The intensity of pain in female patients after gynaecological surgeries

JOURNAL OF OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.1/2014 (32-36) 32 The intensity of pain in female patients after gynaecological surgeries (Nasilenie bólu u pacjentek po operacjach ginekologicznych) M Lewicka 1, A, D, F, M Sulima 1, B, I Brukwicka 2, C, B Stawarz 2, E Abstract - Introduction. Gynaecological surgeries are performed on women of all ages. The choice of the surgery method is dependent on the disease entity, its progression, the location of lesions, the patient s age and the surgical approach to the operated organ. The intensity of postoperative pain is directly related to the extent of the surgical intervention, regardless of the patient s individual features, her genetic predispositions or social and environmental condition. The duration of pain normally should not exceed two or three days after the surgery. The purpose of the study: The purpose of this paper was to analyse the intensity of pain in female patients after gynaecological surgeries. Materials and methods. The research was conducted in the Department of Gynaecology II of the Independent Public Hospital in Lublin on 88 women who underwent gynaecological surgeries. The research tool used was the Numerical Rating Scale - NRS. The database and statistical analysis were managed in the STATISTICA 10.0 software (StatSoft, Poland). Results. The mean pain intensity within one day after the surgery was higher (M=8) than on day three (M=4) and five (M=2). These differences were statistically significant (p<0.000001). The study has shown that the patients whose surgery was abdominal felt significantly greater pain during the first 24 hours after the operation (M=8.00) in comparison to those whose surgeries were vaginal (M=7.50) and laparoscopic (M=6.00). Conclusions. The highest intensity of pain in the group of patients who underwent gynaecological surgeries falls on the first day after the operation. Women after laparoscopic surgeries experience significantly less intense pain in the first and third postoperative day than those after abdominal surgeries. It is advisable to provide analgesic therapy to women operated on for gynaecological reasons in the postoperative period. The application of an analgesic therapy has an impact on the partial relief from pain in the majority of patients in the early postoperative period. Key words - pain, gynaecological surgeries, postoperative period. Streszczenie Wprowadzenie. Operacje ginekologiczne wykonywane są u kobiet w każdym wieku. Wybór drogi operacji uzależniony jest od jednostki chorobowej, zaawansowania choroby, lokalizacji zmian, wieku pacjentki oraz warunków dostępu do operowanego narządu. Nasilenie bólu pooperacyjnego ma bezpośredni związek z rozmiarem interwencji chirurgicznej, niezależnie od cech osobniczych chorego, uwarunkowań genetycznych, środowiskowych lub socjalnych. Czas jego trwania zwykle nie powinien przekraczać dwóch - trzech dób po operacji. Cel pracy. Celem pracy była analiza nasilenia bólu u pacjentek po operacjach ginekologicznych. Materiał i metoda. Badania przeprowadzono w II Klinice Ginekologii Samodzielnego Publicznego Szpitala Klinicznego nr 4 w Lublinie, w grupie 88 kobiet po operacjach ginekologicznych. Zastosowane narzędzie badawcze stanowiła skala numeryczna nasilenia bólu (NRS Numerical Rating Scale). Bazę danych i badania statystyczne przeprowadzono w oparciu o oprogramowanie komputerowe STATISTICA 10.0 (StatSoft, Polska). Wyniki. Wartość średnia nasilenia bólu w pierwszej dobie po operacji była większa (M=8) aniżeli w dobie trzeciej (M=4) i piątej (M=2). Różnice te były istotne statystycznie (p<0,000001). Badania wykazały, że w pierwszej dobie po operacji pacjentki, które miały wykonaną operację drogą brzuszną odczuwały zdecydowanie większe nasilenie bólu (M=8,00) aniżeli badane, u których wykonano operację drogą pochwową (M=7,50) lub laparoskopię (M=6,00). Wnioski. Największe nasilenie dolegliwości bólowych w grupie pacjentek operowanych z powodów ginekologicznych występuje w pierwszej dobie po operacji. Kobiety operowane metodą laparoskopii odczuwają istotnie mniejsze nasilenie dolegliwości bólowych w pierwszej i trzeciej dobie pooperacyjnej aniżeli chore operowane drogą brzuszną. Celowe jest prowadzenie terapii przeciwbólowej w okresie pooperacyjnym w grupie kobiet operowanych z powodów ginekologicznych. Zastosowanie terapii przeciwbólowej ma wpływ na częściowe zniesienie bólu u większości pacjentek we wczesnym okresie pooperacyjnym. Słowa kluczowe - ból, operacje ginekologiczne, okres pooperacyjny. Author Affiliations: 1. Department of Obstetrics, Gynaecology and Obstetrical- Gynaecological Nursing Faculty of Nursing and Health Sciences, Medical University, Lublin; 2. Institute of Health Protection, The Bronisław Markiewicz State Higher School of Technology and Economics in Jarosław

JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No. 1/2014 33 Authors contributions to the article: A. The idea and the planning of the study B. Gathering and listing data C. The data analysis and interpretation D. Writing the article E. Critical review of the article F. Final approval of the article Correspondence to: Magdalena Lewicka MD, PhD, Department of Midwifery, Gynaecology and Gynaecological Nursing; Faculty of Nursing and Health Sciences, Medical University of Lublin, Chodźki 6 Str., PL-20-093 Lublin, Poland, e-mail: m.lewicka@umlub.pl G I. INTRODUCTION ynaecological surgeries are performed on women of all ages. The choice of the surgery method is dependent on the disease entity, its progression, the location of lesions, the patient s age and the surgical approach to the operated organ [1,2]. Pain, as defined by the International Association for the Study of Pain, is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage [3,4,5]. Pain is a subjective sensation and in order to assess it, one needs to have the information on the following: the time and duration of the patient s pain, its intensity, location, nature as well as factors that intensify it or relieve it and the patient s expectations towards the analgesic treatment [6,7,8]. Postoperative pain is a severe pain experienced after the anaesthetic wears off. It is related to physical (nociception) and emotional components (suffering). The intensity of postoperative pain is directly related to the extent of the surgical intervention, regardless of the patient s individual features, her genetic predispositions or social and environmental condition. The duration of pain normally should not exceed two or three days after the surgery [9,10]. The correct selection of postoperative analgesia reduces the hormonal and metabolic stress, minimises the risk of complications, decreases the costs of the treatment and facilitates recovery [11-14]. The purpose of the study The aim of the study was to analyse the intensity of pain in women after gynaecological surgeries. II. MATERIALS AND METHODS The study was conducted in the Department of Gynaecology II of the Independent Public Hospital in Lublin on 88 women who underwent gynaecological surgeries. Their mean age was 41.11 ± 12.73 years old. 31.82% of the patients (n=28) were women of 35 or less, whereas 37.5% of them (n=33) were between 36 and 45. The remaining subgroup (n=27; 30.68%) were 46 or older. Almost a half of the respondents had higher education (n=43; 48.86%), while 29.55% of them (n=26) had secondary education and 21.59% (n=19) primary education. The studied patients lived predominantly in cities and towns (n=54; 61.36%), with the remaining 38.64% (n=34) residing in villages. Almost two thirds of the studied patients (n=55; 62.50%) underwent abdominal surgeries (laparotomy). Other operation methods were vaginal (n=16; 18.18%) and laparoscopic (n=17; 19.32%). The research tool used was the Numerical Rating Scale NRS. Patients were supposed to rate their pain from 0 to 10 (with 0 being no pain and 10 being maximum pain ). The authors have also used their own questionnaire developed in order to obtain the characteristics of the study group. Statistical analysis The results obtained were analysed statistically. The values of the parameters analysed were calculated to obtain mean, median and standard deviation or in the case of nonmeasurable ones cardinality and percentage. The normality of distribution related to the measurable data was assessed using the Shapiro-Wilk test. In the case of unrelated qualitative features, the chi-squared test of homogeneity was used in order to detect the differences between the subgroups analysed. In order to analyse the correlation between the characteristics studied, the chi-squared test of independence was applied. While the Mann Whitney U was utilised to compare two independent subgroups, for comparing more than two groups the the Kruskal Wallis one-way analysis of variance was used. The significance level indicating statistically significant differences was assumed to be p<0.05. The database and statistical analysis were managed in the STATISTICA 10.0 software (StatSoft, Poland).

