Postop: Pain

Because many of us come to a hysterectomy as surgery novices, one of the things that worries us most is the prospect of pain. Chat around at the water cooler or the hairdresser's and you'll hear plenty of scary stuff. But is that realistic? No, not really. Let's look at what we're facing.

You're entitled to a plan

No matter what previous experiences you may have had with surgeries and pain, a minimum expectation of the pre-op planning process is that you and your doctors develop a pain management plan. You should know how they anticipate dealing with the expected pain, what they plan to do if that is not adequate, and what alternatives they are holding in reserve. You should also know when you may have medication and how to get it, including what to take home with you and what to do if you run out. This is very very basic (however much doctors take it for granted and don't discuss it), and you have every right to ask for a discussion of it and to participate in making those decisions.

Immediate postop pain management

One thing that can be beneficial in dealing with pain in the first hours after surgery is the use, from the Recovery Room on, of a relatively new anti-inflammatory called Toradol. It is given IV, regularly, and it seems to keep the level of pain down such that narcotics may not be required or may be required only in lesser amounts than when they are used alone. It also seems to ease the transition to oral meds, particularly of the long-acting NSAID family (such as the 12-hour dose of naproxen), and does not carry the effects of the opiates (in either allergy or constipation).

[Update 12/20/04: FDA warning about naproxen: The FDA has issued warnings about possible heart damage that may be caused by using naproxen. More on this topic in this post.]

It is also reasonable to ask your anesthetist to medicate you for nausea before you wake up in Recovery, rather than waiting for you to request such medication because you are already nauseated. If you make this request at your pre-op appointment, they should be willing to honor it. And, generally speaking, if you can get past the immediate post-op period, nausea should no longer happen to you. In fact, nausea after the first few hours typically means you're being nauseated by something you're receiving after surgery, such as your pain med, not things you received during surgery.

Two fairly common pain management setups are the patient-administered IV and the epidural block. The former is a pump, connected to your IV, that contains morphine or demerol—very potent narcotics. The pump is set for a maximum dose per hour, but you may trigger it to deliver a dose whenever you need it, up to that maximum. This allows you to pre-medicate before doing something that you feel might cause pain (like getting up) and allows you to control the amount of medication you get. This pump is typically used for one to two days, and is gradually replaced by oral medication.

The epidural involves a pump supplying numbing medication into your spinal area, to block sensation from the lower part of your body. It is generally used in conjunction with spinal anesthesia. Women who use it tend to speak very highly of it, especially in terms of promotion of early mobility. It is only left in place for a day or two.

Another, lesser-used but still valuable technique is injecting the area of your incision with numbing medications or running a small continuous drip of medication to that area. This may or may not need to be your total pain coverage.

How bad will it be?

The goal of pain management is not oblivion. Even the best drugs cannot obliterate your awareness that you've had major surgery and your body wants you to be really really careful with it. There are also some tradeoffs with narcotic pain medications that need to be kept in mind: too much will cause you to stop breathing, and excessive use can cause respiratory suppression and pneumonia predisposition as well as increasing postop constipation.

The goal of pain management, then, is making the discomfort tolerable. Note that I don't say "pain." Rather, you are aiming for a level of not-too-bad when lying still and tolerable while moving and "ouch!" with injudicious movement. You have a right to this amount of coverage, but you may need (or you may need someone with you who will do this) to advocate for your needs with busy nursing staff. If your nurses are not responsive to your needs or you feel you are undergoing excessive delays in obtaining medication, you should contact your doctor to let him know this. Even during the night, there will be an answering service that can have the doctor on call for your surgeon's practice get back to you. You should not be left in pain due to lack of medication and the medication your doctor orders for you should provide adequate relief. If you have received your limit of pain medication without obtaining acceptable relief, your doctor should be able to switch to a different drug. We all have different physical responses to different drugs, and so some drugs work for some of us better than for others. The goal should be adequate pain relief.

What about the risk of addiction?

