Prior hysterectomy and discomfort during colonoscopy: a retrospective cohort analysis

Background and study aims: Discomfort during colonoscopy may affect acceptability of the procedure. The study aim was to determine factors, including prior hysterectomy and gender, associated with higher levels of patient discomfort during colonoscopy to help with procedural planning such as choice of instrument and sedation.

Methods: A retrospective cohort study of colonoscopies (n = 1098) performed between February 2007 and March 2012 at the Tees Bowel Cancer Screening Centre within the English Bowel Cancer Screening Programme (BCSP). Determinants of moderate/severe discomfort assessed using the Gloucester Scale were explored, using logistic regression with a range of participant and procedural variables.

Results: Rates of moderate/severe discomfort varied significantly among men, women without hysterectomy, and women with hysterectomy (5.8 %, 10.4 %, and 17.8 %, respectively; P < 0.001). In an unadjusted model, women with hysterectomy were significantly more likely to experience moderate/severe discomfort than those without (odds ratio [OR]1.87, 95 % confidence interval [95 %CI] 1.05 – 3.32, P = 0.005). The very strong influence of sedation on discomfort level precluded an adjusted model. In subgroup analysis of participants receiving sedation, adjusted comparison again showed increased odds for moderate/severe discomfort for women with hysterectomy, compared with women without (OR 1.70, 95 %CI 1.03 – 2.80, P = 0.036).

Conclusions: Prior hysterectomy is associated with greater levels of moderate/severe discomfort in women undergoing colonoscopy. Minimizing participant discomfort is desirable in any screening or surveillance program. This should be considered in preprocedural counseling and in selecting equipment, sedation, and analgesia. Further studies should examine methods to minimize discomfort in those with prior hysterectomy.

• References

• 1 Farraye FA, Horton K, Hersey H et al. Screening flexible sigmoidoscopy using an upper endoscope is better tolerated by women. Am J Gastroenterol 2004; 99: 1074-1080
• 2 Marshall JB, Perez RA, Madsen RW. Usefulness of a paediatric colonoscope for routine colonoscopy in women who have undergone hysterectomy. Gastrointest Endosc 2002; 55: 838-841
• 3 Brooker JC, Saunders BP, Shah SG et al. A new variable stiffness colonoscope makes colonoscopy easier: a randomised controlled trial. Gut 2000; 46: 801-805
• 4 Hoff G, Bretthauer M, Dahler S et al. Improvement in caecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: A randomized trial of patients referred for colonoscopy. Scand J Gastroenterol 2007; 42: 885-889
• 5 Bretthauer M, Thiis-Evensen E, Huppertz-Hauss G et al. NORCCAP (Norwegian colorectal cancer prevention): a randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflations in colonoscopy. Gut 2002; 50: 604-607
• 6 Geyer M, Guller U, Beglinger C. Carbon dioxide insufflation in routine colonoscopy is safe and more comfortable: results of a randomised controlled double-blinded trial. Diagn Ther Endosc 2011; Epub 2011 Jun 15
• 7 Anderson JC, Gonzalez JD, Messina CR et al. Factors that predict incomplete colonoscopy: thinner is not always better. Am J Gastroenterol 2000; 95: 2784-2787
• 8 Eloubeidi MA, Wallace MB, Desmond R et al. Female gender and other factors predictive of a limited screening flexible sigmoidoscopy examination for colorectal cancer. Am J Gastroenterol 2003; 98: 1634-1639
• 9 Elphick DA, Donnelly MT, Smith KS et al. Factors associated with abdominal discomfort during colonoscopy: a prospective analysis. Eur J Gastroenterol Hepatol 2009; 21: 1076-1082
• 10 Schoen RE, Weissfeld JL, Bowen NJ et al. Patient satisfaction with screening flexible sigmoidoscopy. Arch Intern Med 2000; 160: 1790-1796
• 11 Park D, Kim H, Park J et al. Factors affecting abdominal pain during colonoscopy. Eur J Gastroenterol Hepatol 2007; 19: 695-699
• 12 Hull T, Church JM. Colonoscopy: how difficult, how painful?. Surg Endosc 1994; 8: 784-787
• 13 Oh SY, Kim HJ, Park DI et al. Factors affecting abdominal pain during colonoscopy. Gastrointest Endosc 2006; 63: AB114
• 14 Chung YW, Han DS, Yoo KS et al. Patient factors predictive of pain and difficulty during sedation-free colonoscopy: A prospective study in Korea. Dig Liver Dis 2007; 39: 872-876
• 15 Anderson JC, Messina CR, Cohn W et al. Factors predictive of difficult colonoscopy. Gastrointest Endosc 2001; 54: 558-562
• 16 Logan RFA, Patnick J, Nickerson C et al. Outcomes of the Bowel Cancer Screening Programme (BCSP) in England after the first 1 million tests. Gut 2012; 61: 1439-1446
• 17 Lee TJ, Rutter MD, Blanks RG et al. Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme. Gut 2012; 61: 1050-1057
• 18 Saunders BP, Fukumoto M, Halligan S et al. Why is colonoscopy more difficult in women?. Gastrointest Endosc 1996; 43: 124-126
• 19 Sadahiro S, Ohmura T, Yamada Y et al. Analysis of length and surface area of each segment of the large intestine according to age, sex and physique. Surg Radiol Anat 1992; 14: 251-257
• 20 Takahashi Y, Tanaka H, Kinjo M et al. Prospective evaluation of factors predicting difficulty and pain during sedation-free colonoscopy. Dis Colon Rectum 2005; 48: 1295-300
• 21 Saunders BP, Macrae F, Williams CB. What makes colonoscopy difficult? [Abstract]. Gut 1993; 34: 181
• 22 Rostom A, Ross ED, Dubé C et al. Development and validation of a nurse-assessed patient comfort score for colonoscopy. Gastrointest Endosc 2013; 77: 255-261
• 23 Hjermstad MJ, Gibbins J, Haugen DF et al. Pain assessment tools in palliative care: an urgent need for consensus. Palliat Med 2008; 22: 895-903
• 24 Holen JC, Hjermstad MJ, Loge JH et al. Pain assessment tools: is the content appropriate for use in palliative care?. J Pain Symptom Manage 2006; 32: 567-580
• 25 Caraceni A, Cherny N, Fainsinger R et al. Pain measurement tools and methods in clinical research in palliative care: recommendations of an Expert Working Group of the European Association of Palliative Care. J Pain Symptom Manage 2002; 23: 239-255
• 26 Holme O, Bretthauer M, de Lange T et al. Risk stratification to predict pain during unsedated colonoscopy: results of a multicenter cohort study. Endoscopy 2013; 45: 691-696
• 27 Reimann FM, Samson U, Derad I et al. Synergistic sedation with low-dose midazolam and propofol for colonoscopies. Endoscopy 2000; 32: 239-244
• 28 Leung FW, Mann SK, Leung JW et al. The water method is effective in difficult colonoscopy – it enhances cecal intubation in unsedated patients with a history of abdominal surgery. J Interv Gastroenterol 2011; 1: 172-176