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GUIDELINES ON PAIN MANAGEMENT
IN UROLOGY
P. Bader (chair), D. Echtle, V. Fonteyne, K. Livadas, G. De Meerleer, A. Paez Borda, E.G. Papaioannou, J.H. Vranken General principles of cancer pain management
The therapeutic strategy depends on the four goals of care:
1. Prolonging survival
2. Optimising comfort
3. Optimising function
4. Relieving pain.
Table 1: Hierarchy of general principles of cancer pain
management
1. Individualised treatment for each patient.
2. Causal therapy to be preferred over symptomatic
3. Local therapy to be preferred over systemic therapy.
4. Systemic therapy with increasing invasiveness: World
5. Compliance with palliative guidelines.
6. Both psychological counselling and physical therapy
Systemic analgesic pharmacotherapy: the ‘analgesic ladder’
Analgesic pharmacotherapy is the mainstay of cancer pain
management. Although concurrent use of other interventions
is valuable in many patients, and essential in some, analgesic
278 Pain Management in Urology
drugs are needed in almost every case.
Analgesic drugs can be separated into three groups:• non-opioid analgesics;• opioid analgesics;• adjuvant analgesics.
Adjuvant analgesics are drugs with other primary indications that can be effective analgesics in specific circumstances. There are three groups:• corticosteroids; • neuroleptics; • benzodiazepines. The WHO has proposed a useful approach to drug selec-tion for cancer pain, known as the ‘analgesic ladder’. When combined with appropriate dosing guidelines, this approach is capable of providing adequate relief to 70-90% of patients (Figure 1) (LE: 1a).
Figure 1: The World Health Organization’s ‘analgesic ladder’
Step 3
Non-opioid analgesics
+ strong opioids
+ adjuvant analgesics
Step 2
Non-opioid analgesics
+ weak opioids
+ adjuvant analgesics
Step 1
Non-opioid analgesics
+ adjuvant analgesics
Pain Management in Urology 279
Table 2: Treatment of neuropathic pain
Drug
Frequency
(maximum)
Recommendations
Amitriptyline and nortriptyline are first-line treatment Afor neuropathic pain; nortriptyline has fewer side-effects.
Tricyclic antidepressants (TCA) must be used cau- tiously in patients with a history of cardiovascular disorders, glaucoma, and urine retention.
Gabapentin and pregabalin are first-line treatments for neuropathic pain, especially if TCAs are contrain-dicated.
Pain management in urological cancers
Table 3: Docetaxel-based chemotherapy versus
mitoxantrone-based regimens in prostate
Chemotherapy Plus
Frequency Response rate
additional
280 Pain Management in Urology
Recommendation: Anticancer treatment
logues, diethylstilboestrol equivalent)Total androgen blockade: flare prevention, sec- ond lineIntermittent androgen suppression: experimental 3 Monotherapy with anti-androgen: currently not 1b recommendedFirst-line treatment controls disease for 12-18 months; second line individualisedSupportive careLow-dose glucocorticoids ChemotherapyMitoxantrone plus prednisolone Estramustine + vinblastine or etoposide or pacli- 2b Pain management
Pain assessment (localisation, type, severity,
overall distress)Pain due to painful and stable bone metastases (single lesions)External beam irradiation Pain due to painful bony metastases (widespread)Primary hormonal therapy Pain Management in Urology 281
Radioisotopes (strontium-89 or samarium-153) Systemic pain managementWorld Health Organization analgesic ladder step 1a 1: NSAID or paracetamolOpioid administrationDose titration Tricyclic antidepressant and/or anticonvulsant in 1a NSAID = non-steroidal anti-inflammatory drug. External beam radiation
• Single-fraction radiotherapy is an excellent palliative
treatment for symptomatic bone metastases, resulting in complete or partial pain relief in 20-50% and in 50-80% of patients, respectively.
• Metastatic epidural spinal cord compression is a severe complication requiring urgent treatment. Direct decom-pressive surgery is superior to radiotherapy alone. Primary radiotherapy is recommended for patients who are not suited for surgery.
• For impending pathological fractures, a prophylactic orthopaedic procedure should be considered.
