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Guidelines on Pain Management and Palliative Care

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Guidelines on Pain Management and Palliative Care Guidelines on Pain Management & Palliative Care A. Paez Borda (chair), F. Charnay-Sonnek, V. Fonteyne, E.G. Papaioannou © European Association of Urology 2014 TABLE OF CONTENTS PAGE 1. INTRODUCTION 6 1.1 The Guideline 6 1.2 Methodology 6 1.3 Publication history 6 1.4 Level of evidence and grade of guideline recommendations* 6 1.5 References 7 2. PAIN MANAGEMENT IN UROLOGICAL CANCERS 7 2.1 Pain management in prostate cancer patients 11 2.1.1 Clinical presentation 12 2.1.2 Pain due to local impairment 12 2.1.2.1 Bladder outlet obstruction 12 2.1.2.2 Ureteric obstruction 12 2.1.2.3 Lymphoedema 12 2.1.2.4 Ileus 12 2.1.3 Pain due to metastases 12 2.1.3.1 Bone metastases 12 2.1.3.2 Systemic analgesic pharmacotherapy (the analgesic ladder) 13 2.1.3.3 Hormone therapy 13 2.1.3.4 Radiotherapy 13 2.1.3.5 Orthopaedic surgery 13 2.1.3.6 Radioisotopes 13 2.1.3.7 Bisphosphonates 14 2.1.3.8 Denosumab 14 2.1.3.9 Chemotherapy 14 2.1.4 Spinal cord compression 14 2.1.5 Hepatic invasion 15 2.1.6 Pain due to cancer treatment 15 2.1.6.1 Acute pain associated with hormonal therapy 15 2.1.6.2 Chronic pain associated with hormonal therapy 15 2.1.7 Recommendations on prostate cancer pain management 15 2.2 Pain management in transitional cell carcinoma patients 15 2.2.1 Clinical presentation 16 2.2.2 Origin of tumour-related pain 17 2.2.2.1 Bladder TCC 17 2.2.2.2 Upper urinary tract TCC 17 2.2.3 Pain due to local impairment 17 2.2.3.1 Bladder TCC 17 2.2.3.2 Upper urinary tract TCC 17 2.2.4 Pain due to metastases 18 2.2.5 Recommendations on transitional cell carcinoma pain management 18 2.3 Pain management in renal cell carcinoma patients 18 2.3.1 Clinical presentation 19 2.3.2 Pain due to local impairment 19 2.3.3 Pain due to metastases 19 2.3.4 Recommendations for renal cell carcinoma pain management 19 2.4 Pain management in patients with adrenal carcinoma 20 2.4.1 Malignant pheochromocytoma 20 2.4.1.1 Treatment of pain 20 2.4.2 Adrenocortical carcinomas 20 2.4.2.1 Treatment of the pain depending on its origin 21 2.4.3 Recommendations pain management adrenal carcinoma 21 2.5 Pain management in penile cancer patients 21 2.5.1 Clinical presentation 22 2.5.2 Pain due to local impairment 22 2.5.3 Lymphoedema 22 2.5.4 Pain due to metastases 22 2.5.5 Recommendations on penile cancer pain management 23 2 PAIN MANAGEMENT & PALLIATIVE CARE - UPDATE MARCH 2013 2.6 Pain management in testicular cancer patients 23 2.6.1 Clinical presentation 23 2.6.2 Pain due to local impairment 23 2.6.3 Pain due to metastases 23 2.6.4 Recommendations for testicular cancer pain management 24 2.7 References 24 3. PAIN MANAGEMENT AFTER UROLOGICAL OPERATIONS 30 3.1 Specific pain treatment after different urological operations 30 3.1.1 Extracorporeal shock wave lithotripsy 30 3.1.2 Endoscopic procedures 31 3.1.2.1 Transurethral procedures 31 3.1.2.2 Percutaneous endoscopic procedures 31 3.1.2.3 Laparoscopic and robotic procedures 31 3.1.3 Recommendations pain treatment after different urological operations 31 3.1.4 Open surgery 31 3.1.4.1 Minor operations of the scrotum/penis and the inguinal approach 31 3.1.4.2 Transvaginal surgery 31 3.1.4.3 Perineal open surgery 31 3.1.4.4 Transperitoneal laparotomy 32 3.1.4.5 Suprapubic/retropubic extraperitoneal laparotomy 32 3.1.4.6 Retroperitoneal approach - flank incision - thoracoabdominal approach 32 3.1.5 Recommendations for pain management after open surgery 32 3.2 Dosage and method of delivery of some important analgesics 32 3.2.1 NSAIDs 32 3.2.2 Opioids 33 3.2.3 Summary of recommendations for postoperative pain management in adults 34 3.3 Special populations 34 3.3.1 Ambulatory surgical patients 34 3.3.2 Geriatric patients 34 3.3.3 Obese patients 34 3.3.4 Drug- or alcohol-dependent patients 35 3.3.5 Other groups 35 3.3.6 Perioperative problems in children 35 3.3.7 Postoperative analgesia in children 35 3.3.8 Recommendations special populations 36 3.4 References 36 4. NON -TRAUMATIC ACUTE FLANK PAIN 38 4.1 Background 38 4.2 Initial diagnostic approach 39 4.2.1 