What is the management for a patient complaining of pain 4 days after Nexplanon (etonogestrel implant) insertion?

Management of Pain After Nexplanon Insertion

For a patient experiencing pain 4 days after Nexplanon insertion, acetaminophen (650 mg every 6 hours) should be recommended as first-line treatment, along with the application of ice to the insertion site.

Assessment of Pain

When evaluating a patient with pain after Nexplanon insertion, consider:

• Location and character of pain (localized vs. radiating)
• Severity using a validated pain scale
• Presence of signs of infection (redness, warmth, swelling)
• Presence of signs of nerve injury (numbness, tingling, or altered sensation)
• Visibility and position of the implant

Treatment Algorithm

First-Line Management:

• Non-pharmacological approaches:

  • Application of ice to the insertion site for 15-20 minutes several times daily 1
  • Elevation of the affected arm when possible
  • Limited movement of the affected arm for 24-48 hours

• Pharmacological management:

  • Acetaminophen 650 mg every 6 hours (maximum 3000-4000 mg daily) 2
  • This is considered the safest analgesic option with minimal side effects

Second-Line Management (if pain persists):

• NSAIDs (if no contraindications):
  • Ibuprofen 600 mg three times daily for 3-7 days 1, 3
  • Studies show ibuprofen is effective for post-procedural pain management 3, 4

When to Escalate Care:

• Pain associated with:
  • Signs of infection (increasing redness, warmth, fever)
  • Neurological symptoms (numbness, tingling, weakness) suggesting nerve injury 5
  • Implant migration or extrusion
  • Severe pain unresponsive to first and second-line treatments

Special Considerations

Potential Complications to Watch For:

• Nerve injury: Rarely, the Nexplanon implant may contact or irritate the medial cutaneous nerve of the forearm, causing pain and hypoesthesia 5. This complication is related to insertion technique and proper placement.

• Infection: Although rare, infection at the insertion site can occur and should be treated promptly with antibiotics if suspected.

Patient Education:

• Reassure the patient that mild to moderate pain after insertion is common and typically resolves within 1-2 weeks
• Advise against manipulating or pressing on the implant
• Explain that the implant does not typically affect quality of life negatively after the initial adaptation period 6

Follow-up Recommendations:

• If pain persists beyond 7-10 days despite appropriate management
• If pain is severe or associated with other concerning symptoms
• If the patient is unable to palpate the implant or notices any change in its position

Prevention of Future Complications

Proper insertion technique is crucial to prevent complications such as nerve injury. The development of Nexplanon® with its redesigned applicator was specifically intended to increase insertion accuracy and reduce complications compared to its predecessor Implanon® 5.

Multimodal pain management strategies that include both non-pharmacological and pharmacological approaches have been shown to be most effective for procedural pain management 1.