TOTAL Days after the surgery pyralgin ketonal perfalgan diclofenac morphine dolantine TOTAL JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No. 1/2014 34 III. RESULTS Table 1. The assessment of postoperative pain intensity (NRS) in the studied group Days after the surgery mean standard deviation median mode mode quantity 1 6.95 2.61 8 8 20 3 3.99 2.09 4 4 22 5 2.16 1.38 2 2 42 Statistical analysis: Chi-squared ANOVA=130.75; p<0.000001 Table 1 presents mean values of pain intensity 1, 3 and 5 days after the respective surgeries of the studied women. On the basis of the data analysis, the mean pain intensity was found to be higher in the first 24 hours after the surgery (M=8) than on day 3 (M=4) and day 5 (M=2). These differences were statistically significant (p<0.000001). Table 2. The correlation between the intensity of pain in the postoperative period and the surgery method Day 1 after the surgery Surgery method mean median standard deviation abdominal 7.49 8.00 2.55 vaginal 6.44 7.50 2.42 laparoscopic 5.71 6.00 2.59 Statistical analysis: H =9.56; p=0.008 Day 3 after the surgery Surgery method mean median standard deviation abdominal 4.49 4.00 2.14 vaginal 3.31 4.00 1.66 laparoscopic 3.00 3.00 1.80 Statistical analysis: H =8.69; p=0.01 Day 5 after the surgery Surgery method mean median standard deviation abdominal 2.35 2.00 1.54 vaginal 1.94 2.00 0.85 laparoscopic 1.76 2.00 1.15 Statistical analysis: H =0.96; p=0.62 Table 2 shows the correlation between the intensity of pain in the postoperative period and the surgery method. The study has shown that patients who underwent abdominal surgeries felt, on the 1 st day after the surgery, significantly more severe pain (M=8.00) than those operated on vaginally (M=7.50) or laparoscopically (M=6.00). These differences were discovered to be statistically significant (p=0.008). Furthermore, on the basis of the analysis of the results, statistically significant correlations (p=0.01) were found between the pain intensity and the surgery method for the day 3 after the operation. However, the statistical analysis did not indicate towards any statistically significant differences (p=0.62) between the pain intensity and the surgery method for the day 5 after the operation. The mean value of pain intensity was 2.00 in all the subgroups, i.e. among the patients who underwent abdominal, vaginal and laparoscopic surgeries. Table 3. Painkillers applied postoperatively to the group of studied patients 1 3 5 47 44 68 13 14 14 200 23.5% 22.% 34% 6.5% 7% 7% 100% 12 12 26 54 0 1 105 11.% 11.% 24.7% 51.4% 0.0% 0.9% 100% 6 0 4 10 0 0 20 30.0% 0.0% 20.0% 50.0% 0.0% 0.0% 100% 65 56 98 77 14 15 325 20.% 17.% 30.1% 23.% 4.3% 4.6% 100% A vast majority of the studied patients (n=79; 89.77%) were subjected to an analgesic therapy in the postoperative period. The remaining patients (n=9; 10.23%) claimed to never have undergone a therapy of that kind. The study shows that 42.05% of the women (n=37) felt a partial relief from pain. 32.95% of the patients (n=29) did not experience a significant

JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No. 1/2014 35 relief from pain despite undergoing an analgesic therapy, whereas in 26.00% of the cases (n=22), the pain did not withdraw although painkillers were applied. The most commonly used drug in the first 24 hours after the surgeries was perfalgan (n=68; 34.00%). On day 3 and 5, diclofenac was applied most frequently (n=54; 51.43% and n=10; 50.00%, respectively) see Table 3. IV. DISCUSSION Gynaecological diseases are the most common cause of hospitalisation at gynaecology departments. Most patients find it exceptionally difficult, especially in the cases when the only form of treatment possible is a surgery, which is related to many complications, including pain [1, 2]. The study has shown that 62.50% of the patients in the studied group