The addictive potential of postop narcotics is very low because you are taking them for pain relief, not for the sensation of taking the narcotics themselves. Taken in the amount necessary to control pain, the pain "uses up" much of the action of the narcotic and it does not provide the sensations that cause addicts to seek it out. The duration of postop use is not at all close to the amount of time required to create any physical addiction. Neither you nor your doctor should stint on your legitimate use of narcotic medications for pain relief.

That does not, however, mean that you should not take them for the shortest necessary time. Narcotics carry negative effects as part of their normal mechanism of actions. For example, they are quite constipating. Since gas and bowel motility are some of the most pressing concerns in the first couple postop weeks, it doesn't make sense to continue adding to that problem by taking narcotics longer than necessary.

The usual practice is to be on IV or injectable (narcotic) pain meds for a day or two postop. These are gradually replaced by oral drugs, usually those containing a narcotic such as codeine. Codeine and other oral narcotics have the same constipating effects as the injectables. So while they may be good at controlling pain, they are also not a great long term management drug. Many women go directly from injectables/IV narcotics to oral anti-inflammatories, or use anti-inflammatories to stretch the effects of oral narcotics. In the first few postop weeks at home, anti-inflammatories can gradually replace narcotics while providing still-adequate coverage.

One of the most convenient anti-inflammatory drugs is naprosyn (naproxen), because it has a 12-hour duration of action. This means you can take it at bedtime and still wake up with some in your system in the morning. Using the 4-6 hour anti-inflammatories can mean waking up in the morning in discomfort. Since some asthmatics or those with cardiovascular disease may be sensitive to this whole family of drugs, be sure to ask your doctor about what drugs you should take even when you are ready to leave the narcotics.

Now, all of this presupposes that you are not already on a pain management program or do not have an addictive problem. If this is the case, then you will obviously need to involve your therapists in your operative planning so that you meet your increased pain control needs without derailing your present level of control. The fact of a previous narcotic addiction should not mean that you cannot control your pain during your recovery, but it will obviously mean that you have a greater need for pre-planning and monitoring the situation.

Pain and medication on discharge from the hospital

By the time you are released from the hospital, you should be able to get around and get by, within the limits of exercise tolerance, on fairly mild oral medications. The gas/constipation problem is the source of the most discomfort in the first post-op week or so, and it yields better to specific medications/approaches (lots of fiber, drinking lots and lots of liquids, exercise, stool softeners) than to pain meds (and opiates are especially bad in that they slow your bowel activity down and compound the problem).

What about if my prescription runs out and I'm still hurting?

Your doctor sends you home from the hospital with a standard prescription. That doesn't mean that this is all you can have. If you have used the pills as directed and find that you are running out and will need more, call your doctor's office and let them know. Often, they are more than willing to call a refill to your pharmacy. Other times, they may suggest alternatives that will be effective for the point you're now at in recovery. Whatever the plan, don't feel you have to suffer once the first prescription runs out.

Do be sure, however, that you understand how and how often your take-home pain meds are to be taken. Typically the prescription reads something along the lines of "Take 1-2 every 4-6 hours as needed." That means that you may take them that often (if you need that level of pain relief), not that you must take them that often (to get any relief). All too often women in the fluster of getting ready to be discharged from the hospital are handed a fistful of papers and hear only "2 every 4 hours" and just tear through their prescription and wonder why, a few days later, the prescription that they thought was to last them till their two-week checkup is all used up. Those dose intervals are the most frequent at which you can safely use that medication; it's fine if you don't need to take it that often or if you find that you need only 1-2 in a whole day, just to give a little extra boost to your non-prescription medications.

On the other hand, if you need more medication than that or you feel that even at the largest/most frequent dose you're not getting adequate coverage, it's a good idea to call your doctor about this as well. Your prescription is based on your doctor's expectations of how you should be doing, given your surgery and the speed/extent of recovery he sees when he visits you in the hospital. If you are not progressing as he thought you might, you may need a recheck to be sure everything is going as it should. Your doctor makes treatment decisions based on what he sees in the hospital; he can't see you once you are at home, so if things change, it's your responsibility to let him know that.

