(prospective randomized)
Intra-arterial lidocaine
after UAE (A)
vs.
Control (B)
Postprocedural pain at
2 h and opiate use were
decreased in group A
Mean pain at 2 h
A: 42.7
B: 61.1
(n ¼ 40, p 0.02)
Katsumori et al26
(retrospective review)
Intra-arterial lidocaine
after UAE (A)
vs.
Control (B)
No significant reductions in
pain or opiate use between
the groups
Mean pain at 3 h
A: 2.2
B: 2.9
(n ¼ 100, p ¼ 0.07)
Intra-arterial lidocaine
Superior hypogastric nerve block
Yoon et al13
(prospective randomized)
SHNB (A)
vs.
Sham procedure (B)
Postprocedural pain was
significantly decreased in
group A immediately after
UAE but not upon arrival at
PACU or beyond. Opiate
and antiemetic use was
decreased in group A
Mean pain immediately after UAE
A: 1.0
B: 2.6
(n ¼ 44, p ¼ 0.01)
Park et al31
(retrospective review)
SHNB (A)
vs.
No SHNB (B)
Postprocedural opiate use
was decreased in group A
Mean postprocedural morphine use
A: 35.9 mg
B: 51.7 mg
(n ¼ 88, p ¼ 0.08)
Embolic agent and embolization techniques
Bilhim et al32
(prospective randomized)
Initial 500–700 µm
particles in UAE (A)
vs.
Initial 350–500 µm
particles in UAE (B)
Postprocedural morphine
use was decreased in
group A. No difference in
decrease in size of uterus
and dominant leiomyoma
or clinical outcomes
Mean pain UAE (during, after)
A: 0.97, 3.42
B: 1.44, 4.71
(n ¼ 160, p ¼ 0.03, p 0.0001)
Spies et al34
(prospective randomized)
UAE with PVA particles
(A)
vs.
UAE with tris-acryl
gelatin microspheres (B)
No difference in pain
severity, frequency of
incompletely infarcted
fibroids, symptom
improvement, or patient
satisfaction between
groups
Maximum pain score after UAE
A: 3.1
B: 3.0
(n ¼ 100, p ¼ 0.87)
Han et al33
(prospective randomized)
UAE with PVA particles
(A)
vs.
UAE with tris-acryl
gelatin microspheres (B)
No difference in pain
severity fentanyl use, and
incompletely infarcted
fibroids. Group A had
higher occurrence of
transient uterine ischemia
and rescue analgesia
Mean pain score during first 24 h
A: 7.0
B: 7.3
(n ¼ 54, p ¼ 0.55)
Unilateral UAE (A)
vs.
Bilateral UAE (B)
Mean maximum pain
score, morphine dose, and
fluoroscopy time were
decreased in group A
Mean maximum pain score
A: 3.7
B: 5.7
(n ¼ 56, p ¼ 0.03)
Unilateral UAE
Stall et al36
(case–control)
Abbreviations: PACU, post-anesthesia care unit; PVA, polyvinyl alcohol; SHNB, superior hypogastric nerve block; UAE, uterine artery embolization.
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Management of Postprocedural Uterine Artery Embolization Pain
Pisanie et al.
591
Superior Hypogastric Nerve Block
The superior hypogastric nerve plexus (SHNP) innervates the
uterus, bladder, and other pelvic structures in females and as
such has been a favorable target for controlling pain in
patients undergoing pelvic procedures and with pelvic cancer–related pain.28 The SHNP lies just anterior and inferior to
the aortic bifurcation in the retroperitoneum in around 83%
of patients with the remaining lying superior to the bifurcation based on cadaveric studies.28 A superior hypogastric
nerve block (SHNB) with local anesthesia is commonly
performed under fluoroscopic guidance with a 15-degree
craniocaudal tilt. A catheter at the aortic bifurcation and the
L5 vertebral body act as targets for injection. A 21- or 22gauge 15- or 20-cm Chiba needle is inserted 2 to 5 cm below
the umbilicus and advanced to the anterior surface of the L4
or L5 vertebral body below the aortic bifurcation. Lack of
blood aspiration, the injection of contrast, and lateral views
can help confirm extravascular positioning. Local anesthesia
(10 mL ropivacaine 0.75% or 20 mL bupivacaine 0.5%) mixed
with a small volume of contrast is injected under fluoroscopic guidance with intermittent aspiration. Mild systemic
analgesia and an antibiotic (3 g IV ampicillin/sulbactam)
are also given before the procedure (►Fig. 1).3,29 The addition to overall procedure time is also minimal at around 8 to
10 minutes.10 The addition of 40 mg of triamcinolone can
also prolong SHNB analgesia from around 8 to 10 hours (as is
commonly reported) to 33.8 hours.29 Although SHNB has
been shown to be less effective at reducing pain relative to
epidural anesthesia, a recent double-blind randomized control trial showed SHNB to significantly lower mean postprocedural pain scores immediately after UAE, opiate use,
and antiemetics with no major complications as compared
with a sham procedure.13,30 Of note, pain reduction compared with the sham procedure was not significant on arrival
at the post-anesthesia care unit (PACU), or at departure from
the PACU (►Table 2).13 Finally, SHNB was also shown to
decrease the amount of post-procedural morphine used
when compared with no SHNB by 47.2% (►Table 2).31
Embolic Agent and Embolization Techniques
Choice of embolic agent and embolization techniques has
been shown to affect postoperative UAE pain levels. In
comparing the size of embolic particles used, one study
found that the initial use of small PVA particles (350–
500 μm) as compared with larger particles (500–700 μm)
resulted in significantly higher mean pain scores at 4 to
8 hours with similar postprocedural results (►Table 2).32 In
assessing the relationship between commonly used embolic
agents and postoperative pain scores, studies have shown
that there is no significant difference between nonspherical
PVA particles when compared with tris-acryl gelatin microspheres (►Table 2).33,34 A final important factor to assess is
embolization technique. Although no randomized control
trials have been conducted, the commonly accepted angiographic embolization endpoint of choice to reducing postprocedural pain is a “pruned-tree” appearance of the uterine
vasculature. The fibroid vessels are “pruned” off by the
embolization and there remains slow uterine artery flow