282 Pain Management in Urology
Table 4: Criteria for selecting patients for primary
therapy for spinal cord compression
Absolute criteria
Radiotherapy
Relative criteria
Diagnosis of pri-
with compressionNumber of foci of 1 focus Radioisotopes
The most important radiopharmaceuticals are:
• 89Sr (strontium-89 chloride);
• 153Sm (samarium-153 lexidronam);
• and, to a lesser extent, 186Re (renium-186 etidronate).
There is no clear difference in treatment response between
89Sr, 153Sm and 186Re. However, there is a difference in onset
of response, duration of response and toxicity. For 153Sm and
186Re, the onset of response is rapid, but duration is shorter
than 89Sr.
89Sr and 153Sm lexidronam are indicated for treatment of bone pain, resulting from skeletal metastases involving more Pain Management in Urology 283
than one site and associated with an osteoblastic response
on bone scan but without spinal cord compression (LE: 2,
GR: B). Overall, the response rate is 60-80%. However, pain
reduction is unlikely to occur within the first week, and can
occur as late as 1 month after injection. Analgesics should
therefore continue to be prescribed to patients until bone
pain improves.
If the pain responds to the initial treatment, administration of 153Sm lexidronam can be repeated at intervals of 8-12 weeks in the presence of recurrent pain (LE: 2, GR: B).
Radiopharmaceuticals should not be administered if the glomerular filtration rate is < 30 mL/min in patients who are pregnant or who are breast feeding. Because of myelosup-pression, a white blood cell count > 3500/μL and a platelet count > 100,000/μL are desirable.
Post-operative pain management
Recommendations
Post-operative pain should be treated adequately to avoid post-operative complications and the develop-ment of chronic pain.
Pre-operative assessment and preparation of the patient allow in more effective pain management.
Adequate post-operative pain assessment can lead to more effective pain control and fewer post-operative complications.
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Specific pain treatment during ESWL
Table 5: Analgesic drug options during extra-corporeal
shock wave lithotripsy (ESWL)
Method of
Frequency
administration (maximum)
Recommendations
Analgesics should be given on demand during and after ESWL because not all patients need pain relief.
Premedication with NSAIDs or midazolam often decreases the need for opioids during the procedure.
Intravenous opioids and sedation can be used in com- Cbination during ESWL; dosage is limited by respira-tory depression.
Post-ESWL, analgesics with a spasmolytic effect are ESWL = extracorporeal shock wave lithotripsy; NSAID = non-steroidal anti-inflammatory drug.
Pain Management in Urology 285
Specific pain treatment after different urological
operations
Table 6: Analgesic drug options after transurethral
procedures
Method of
Frequency
administration (maximum)
iv = intravenously; im = intramuscularly; sc = subcutaneously. Recommendations
Post-operative analgesics with a spasmolytic effect or mild opioids are preferable.
Antimuscarinic drugs could be helpful in reducing discomfort resulting from the indwelling catheter.
Antimuscarinic drugs may reduce the need for 286 Pain Management in Urology
Table 7: Analgesic drug options after laparoscopic
surgery, minor surgery of the scrotum, penis,
and inguinal region or transvaginal urological
Method of
Frequency
administration (maximum)
iv = intravenously; im = intramuscularly; sc = subcutaneously; PCA = patient-controlled analgesia. Pain Management in Urology 287
Recommendations
Low intra-abdominal pressure and good desufflation at the end of the laparoscopic procedure reduces post-operative pain.
NSAIDS are often sufficient for post-operative pain control.
NSAIDs decrease the need for opioids. For post-operative pain control after minor surgery of Bthe scrotum, penis and inguinal region, multi-modal analgesia with a combination of NSAIDs or paraceta-mol plus local anaesthetics should be used.
If possible, avoid opioids for out-patients. NSAIDS are often sufficiently effective after minor or NSAID = non-steroidal anti-inflammatory drug. Table 8: Analgesic drug options after major perineal
open surgery, suprapubic extraperitoneal,
retroperitoneal or transperitoneal laparotomy
Method of
Frequency
administration (maximum)
288 Pain Management in Urology
iv = intravenously; im = intramuscularly; sc = subcutaneously; PCA = patient-controlled analgesia. Recommendations
The most effective method for systemic administration Aof opioids is PCA, which improves patient satisfaction and decreases the risk of respiratory complications.