You should expect, and demand if necessary, a reasonable and adult discussion of these things at your pre-op appointment. If your doctor is not willing to allow your participation in pain management planning or to discuss his plans with you, then you might be well advised to seek another consult. A surgery is about your needs, not the doctor's.

Preop concerns

Many of us come to this surgery as complete novices and when our doctors' appointments are rushed, we don't always get to explore all the questions we might have. Today I'm going to look at some of the questions I see asked a lot on HysterList.

What if I'm having my period when it comes time for surgery?

Don't sweat it. It is truly irrelevant to the surgery, so long as you don't get such a head start on things that you get anemic right beforehand. Call your dotor's office and check, but I suspect that their only concern would be that you wear a pad, rather than using tampons, just to limit what's had a chance to grow in there (sorry to be gross). But many women have gone to the OR wearing a pad, and it will be dealt with once you are anesthetized. It's not something that the OR crew is going to give a second thought to, really.

Look at it this way: how better to celebrate than to go in gushing and to come out spotting?!

Does the nausea go away before they release you from recovery or will the nausea continue?

It depends on whether the nausea is in response to anesthesia, in which case it'll go away, or the pain meds you're getting, in which case it may linger as long as you get that particular drug. Generally speaking, if it lasts more than a few hours after you get back to your room, you need to consider asking for a pain med switch.

Can we shave ourselves prior to coming to the hospital or must we let them do it?

Yikes, no! Be sure sure sure you ask your doctor about this. Some will okay it, but others feel that the slightest nick exposes you too much to the risk of infection. I've seen surgeons walk out of the room and cancel a surgery when they found self-shaved patients. Don't get all modest—the nurses in pre-op are very low-key about this and won't make you feel like a spectacle and by and large will do a better job than you can. And many docs no longer feel a full shave is necessary: mine just had the nurse run one swath across the top with the clippers, down to about 1/4", to keep the hair ends out of my just-above-pubes-line incision. And I was pretty grateful later, when all I had to suffer the crazy-itchies-stickery-grow-back from was that little line.

What is a "bowel prep"? Does everyone having a hysterectomy have to have this done?

It's some method of cleaning out your large intestine, whether laxative or enema or one of the new "lytely" drinks. The objective is to lower the bacterial counts in the bowel and to prevent post-op constipation.

Please do not do this unless instructed to by your physician.

I apologize for shouting, but this is very important. Not every surgeon wants their patients to go through this, and because it can have serious effects on your operative/post-op fluid status, it's very important that you do exactly as he tells you so your status is exactly as he expects.

Think I'm over-dramatizing? Consider this story:

In the chat room of a big hysterectomy board a couple years ago all of the "knowledgeable and experienced" women present encouraged a poor scared pre-op lady to do her own bowl prep "just to be safe" even though her doc had not ordered one for her. She did this according to their instructions, and was so dehydrated from the process that she required many extra hours and considerable extra treatment in the Recovery Room before she was stable enough that she could go to her room. Yes, from just a little bowel prep, and the surgeon/anesthesiologists' assumptions about her status that she made incorrect by her actions.

So please, discuss this with your own surgeon, who best knows how he plans to do the surgery and what your own physical condition is. And if he does want you to do a prep, he will specify the agent and when and how it is to be taken. If for some reason you don't get these directions, call the office, call the on-call service—call until you do get clear, personal directions on how your own surgeon wants this procedure done. It's for your own good, and, really, isn't the best possible surgical outcome what we're all rooting for?

Why would your doctor not want you to do this prep? Many surgeons believe it's an outdated concept in that you cannot sterilize the bowel in the time and with ordinary measures, so the risks of the stress are worse than the risks of puncture and contamination. Obviously, women with rectal repairs don't fit into this picture, and may have special preps.

The same thing, by the way, goes for pre-operative douches and any other schemes you might cook up or have helpful folks recommend. Aside from a good diet, cutting down on caffeine, and major hydration, you should only do what your doctor tells you to do: no more, no less.

My doctor said to take a fleets enema the night before and also a betadine douche. Why can't the enema and the douche be taken on the morning of the surgery?

