Patient Satisfaction and Postoperative Pain After Diagnostic Hysteroscopy: Spinal Versus General Anesthesia

BACKGROUND : Diagnostic hysteroscopy is widely performed as an ambulatory procedure to investigate abnormal uterine bleeding, infertility, and suspected intrauterine pathology. Despite being minimally invasive, it may generate discomfort and postoperative pain, particularly during cervical dilation and uterine distension. Choosing an anesthetic technique that optimizes patient comfort while preserving rapid recovery is therefore crucial.

General anesthesia with short-acting agents and supraglottic airway devices is commonly used in the operating room because it provides predictable conditions and fast emergence; however, it may be associated with postoperative nausea and vomiting and hemodynamic instability. Spinal anesthesia provides effective analgesia and stable surgical conditions, but may result in hypotension, urinary retention, post-dural puncture headache, and occasional failure requiring conversion to general anesthesia. Current evidence comparing these techniques in diagnostic hysteroscopy remains conflicting, and patient satisfaction-an important outcome in ambulatory care-has not been consistently evaluated.

This study compared spinal anesthesia and general anesthesia with a supraglottic airway in women undergoing diagnostic hysteroscopy, focusing on postoperative pain and patient satisfaction, as well as recovery outcomes and anesthesia-related adverse events.

Methods:

Study Design and Setting This prospective, randomized, single-blind controlled study was conducted over a four-month period, from September to December 2024, in the operating rooms of the Gynecology Departments A and B of Charles Nicolle University Hospital, Tunis.

Participants Adult women (≥18 years) scheduled for diagnostic hysteroscopy were screened during the pre-anesthetic consultation.

Randomization and Blinding:

Eligible patients were randomly assigned to one of two groups: general anesthesia (GA group) or spinal anesthesia (SA group). Randomization was performed preoperatively. Patients were blinded to the anesthetic technique used, whereas the anesthesiologist was not.

Anesthetic Management:

General Anesthesia: Patients in the GA group received preoxygenation followed by intravenous induction with fentanyl (approximately 3 μg/kg) and propofol (approximately 3 mg/kg). A supraglottic airway device (I-gel®) was inserted once adequate depth of anesthesia was achieved. Mechanical ventilation was provided in volume-controlled mode with lung-protective settings. Anesthesia was maintained with a continuous propofol infusion adjusted to achieve a Ramsay sedation score of 5. Intravenous paracetamol (1 g) was administered intraoperatively for postoperative analgesia. The supraglottic airway was removed after recovery of protective airway reflexes.

Spinal Anesthesia: In the SA group, spinal anesthesia was performed under aseptic conditions at the L3-L4 or L4-L5 interspace using a 25-gauge spinal needle. After confirmation of free cerebrospinal fluid flow, a mixture of hyperbaric bupivacaine 0.5% (8 mg) and sufentanil (2.5 μg) was injected intrathecally. Oxygen was administered via nasal cannula at 2 L/min. Surgery was initiated once a sensory block level of at least T10 was achieved.

Perioperative Monitoring and Management:

Standard monitoring included non-invasive blood pressure, continuous electrocardiography, pulse oximetry, and temperature measurement and (with respiratory parameters in GA groupe). Hypotension (defined as a decrease ≥20% from baseline) was treated with intravenous ephedrine boluses, and bradycardia (HR ≤ 50 beats/min) was treated with atropine as needed. Perioperative complications were recorded.

Postoperative Management and Outcomes:

All patients were transferred to the post-anesthesia care unit (PACU). Postoperative pain was assessed using the Numeric Rating Scale (NRS) in the PACU, on postoperative day 1, and day 2. Analgesic consumption and anesthesia-related adverse events were recorded. Patient satisfaction with anesthesia was evaluated before discharge using the Iowa Satisfaction with Anesthesia Scale (ISAS). Discharge readiness from the PACU was assessed using the modified Aldrete score, and readiness for home discharge was evaluated using the Post-Anesthetic Discharge Scoring System (PADSS).

Primary outcomes : patient satisfaction and pain scores. Secondary outcomes: PACU discharge delays, home discharge delays, frequency of nausea and vomiting, headache and bladder globe.

• Statistical Analysis: Sample size calculation was based on previously published data comparing postoperative pain scores between anesthetic techniques, with a power of 80% and a significance level of 5%. Data were analyzed using IBM SPSS Statistics (version 26). Continuous variables were expressed as mean ± standard deviation and compared using Student's t-test or the Mann-Whitney U test, as appropriate. Categorical variables were expressed as frequencies and percentages and compared using the chi-square test or Fisher's exact test. Multivariate logistic regression analysis was performed to identify factors independently associated with postoperative pain and patient satisfaction. A p value ≤0.05 was considered statistically significant.

Inclusion criteria

• written informed consent.
• an American Society of Anesthesiologists (ASA) physical status of I, II, or stable III in
• women scheduled for diagnostic hysteroscopy

Exclusion criteria

• operative hysteroscopy.
• contraindications to spinal anesthesia.
• known allergy to anesthetic agents.
• full stomach.
• body mass index >35 kg/m².
• history of migraine.
• communication difficulties

Patients were excluded from the final analysis in case of:

• spinal anesthesia failure requiring conversion to general anesthesia.
• failure of ventilation with a supraglottic airway requiring tracheal intubation.
• conversion to laparotomy.
• prolonged hospitalization for non-anesthesia-related complications.
• loss to follow-up after discharge.