Epidural analgesia, especially PCEA, provides superior Apost-operative analgesia, reducing complications and improving patient satisfaction. It is therefore preferable to systemic techniques.
PCA = patient-controlled analgesia; PCEA = patient-controlled epidural analgesia. Pain Management in Urology 289
Analgesics
Recommendations
Paracetamol can be very useful for post-operative pain Bmanagement as it reduces the consumption of opioids.
Paracetamol can alleviate mild post-operative pain as a Bsingle therapy without major adverse effects.
NSAIDs are not sufficient as a sole analgesic agent after major surgery.
NSAIDs are often effective after minor or moderate surgery.
NSAIDs often decrease the need for opioids.
Avoid long-term use of COX inhibitors in patients with atherosclerotic cardiovascular disease.
NSAID = non-steroidal anti-inflammatory drug. Metamizole (dipyrone)
Metamizole is an effective antipyretic and analgesic drug
used for mild-to-moderate post-operative pain and renal
colic. Its use is prohibited in the USA and some European
countries because of single reported cases of neutropenia and
agranulo-cytosis. Dosage per day is 500-1000 mg four times
daily (orally, intravenously or rectally). If given intravenous-
ly, metamizole should be administered as a drip (1 g in 100
mL normal saline).
Table 9: Drug, administration, dosage and delivery
Drug
Method Single
Frequency
stration
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Antipyretics
Conventional NSAIDs (i.e. non-selective COX inhibitors)
Pain Management in Urology 291
COX-2 selective inhibitors
Strong opioidsMorphine** Orally or Starting Six to eight No maxi- 292 Pain Management in Urology
** A simple way of calculating the daily dosage of morphine for adults (20-75 years) is: 100 – patient’s age = morphine per day in mg.
NSAID = non-steroidal anti-inflammatory drug; sc = subcutane-ous; im = intramuscularly; iv = intravenously. Pain Management in Urology 293
Table 10: Common equi-analgesic dosages for
parenteral and oral administration of
opioids*
Parenteral (mg)
Oral (mg)
*All listed opioid doses are equivalent to parenteral morphine 10 mg. The intrathecal opioid dose is 1/100th, and the epidural dose 1/10th, of the dose required systemically. Table 11: Typical patient-controlled analgesia (PCA)
dosing schedule
Bolus size
Continuous
(concentration)
interval (min) infusion
294 Pain Management in Urology
Recommendations
Intravenous PCA provides superior post-operative analgesia, improving patient satisfaction and decreas-ing the risk of respiratory complications.
Table 12: Typical epidural dosing schemes*
Drug
Single dose
Continuous
infusion
* L-bupivacaine doses are equivalent to those of bupivacaine. Table 13: Typical patient-controlled epidural analgesia
(PCEA) dosing schemes
Lockout Continuous
interval rate
+ fentanyl 4 μg/mLRopivacaine 0.2% + 2 mL Pain Management in Urology 295
Recommendations
Epidural analgesia, especially PCEA, provides superior Apost-operative analgesia, reducing complications and improving patient satisfaction. It is therefore prefer-able to systemic techniques.
Table 14: Examples of neural blocks
Procedure
Recommendations
Multi-modal pain management should be employed whenever possible since it helps to increase efficacy while minimising adverse effects.
For post-operative pain control in out-patients, multi- B modal analgesia with a combination of NSAIDs or paracetamol plus local anaesthetics should be used.
Multi-modal and epidural analgesia are preferable for Bpost-operative pain management in elderly patients because these techniques are associated with fewer complications.
Post-operative use of opioids should be avoided in obese patients unless absolutely necessary.
296 Pain Management in Urology
An epidural of local anaesthetic in combination with NSAIDs or paracetamol is preferable in obese patients.
There are insufficient data to support a specifc post- operative pain management plan for critically ill or cognitively impaired patients.