There may be more prep then, but the really crucial thing is the timing. You need to not be responding to the enema as they are taking you into the OR, and you need to have had all that douche drained out and the bacteria as discouraged as possible (takes time) before surgery.

Also, is a betadine douche sold over the counter?

Yes, it should be. I suggest buying all your prep items at least several days beforehand, so that if your chosen outlet is out of them, you have time to locate them without being in a pre-op panic.

Also, if you have never had a betadine douche, test a little on your inner labia for about 15 minutes, just to be sure you're not allergic to or excessively irritated by the betadine. Some women can tolerate it on regular skin just fine, but it's too severe for their more delicate vaginal membranes. Burning or itching would be what you'd experience. It's one of those things it's good to figure out before you douche with it—your doctor does not want to look in there ready to do the surgery and find blisters, oh no. And unless you've been instructed differently, do the douche after you have emptied out from the enema and washed up well with regular soap and water. Beyond that, read the directions on the douche (if you haven't been given others on how to do it, how long to hold it in, etc.) and follow them.

What supplements and stuff do I need to stop taking for my surgery?

There's an interesting article from the American Medical Assoc. that succinctly sums up which herbs to stop when, and why. If you have trouble accessing it, just know that "the eight most commonly used herbs that can impact surgery are valerian, echinacea, ephedra, ginko biloba, kava, garlic, ginseng and St. John's wort."

The article also offers "the following guidelines for discontinuing herbal use before surgery:"

Ephedra, ginko and kava - stop using 24 to 36 hours before surgery Garlic, ginseng and St. John's wort - stop using one week before surgery Valerian and Echinacea - start tapering off use two weeks before surgery

The author says "prospective surgery patients should also check the ingredients in vitamin supplements to see what herbs may be included."

Do be sure to include all the herbals and vitamins and otc meds you might be taking when you have that "what are you taking" chat with your surgeon and anesthesiologist. Quite a few really innocent-sounding things will interact with anesthesia (which is really a whole bunch of different drugs, carefully balanced to work together) and pain meds and antibiotics. This just isn't a time to second-guess them: tell all. And if you are taking a combo supplement product, lug the bottle along (or transcribe the ingredient list: there are too many brands and the name won't mean nearly as much as what's really in it). Don't rely on your memory for this, either. Write out a list to give your doctor to put in your chart. And when you're discussing them, do ask your doctor when it will be okay to resume taking them.

I'm not wild about the idea of getting a transfusion. Who would I ask to be very cautious in doing this?

Everyone: your surgeon, their assistant, anesthesia, pre-op nurse who checks you in, circulating nurse in the OR, recovery room; have your spouse or whoever might be "tending" you in the first night after surgery be prepared to mention it to floor nurses as well. You and your surgeon should discuss beforehand and come to an agreement just when he'll transfuse you (just how far your red count will have to drop, what other measures must be employed first, before you'll agree to it). If a blanket permission to transfuse is in your operative permit, be sure to add your stipulations to the permit and have you and your doctor or the witness both initial the addendum. If you have a spouse or other who will be standing by for you, be sure to include them in this discussion, as they may be the ones to advocate for your desires if you are still under anesthesia or too groggy to make a sound judgment.

My mother said that when she had surgery, the preop room was so cold she nearly froze to death. Why do they go out of their way to make you miserable?

Many women have questioned getting colder on their way to the OR or waking up in Recovery shivering. This is actually normal and even desirable. No, not to make you fear things worse, although that certainly happens if you are not expecting it and let it add to your panic.

In fact, you are deliberately chilled down as you go into surgery and even more so during surgery. This lowering of your body temperature helps slow your metabolism down, causing less bleeding, making smaller doses of drugs go further, and generally making the whole procedure less stressful on your body.

Once you reach Recovery, you will be bundled up in warmed blankets, given warmed IV fluids and generally helped to return to your normal body temp again. By the time you get to your room, you should start gradually kicking those blankets off and icewater sips will become very welcome as you try to moisten your dehydrated mouth and body back up (getting oxygen and air is very dehydrating, not to mention the fact that when you aren't conscious, you don't swallow and keep your mouth moistened—also a good reason for doing a super job of brushing your teeth pre-op).