underwent abdominal surgeries (laparotomy), 18.18% of them had vaginal surgery and 19.32% - a laparoscopic surgery. The sensation of pain is an individual characteristic of every human being. The factors influencing the sensation of pain are: age, sex, race, pain threshold, emotionality, spirituality, life history and history of the relations with the environment [11-17]. Women, as compared to men, suffer more from acute postoperative pain and handle chronic pain worse. Women s pain threshold gradually increases as the time after the surgical trauma passes, which may make it necessary to modify the painkiller dose. Postoperative pain is an acute pain accompanied by hypersensitivity. A patient feels it after the intraoperative analgesia wears off it consists in an unpleasant sensory and emotional sensation. It reaches its highest intensity during the first and the second day after the surgery, whereas on days 3 and 4 after the operation, the intensity drops significantly [18-20]. The study has shown that the patients who were operated on abdominally experienced significantly more intense pain on the postoperative days 1 and 3 as compared to those who underwent vaginal and laparoscopic surgeries. The aim of analgesic treatment after gynaecological operations is the subjective improvement of the patient s somatic and mental well-being [12,21,22]. The details of an analgesic therapy should be established on an individual basis in each case, taking into consideration factors such as: the intensity and duration of preoperative pain, the location of the pain, the duration and extent of the surgery, the patient s age and body mass, the data on possible drug abuse and tolerance for opioids, cultural and psychological factors [13,14,22,23]. Proper analgesia decreases pain and improves the patient s quality of life [10,11,12,19,20,21]. Analgesic postoperative treatment in gynaecology is based on the algorithm developed by the specialists from the Polish Association for the Study of Pain and the Polish Gynaecological Society [3,12,19]. The study has shown that a vast majority of the patients studied (89.77%) underwent an analgesic therapy after the surgery. The research also indicates that 42.05% of the patients felt partially relieved of pain, whereas 32.95% of them did not experience a significant relief from pain despite having undergone an analgesic therapy. 26.00% of the studied women felt no relief from pain in spite of taking painkillers. The study has also shown that the medication used most commonly during the first 24 hours after surgery was perfalgan, whereas on days 3 and 5 it was diclofenac. The assessment of pain intensity in women treated for gynaecological reasons should be a permanent element of treatment and nursing, which could improve patients quality of life and comfort after surgeries. According to Sochacka et al. [4], interdisciplinary cooperation of different specialists should be implemented in order to fight pain. V. CONCLUSIONS 1. The greatest intensity of postoperative pain in patients who have undergone a gynaecological surgery falls on the first 24 hours after the operation. 2. Women after laparoscopic surgeries experience significantly less severe pain on the first and third day after the operation in comparison to those operated on abdominally. 3. It is advisable to provide analgesic therapy to women operated on for gynaecological reasons in the postoperative period. The application of an analgesic therapy has an impact on the partial relief from pain in the majority of patients in the early postoperative period. VI. REFERENCES [1] Kotarski J. Leczenie mięśniaków macicy metodą embolizacji tętnic macicznych. W: Postępy w ginekologii i położnictwie. Redakcja Spaczyński Marek. Poznań, Polskie Towarzystwo Ginekologiczne: 2006. [2] Skręt A. 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