Drug overdose deaths involving prescription opioids peaked at 17,029 in 2017 and subsequently decreased to 14,139 in 2019.¹ Unfortunately, drug overdose deaths have rapidly accelerated during COVID-19.² To mitigate opiate-related risks physicians, including Female Pelvic Medicine and Reconstructive Surgeons (FPMRS), have examined their opioid prescribing practices, revealing that surgeons have been prescribing more narcotic than patients require. In a study that assessed all patients over 18 years old who underwent gynecologic and pelvic floor reconstructive procedures from April to August 2016, more than half of participants reported being prescribed more opioids than they needed. The median number of opioid tablets used by the 2-week postoperative visit was fewer than 10 for all types of surgeries except laparotomy.³

Stemming from a desire to improve the postoperative recovery phase in a more holistic fashion and to minimize narcotic burden, Enhanced Recovery After Surgery (ERAS®) protocols have been growing in popularity within the past 10 years. ERAS protocols span the preoperative through postoperative care phases and aim to moderate the various physiological insults posed by surgical procedures so as to improve recovery. More recently, there are mounting data supporting the effectiveness of ERAS protocols even for FPMRS surgeries. The discussion of such protocols in this article will be limited to recommendations on multimodal analgesia. For further information, the ERAS Society maintains a compendium of specialty-specific guidance at www.erassociety.org. Recommendations specific to the FPMRS population were recently reviewed in a White Paper by the American Urogynecologic Society Quality Committee.⁴

Multimodal analgesic regimens initiated preoperatively and continued through discharge have been shown to reduce opiate consumption in FPMRS patients while providing similar pain relief. A multimodal regimen should include a standing combination of acetaminophen and a nonsteroidal anti-inflammatory (NSAID) together with a GABA analogue (see figure). This combination of therapies aims to address the pain pathway at multiple levels, providing relief without relying heavily on narcotics. A limited quantity of narcotic may be administered on an as-needed basis limited to the immediate postoperative period, with the goal of reducing total narcotic load. For minor vaginal or vulvar procedures, a home-going narcotic prescription is likely unnecessary. As postoperative nausea and vomiting (PONV) can exacerbate pain, an anti-emetic regimen should be initiated preoperatively, particularly for patients with a prior history of PONV. Similarly, avoiding constipation will improve postoperative pain control; thus a high-quality bowel regimen should be included.^5,6 In more extensive reconstructive procedures where a larger narcotic burden is anticipated, a mu-opioid receptor antagonist may be included to help prevent opioid-related constipation.

Figure. ERAS analgesic recommendations for FPMRS surgical procedures

A 2017 randomized controlled trial by Reagan and colleagues investigated a regimen consisting of preoperative and postoperative celecoxib and gabapentin, intraoperative and postoperative intravenous and oral acetaminophen and oral ibuprofen, and narcotics as needed.⁷ The control arm consisted of no specific preoperative or intraoperative medications, and a combination of ibuprofen and narcotic postoperatively. Patients in the multimodal arm used significantly fewer intravenous narcotics both intraoperatively and postoperatively, and were more likely not to use any narcotics following discharge. There were no significant differences in pain scores between groups.⁷

There has been interest in the effectiveness of field and regional blocks in general gynecologic, gynecologic oncology and FPMRS procedures. Such blocks include transversus abdominis plane (TAP) block, paracervical block, pudendal block and local incisional field blocks. Data on these specific to FPMRS procedures are limited but indicate that paracervical block may be useful in procedures that include vaginal hysterectomy.⁷ TAP block for laparoscopic/robotic procedures⁸ and pudendal block for vaginal procedures⁹ seem less effective, though given the low risk of these blocks they may be reasonable to include in a multimodal approach.

A multimodal approach to pain control after FPMRS procedures is a safe and effective means by which to manage postoperative pain while minimizing narcotic use. ERAS protocols for FPMRS procedures should be adopted in accordance with hospital-specific policies. FPMRS surgeons should continue the momentum in evaluating how to enhance recovery after FPMRS surgery with a focus on avoiding narcotics, especially when alternative regimens are as effective.