characterized by remnant contrast within the vessel at five
heartbeats.3,6,35 The physiologic rationale behind this endpoint is that this near-stasis within the uterine artery will
allow partial recanalization preventing myometrial ischemia
and thus a decrease in postoperative pain.35
Unilateral UAE in Select Patients
Some authors have explored the efficacy of unilateral UAE in
select patients to reduce embolization of normal myometrium; however, it is also thought that this may decrease
efficacy of the UAE, as collaterals from the contralateral
artery could maintain supply.36,37 One retrospective trial
found that only embolizing the ipsilateral uterine artery in
patients with unilateral disease (fibroids only supplied by a
single uterine artery on preprocedural imaging and intraprocedural angiography) can significantly reduce postprocedural pain and radiation dose with similar patient
satisfaction, fibroid infarction rate, and symptom resolution
as compared with standard bilateral UAE (►Table 2).36
Postoperative Management
Although postprocedural management varies, many previously studied protocols utilize some combination of opioids
nonsteroidal anti-inflammatory drugs (NSAIDs) acetaminophen at the core of their pain control regimen. A
recent systematic review of the literature concerning post-
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Fig. 1 Intraprocedural fluoroscopy images of superior hypogastric nerve block: (a) Digital subtraction aortogram of the aortic bifurcation
(arrow). (b) Needle (arrow) is directed toward the L4 vertebral body just below the region of the aortic bifurcation. (c) Lateral view of the lumbar
spine showing extravascular contrast (arrow) pooling anterior to the L4 vertebral body. Arrowhead—needle. (d) Extravascular contrast (arrow) is
noted to pool in the region of the L4 vertebral body around the level of the aortic bifurcation.
Management of Postprocedural Uterine Artery Embolization Pain
UAE pain control protocols compared the mean maximum
postprocedural pain scores between 26 different studies
with a total of 3,353 patients. The analysis splits the postprocedural pain regimens into four different groups which all
included opioids NSAIDs acetaminophen with no additional therapy (16 studies, 2,632 patients), SHNB (4 studies,
313 patients), intra-arterial lidocaine (3 studies, 238
patients), and other (steroids, ketamine, or α2 adrenergic
receptor agonists; 3 studies 170 patients). When comparing
mean maximal pain scores of the four groups, the authors
found no significant difference, concluding that opioids NSAIDs acetaminophen may be adequate in controlling
pain post-UFE. However, the authors also note that there is
large heterogeneity in the included studies and that more
investigation is needed.11
Patient-Controlled Analgesia
Some providers incorporate PCA into their regimens as an
effective opiate-based method for controlling pain.6 Although effective, opiate PCA is associated with nausea,
drowsiness, and constipation prompting some providers
to employ more local methods of pain control such as
SHNB, which has been shown to decrease the need for
PCA.38 Many studies have been conducted analyzing variations on medications in the PCA regimen and its effect on
post-UAE pain. A prospective nonrandomized trial showed
that morphine PCA was superior to fentanyl PCA at controlling pain with the possibility of increased nausea.39 Another
study found that the addition of dexmedetomidine to a
fentanyl PCA may also decreased the need for fentanyl.40
Interestingly, the above describe systematic review of the
literature on post-UAE pain treatment performed a subgroup analysis of the four groups studied and compared the
same groups now including the variable of PCA or no PCA.
The analysis showed that the addition of PCA did significantly decrease pain in patients in the included studies;
however, it again noted that further analysis is needed to
support these findings.11
IV Nonopiate Analgesia
Due to the side effects associated with opiate medications
including nausea, drowsiness, itching, constipation, and
respiratory depression, there has been move toward multimodal pain control regimens. The nausea experienced by
some patients may make it difficult to deliver oral medications and as such some providers utilize IV NSAIDS and
acetaminophen to help ensure a sustained multimodal regimen. One double-blind randomized control trial studied the
effect of four different pain regimens on post-UAE pain and
nausea: IV acetaminophen 1 g, IV ibuprofen 800 mg, IV
acetaminophen þ IV ibuprofen, and IV ketorolac 30 mg given
prior to the procedure and every 6 hours up to 24 hours along
with hydromorphone IV PCA. The study showed that the IV
acetaminophen þ ibuprofen group provided similar pain
control with less opiate use compared with the ketorolac
group (28.09 mg compared with 40.33 mg of morphine
equivalents); however, there was more nausea experienced
in the IV acetaminophen/ibuprofen group.41
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Pisanie et al.
Discharge Medications
Discharge medications rely on over-the-counter options such
as NSAIDs and acetaminophen with the addition of oral
opiate analgesia (oxycodone 5 mg/acetaminophen 325 mg)
for break through pain. Antiemetics and stool softeners are
also commonly provided.6
Conclusion
Although no consensus guidelines exist to date, a breadth of
literature exists exploring a wide variety of multimodal
approaches to managing and controlling post-UAE pain.
With the knowledge of the literature, trainees can tailor
pain control regimens which best suit their own practice
style and skillset as well as better modulate therapy on an
individual basis to provide adequate and safe post-UAE pain
control for their patients.
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