NSAID = non-steroidal anti-inflammatory drug. Peri-operative pain management in children
Table 15: Pre-operative analgesia and sedation in
children
Dosage and route Action
of administration
Can prevent crying, which therefore reduc-es oxygen consump-tion and pulmonary vasoconstriction Pain Management in Urology 297
6 mg/kg orally or and separation anxiety intranasally 0.5 mg/kg orally, intranasally, or rectally iv = intravenously; im = intramuscularly.
Table 16: Post-operative analgesia in children
Drug
Administration Severity
of
surgical
procedure
298 Pain Management in Urology
iv = intravenously; sc = subcutaneously. Patient-controlled analgesia can be used safely in children more than 6 years old. In infants and children unable to use PCA, nurse-controlled analgesia is effective. Locoregional techniques such as wound infiltration, nerve blocks, caudal and epidural analgesia are also used successfully.
Pain Management in Urology 299
Non-traumatic acute flank pain
Urological causes:
• Renal or ureteral stones
• Urinary tract infection (pyelonephritis, pyonephrosis, or
• Uretero-pelvic junction obstruction• Renal vascular disorders (renal infarction, renal vein • Papillary necrosis• Intra- or peri-renal bleeding• Testicular cord torsion Laboratory evaluation
All patients with acute flank pain require a urine test (red
and white cells, bacteria or urine nitrite), blood cell count,
and serum creatinine measurement. In addition, febrile
patients require C-reactive protein (CRP) and urine culture.
Pyelonephritis ± obstructive uropathy should be suspected
when the white blood count exceeds 15,000/mm3.
Recommendations on Diagnostic imaging
Febrile patients (> 38ºC) with acute flank pain and/or B with a solitary kidney need urgent imaging. Unenhanced helical CT (UHCT) is the imaging diagnostic modality with the highest sensitivity and specificity for evaluation of non-traumatic acute flank pain.
Ultrasound can be an alternative to UHCT in the ini- Atial approach to non-traumatic acute flank pain.
300 Pain Management in Urology
Figure 2: Diagnostic approach to non-traumatic acute flank
History, Physical examination, Temperature, Urinalysis → Pain treatment Ultrasonography and/or unenhanced CT scan CT = computed tomography; UTI = urinary tract infection. Pain Management in Urology 301
For a quick Differential Diagnosis and Management Options the Decision tree (figure 2) is suggested: Initial emergency treatment
Systemic analgesia
Pain relief is usually the first, most urgent, therapeutic step:
• A a slow intravenous infusion of dipyrone, 1 g or 2 g, is
just as effective as diclofenac (75mg bolus) (LE: 1a). • Intravenous papaverine (120 mg)can effectively and safely relieve patients not responding to conventional agents (diclofenac) and can be an alternative to diclofenac in patients with contraindications to NSAIDS (LE: 1b).
• The combination of intravenous morphine + ketorolac seems superior to either drug alone and appears to be associated with a decrease in rescue analgesia. Recommendation
NSAIDs such as diclofenac (75 mg, bolus), and dipy- rone (1-2 g, slow intravenous injection) are both very effective for acute flank pain.
Upper urinary tract decompression
If pain relief cannot be achieved using medical therapy and
there are signs of infection and of impaired renal function,
upper urinary tract drainage should be carried out (Ureteral
stenting or percutaneous nephrostomy).
302 Pain Management in Urology
Indications for stenting for urgent relief of obstruction
• Urine infection with urinary tract obstruction
• Urosepsis
• Intractable pain and/or vomiting
• Obstruction of a solitary or transplanted kidney
• Bilateral obstructing stones
• Ureteral calculus obstruction in pregnancy
Aetiological treatment
Urolithiasis should be treated as defined in the EAU
Guidelines on Urolithiasis.
Infectious uncomplicated conditions (i.e. acute pyelonephri-tis in otherwise healthy individuals) should be treated with appropriate antibiotics and analgesics. When a diagnosis of UPJ obstruction, papillary necrosis, renal infarction renal vein thrombosis, spontaneous renal hemorrhage or testicular cord torsion has been made the patient should be treated accordingly (see long version).
This short booklet is based on the more comprehensive EAU guidelines (ISBN 978-90-79754-70-0), available to all members of the European Association of Urology at their website, http://www.uroweb.org. Pain Management in Urology 303

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