So when you notice that you are getting cold, don't worry and don't fight it. If anything, try to embrace it with a calming mind and a positive vision of a successful surgery and smooth recovery to a new healthier, pain-free you.

What is it like when you are under general anesthesia?

It's not. Like anything, that is—it's like it's not there, that part of time. You simply live on from one moment to the next, and it's only the mangled context that tells you that things have gone on without you.

I had Versed (the amnesia drug) as a pre-op, and while it did help keep me mellow, it never did make me oblivious and I remember a lot of what went on getting settled in the operating room before I was given anesthesia (I recognized the circulating OR nurse's voice through party noises a week and a half later, not to mention remembering talking with her and the anesthesiologist). I respond atypically to drugs, though, so don't go by my experience. Actually, even though its effect was limited, it was just fine and left me with enough wits about me to get myself into a very relaxed, accepting, positive frame of mind (I am very into positive imaging) just as the anesthesiologist said he was ready to start my anesthesia.

And the next thing I know, the very next instant later, I was skunching from the stretcher over onto my bed after surgery. That's it: nothing at all in between, including any sense that time had passed. And once I was that awake, I was drowsy but fully lucid.

And that is how general anesthesia typically feels.

If you have your procedure under a spinal, you may, depending on how you and your surgeon feel about it, be sedated but semi-awake.

I actually wanted to do this (I'm not especially squeamish) but my surgeon said that my uterus was so huge that in order to get it out through a reasonable-sized incision, he needed me fully relaxed, not trying to look around and ask questions (we only met in referral for this surgery, but it didn't take him long to figure me out *grin*). As it turned out, it's probably a good thing, because I swear that in the first few days after surgery, I could see boot tread marks on either side of my incision where someone braced themselves to pull that mess outa there!

I think that everyone has the pre-op fear that they will wake up during surgery. Rest assured that your anesthesiologist is at your head through the entire operation with nothing to do but monitor your anesthesia and how you are doing. "Anesthesia" is actually a group of drugs, and the person administering it is frequently giving you a bit of this and a bit of that to keep you at just the right level of "out" while being as gentle as possible on your system and making for as quick as possible an "awakening" once the surgery is over. Waking up just doesn't happen. While you may remember some of Recovery Room, you aren't around during anesthesia. You aren't.

What are these "pain pumps" I hear about? Do I need one? Will that keep me pain-free?

A "pain pump" is an IV that is administered by a special pump, a blocky machine that's mounted on the pole that holds the bag of IV fluid. It adds a pre-set amount of pain-relieving medication to the general fluid flowing into you when you press a button. In other words, it allows you to control when and how often you get a little boost of pain med. The pump also has a pre-set maximum, so it's not possible to overdose yourself. Pumps generally get favorable reviews from patients because they appreciate that sense of control it gives them.

They are generally set up to dispense one of two different drugs: morphine or demerol. If you are nauseated and are getting demerol, consider that as a potential culprit. If you break out in itches (or find yourself rubbing your nose a lot) you are most likely sensitive to the morphine. Don't hesitate a nanosecond to complain to your nurse and ask that your doctor be notified, whatever the time of day or night, if you feel you are reacting badly to the med or it's not giving you adequate pain relief. There are too many medication choices, so there is no reason to have to put up with unreasonable discomfort.

On the other hand, keep in mind that there are costs to medication. You really need to drink, deep breathe, move your legs and your bowels. Narcotics act against all those. So you can't expect to be totally unconscious and oblivious and 100% discomfort free from your meds.

A good level of comfort in the hospital period is being able to move with caution and discomfort, but not cry-out pain, and you should be fairly comfortable when you are well-positioned and not moving in bed. I've read about some pretty sad events where patients were led to believe they would be pain-free after a surgery, and of course they weren't, and their fear and hysteria made the whole thing quite out of control. Tolerable is the goal, and the word should be discomfort, not pain.

I'm so scared! I'm confused, I'm second-guessing myself. I want to change my mind every five minutes! Please tell me that these emotions are normal.

