Our results show that vaginal cleansing with iodine-based solution prior to commencing office-based hysteroscopy, does not decrease post-operative infections nor 30-days revisits and other postoperative complications, irrespective of indication or any intra-uterine activity.
OH is usually done without the use of preoperative prophylactic antibiotics, thus some initiate the procedure by using preoperative vaginal cleaning with iodine-based solution, while others- do not.
Several international guidelines exist [5–8], regarding hysteroscopic setup for both operative and OH, for which only few[7, 8] reported expert opinion for any vaginal disinfection .
Generally, rationale behind cervical cleansing prior to gynecological surgeries, is to allow a sterile procedure prior to initiating an invasive procedure, thus decreasing postoperative infections, as recommended for example, by the ACOG practice bulletin number 195 [9].
A randomized control trial published in 2019, showed that the rate of postoperative infections rate was comparable between OH and operative hysteroscopy (3% and 4% respectively) [2], while an earlier randomized control trial [10], reported a 0.53% risk for postoperative infections after OH when no preoperative antibiotics were given, interestingly they have used iodine cleansing of the vagina in all study’s participants.
A recent meta-analysis[4] examined the effectiveness of antibiotics prophylaxis before operative hysteroscopies, report a cumulative 1.8% for postoperative fever, and 0.2% overall infection rate in the groups who were not given perioperative antibiotics, similarly to those who did receive antibiotics. Importantly however, in the aforementioned meta-analysis, the lack of a defining consensus for postoperative infection, precludes some authors from drawing a solid conclusion against the use of antibiotics.
It is safe to assume, that in OH, the postoperative infection rate is perhaps lower than operative hysteroscopy [11].
Similarly in our study, we did not find any cases of postoperative infection, according to the predetermined criteria [2], which suggests that the postoperative infection rate is perhaps even lower than previously reported. Although overall 25 patients (4.95% of the total cohort) received immediate postoperative antibiotics upon discharge, the list of indications for the antibiotics suggests they were prescribed as a prophylactic measure, and not due to an intraoperative-related infection. Overall, there was 1 case of PID, 8 cases of vaginal bleeding, 4 cases of abdominal pain and 1 case of abnormal vaginal secretion, this corresponded to an overall OH- postoperative complications rate of 0.19%, 1.58%, 0.79% and 0.19% overall, irrespective of the use in iodine.
Patients in the control group, were more likely to receive general anesthesia (54% vs. 23%), perhaps due to the anticipation for a more painful procedure, although the list of indications for OH was comparable between the groups. Regardless of the actual level of intraoperative difficulty, we have recorded a low postoperative infection rate.
Several risk factors for surgical site infections were previously reported, and were broadly categorized into patient dependent (such as age and comorbidities), operation dependent (such as duration of operation and the use of antibiotics) and preoperative microbial load [9, 12].
In OH, the inherent factors are possibly responsible for the low infection rate such as relative short operative time and minimal reentries into the cervical canal [10] .
In a stressful situation for the patient, such as hysteroscopy [13], and especially when done without general anesthesia, the operating surgeon should strive for the least painful and stressful process, when possible, such as maintaining low filling pressure, using pharmacological treatments or other non-pharmacological methods [14].
The use of vaginal cleansing irrespective of the used solution, can lead to an undesired patient’s discomfort when done in an awaken patient, thus the level of pain felt by the patient are increased.
Although we did not factor for subjective complaints or sensations by our patients during the operation, iodine solution can led to unpleasant sensation, such as vaginal dryness, burning, itching, abnormal discharges and even pain [15]. Alternatively, if deemed necessary, other solutions can be used for vaginal cleansing with possibly less side effects than iodine [16, 17].
Our study has several limitations, its retrospective nature, low patients’ compliance with follow up appointments- thus diagnosing any stage of infection of inflammation, become challenging. Moreover, patients can choose to attend any other medical center or even private follow-ups which are not recoded in our database; thus, it is possible that the low infection rate is under diagnosed. Lastly, no data is available for long term consequences – such as future fertility.
The strengths of the study can be found in Its relatively large sample size, compliance with sufficient participants for power analysis, availability of data for patients who have visited other medical institutes.
In conclusion, the very low postoperative infection rate after OH remained unaffected by preoperative vaginal cleansing with iodine-based solution, thus it could be avoided. Future prospective studies are needed.