Cervical Anesthesia for IUD Insertion
For cervical anesthesia during IUD insertion, use either an intracervical block (ICB) with 3.6-4 mL of 2% lidocaine injected at the 3,6,9, and 12 o'clock positions before tenaculum placement, or apply 4-5 grams of EMLA cream (2.5% lidocaine/2.5% prilocaine) to the cervix with a 5-10 minute wait time. 1
Primary Anesthetic Options
Intracervical Block (ICB) - Preferred for Immediate Effect
- Inject 3.6-4 mL of 2% lidocaine intracervically at the 3,6,9, and 12 o'clock positions of the cervical stroma using a 27-gauge needle before tenaculum placement 1
- Alternative: Use 1% lidocaine with a standard syringe if 2% lidocaine is unavailable 1
- No wait time is required after injection, as waiting does not appear to reduce pain 1
- ICB with 3.6 mL of 2% lidocaine demonstrated reduced pain with both tenaculum and IUD placement in nulliparous patients 1
- Another study showed ICB with 6 mL of 2% lidocaine was more effective than naproxen 550 mg alone in reducing insertion pain 1
Paracervical Block (PCB) - Alternative Regional Block
- Start with a superficial intracervical injection of 2 mL of buffered 1% lidocaine at the tenaculum site (typically anterior lip, or posterior lip if significant anteflexion) 1
- After placing the tenaculum, inject the remaining anesthetic at the 4 o'clock and 8 o'clock positions at the cervicovaginal junction using a 22- or 25-gauge 1.5" needle 1
- Create a small wheal at the junction and inject slowly while moving the needle to avoid intravascular injection 1
- Aspirate for blood prior to injection to prevent intravascular administration 1
- Maximum recommended dose for paracervical block is 200 mg total lidocaine per 90-minute period 2
Topical Anesthetics - Non-Invasive Option
- Apply 4-5 grams of EMLA cream (2.5% lidocaine/2.5% prilocaine) to the cervix and wait 5-10 minutes before proceeding 1, 3
- EMLA cream was shown to reduce IUD-insertion pain with a mean difference of -1.96 (95% CI -3.00 to -0.92) compared to placebo 4
- A network meta-analysis ranked lidocaine-prilocaine cream as the most effective medication for reducing pain at both tenaculum placement and IUD insertion 5
- Do NOT use 2% lidocaine gel—multiple studies show it is ineffective for pain reduction 1, 4, 6
- Topical 10% lidocaine spray showed effectiveness in parous women, with median pain scores of 1.00 versus 3.00 for placebo 1, 7
Adjunctive Pain Management
Pre-procedure NSAIDs
- Administer naproxen 550 mg orally 1-2 hours before the procedure 8, 3
- Alternative: Ketorolac 20 mg taken 40-60 minutes before insertion for faster onset 8, 3
Non-Pharmacologic Techniques
- Apply bilateral acupressure at LI4 (dorsum of hand between thumb and index finger) and SP6 (above medial malleolus) during and after the procedure 1, 8, 3
- Use trauma-informed language and verbally check in for discomfort throughout the procedure 1
- Offer to pause or stop at any point 1
Critical Technique Considerations
Tenaculum Placement
- Gently rock the tenaculum points onto the cervix and time the closure with the patient's exhalation 1
- Close the tenaculum one notch only to minimize trauma 1
- Consider using a single-tooth tenaculum or Allis forceps 1
Special Situations Requiring Enhanced Anesthesia
- Retroflexed uterus: More dilation may be required, so consider topical anesthetics or regional block before dilation 8
- Failed first insertion attempt or known cervical stenosis: Consider topical local anesthetic or regional block before using dilators 1
- Start with an os finder, then use the smallest possible dilator or sound 1
Important Safety Warnings
Lidocaine Toxicity Prevention
- Maximum individual dose should not exceed 4.5 mg/kg (2 mg/lb) of body weight, with a general maximum total dose of 300 mg 2
- Maximum recommended dose for paracervical block is 200 mg total per 90-minute period 2
- Warn patients of self-limiting side effects of intravascular lidocaine, such as numbness of the tongue or tinnitus 1
- Aspirate before injection to avoid intravascular administration 1
What NOT to Use
- Avoid routine misoprostol—it increases postprocedure cramping, abdominal pain, nausea, and shivering without clear benefit 3
- Reserve misoprostol only for failed first insertion attempt, known cervical stenosis, or selected high-risk patients 3
- Do NOT use 2% lidocaine gel topically or intracervically—it is ineffective 4, 6
Post-Procedure Care
- Keep patient lying flat for 5 minutes with legs out of stirrups 1
- Gradually raise head of table in increments to prevent vasovagal reaction 1
- Apply bilateral acupressure on LI4 or SP6 for a few minutes 1
- Prescribe scheduled naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours with food for the first 24 hours post-procedure 1