Emotions are so normal at this time that I'd really worry about someone who didn't feel like a mouse dropped into a sack of hungry cats when contemplating their hyst. This is a major life stage, regardless of our age, on top of a rightly-serious surgery. How could that not unhinge us?

I was so discombobulated by the whole idea that it took me 5 years to admit that I needed the surgery, and those 5 years were no picnic (call me a slow learner). My surgery turned out so much easier and more doable than I had convinced myself it would be, my recovery has been great, and my health so much improved that I have real trouble these days believing I could be such a dodo as to have delayed so long.

There's no rational answer for the pre-op panic, though, because rational isn't what it's about. I suggest sharing it with someone who can be sympathetic but not try to "fix" it for you. Admit what you are doing while indulging in it (do that crying—it's an important part of the coming-to-acceptance part), and trying to use the frenzy part as productively as possible. Many of us joke about alphabetizing the contents of the refrigerator while waiting for our surgical date to finally arrive, but the nesting frenzy is real and you might as well use it to bank housekeeping against recovery, when you will be letting things slide (oh yes you will or you'll be hearing from me about it, missy!). If your state of health permits, this is a good time for walking and exercise—you can use the endorphins as well as the break from your brain, and the stamina you gain will stand you in good stead in recovery.

So just try to go easy on yourself, and accept that this is what the waiting does to you. It does to us all. And yes, if you can focus ahead, think a year down the road to wearing white pants with no fear. There, my friend, is an image to hang onto.

All of this confuses me—if I think positive I'll be fine? Sounds like Pollyanna—or maybe I'm just too cynical.

It seems that a significant part of the "positive attitude" thing is not a Pollyanna rosiness but rather the sense of control of the situation that comes with having as good a grasp as possible of the physiology and pathology underlying your candidacy for a hyst, the available treatment options for that pathology and how they relate to your own situation, and the sense, arrived at after studying the above and trying out various solutions (whether physically or simply exploring them conceptually), that for your own situation the hyst is the best remaining treatment option.

Once you are able to commit wholeheartedly to the hyst as your best option, then you are able to take in stride the stresses, the inevitable failure of the surgery to leave you in "as new" condition, and the possible realization of any negative outcomes that are simply "risks" before the surgery.

Most typically, the women who suffer really crippling regrets later are those who did not successfully achieve this personal sense that this is the only remaining treatment option for regaining some degree of relief from their pathology. For the rest of us, even though we all experience some lingering negative effects (even if only some nerve weirdness around the incision, but up to and including life- threatening complications), we are able to view that balance and remember that at the time, these risks were preferable to the risks of continuing as we were. It's very important to understand, deeply understand, that we are not healthy people and we cannot be made so, ever again. What is within our reach is improvement, not total restoration.

When that commitment is made, then we can embrace the surgery as a positive action we are taking, and throw ourselves wholeheartedly into making it as successful as possible. A body that seeks aid suffers the physical stresses of surgery and recovers more promptly and with fewer complications than one that fights the process. This is demonstrated by research. If you willingly embrace anesthesia, calmly and with positive outlook, you will require fewer drugs and your body will be less stressed and bounce back more strongly and rapidly than if you go under fighting the process in fear. If you get out of bed as soon as possible after surgery, breathe deeply, stand up straight and walk knowing that every step you take moves you towards health and strength, you will have fewer complications and recover more rapidly. If you balance needed rest with the challenges of increasing activity in your recovery, your healing will be stronger and more durable than if you only rest when you collapse recovering from over-exuberance and stress. These are all things that are known about healing, and all things that bring a positive attitude out of the Pollyanna realm and into the hard cold scientific light of Things You Can Do That Really Make A Difference.

The short list, then, becomes:

1. Educate yourself fully about your pathology and about the hyst, both before and after surgery
2. Try all lesser treatments until you can accept that only this extreme and irrevocable treatment offers you relief from a situation you can confidently declare intolerable
3. Research and actively embrace positive measures for a healthy hyst experience and recovery

When you have done all of these, then you have prepared yourself for an experience that should not leave you crippled for the rest of your life with regrets.