Symptomatology 39 4.2.2 Laboratory evaluation 39 4.2.3 Diagnostic imaging 39 4.2.3.1 Computed tomography (CT) 39 4.2.3.2 Ultrasound imaging (US) 39 4.2.3.3 Intravenous urography and unenhanced helical CT 39 4.3 Initial emergency treatment 41 4.3.1 Systemic analgesia 41 4.3.2 Local analgesia 41 4.3.3 Supportive therapy 41 4.3.4 Upper urinary tract decompression 41 4.3.5 Recommendations non-traumatic acute flank pain 42 4.4 References 42 5. PALLIATIVE CARE 44 5.1 Introduction 44 5.2 Supportive care 44 5.3 Definition and aim of palliative care 45 5.4 General principles 45 PAIN MANAGEMENT & PALLIATIVE CARE - UPDATE MARCH 2013 3 5.4.1 Communication 45 5.4.2 Patient-centered treatment 46 5.4.3 Cultural and spiritual approach 47 5.4.4 Setting for the provision of terminal care 47 5.4.5 Multidisciplinary approach 47 5.4.6 Can anyone provide palliative care? Health care staff and advanced urological diseases 47 5.5 Treatment of physical symptoms 47 5.5.1 Pain 47 5.5.2 Dyspnoea and respiratory symptoms 47 5.5.3 Cancer anorexia-cachexia syndrome 48 5.5.4 Vomiting 48 5.5.5 Other symptoms 48 5.5.5.1 Fatigue 48 5.5.5.2 Restlessness 48 5.5.5.3 Agitated delirium 49 5.5.5.4 Constipation 49 5.5.5.5 Anxiety 49 5.5.6 Recommendations treatment of physical symptoms 49 5.6 Terminal care 49 5.6.1 When and how to withdraw specific treatment 50 5.6.2 Parenteral hydration: should it be discontinued in the terminal phases? 50 5.6.3 Palliative sedation 51 5.7 Treatment of psychological aspects 51 5.7.1 Fear 51 5.7.2 Depression 52 5.7.3 Family care 52 5.7.4 Communication of bad news 53 5.7.5 Recommendations treatment of psychological aspects 53 5.8 References 53 ADDENDUM 59 A.1 PAIN MANAGEMENT (GENERAL) 59 A.1.1 Pain evaluation and measurement 59 A.1.1.1 Pain evaluation 59 A.1.1.2 Assessing pain intensity and quality of life (QoL) 59 A.1.2 References 60 A.2 CANCER PAIN MANAGEMENT (GENERAL) 61 A.2.1 Classification of cancer pain 61 A.2.2 General principles of cancer pain management 61 A.2.3 Non-pharmacological therapies 62 A.2.3.1 Surgery 62 A.2.3.2 Radionuclides 62 A.2.3.2.1 Clinical background 62 A.2.3.2.2 Radiopharmaceuticals 62 A.2.3.3 Radiotherapy for metastatic bone pain 63 A.2.3.3.1 Clinical background 63 A.2.3.3.2 Radiotherapy scheme 63 A.2.3.3.3 Spinal cord compression 64 A.2.3.3.4 Pathological fractures 64 A.2.3.3.5 Side effects 64 A.2.3.4 Psychological and adjunctive therapy 64 A.2.3.4.1 Psychological therapies 64 A.2.3.4.2 Adjunctive therapy 65 A.2.4 Pharmacotherapy 65 A.2.4.1 Chemotherapy 66 A.2.4.2 Bisphosphonates 66 A.2.4.3 Denosumab 66 A.2.4.4 Systemic analgesic pharmacotherapy - the analgesic ladder 66 4 PAIN MANAGEMENT & PALLIATIVE CARE - UPDATE MARCH 2013 A.2.4.4.1 Non-opioid analgesics 66 A.2.4.4.2 Opioid analgesics 67 A.2.4.5 Treatment of neuropathic pain 70 A.2.4.5.1 Antidepressants 70 A.2.4.5.2 Anticonvulsant medication 71 A.2.4.5.3 Local analgesics 71 A.2.4.5.4 NMDA receptor antagonists 71 A.2.4.5.5 Other drug treatments 72 A.2.4.5.6 Invasive analgesic techniques 72 A.2.4.6 Breakthrough cancer pain 73 A.2.4.7 Recommendations pharmacotherapy 74 A.2.5 Quality of life 74 A.2.6 Conclusions 75 A.2.7 References 75 A.3 POSTOPERATIVE PAIN MANAGEMENT 87 A.3.1 Background 87 A.3.2 Importance of effective postoperative pain management 87 A.3.2.1 Aims of effective postoperative pain management 87 A.3.3 Pre- and postoperative pain management methods 87 A.3.3.1 Preoperative patient preparation 87 A.3.3.2 Pain assessment 88 A.3.3.3 Pre-emptive analgesia 88 A.3.3.4 Systemic analgesic techniques 88 A.3.3.4.1 Non-steroidal anti-inflammatory drugs 88 A.3.3.4.2 Paracetamol 88 A.3.3.4.3 Metamizole (dipyrone) 89 A.3.3.4.4 Opioids 89 A.3.3.4.5 Patient-controlled analgesia 89 A.3.3.4.6 Adjuncts to postoperative analgesia 89 A.3.3.5 Regional analgesic techniques 90 A.3.3.5.1 Local anaesthetic agents 90 A.3.3.5.2 Epidural analgesia 90 A.3.3.5.3 Patient-controlled epidural analgesia 90 A.3.3.5.4 Neural blocks 90 A.3.3.5.5 Wound infiltration 91 A.3.3.5.6 Continuous wound instillation 91 A.3.3.6 Multimodal analgesia 91 A.3.3.7 Postoperative pain management teams 91 A.3.3.8 Recommendations postoperative pain management\ 91 A.3.4 References 92 6.
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