Managing the pain

Prostate cancer occurs when the cells in the prostate gland start to grow out of control. Symptoms may include frequent urination, difficulty urinating, weak or interrupted flow of urine, difficulty to produce an erection as well as pain or stiffness in the lower back, hips or upper thighs.

For men with prostate cancer, pain is a symptom that is experienced differently for each individual. In the early stages of the disease, pain can occur during urination or ejaculation. The tumour may start to pressure the surrounding organs and tissues, which can also cause pain. In advanced prostate cancer, or metastatic prostate cancer, the pain can be in a few different forms.

Types of pain

  • Bone pain
    If cancer spreads to the bone, it may damage or weaken it, causing pain. However, not all men will feel bone pain and each experience will be different.
  • Nerve pain
    This type of pain can be a part of bone pain, or a result of the cancer pushing against a nerve. It may be described as shooting, stabbing, tingling or numbness. Some men may experience referred pain, where damage in one part of the body is felt in another area.
  • Lymphoedema
    This occurs when there is a blockage in the lymph system caused by the cancer, or occasionally by the surgery or radiotherapy used for treatment. It usually affects the legs but can affect other areas such as the penis or scrotum.
  • Metastatic spinal cord compression
    The happens when cancer cells grown near the spinal cord, pushing against it. It is uncommon and presents as pain or soreness in the back, pain that moves up and down the arms or legs, weakness in your arms or legs or difficulty standing or walking amongst other symptoms.

Pain can have a significant impact on your quality of life if not controlled. It can cause reduced strength, limited mobility and sleeping problems. Psychologically it can lead to increased fear, anxiety, depression and a decrease in your overall enjoyment of life.

It may also affect your ability to form and maintain relationships as well as increasing the burden placed on caregivers. Your doctor will use different assessment tools to determine where your pain is coming from, the severity and the best way to treat it.

Treatment

Many health professionals use the pain relief ladder, as developed by the World Health Organisation to guide their use of pain relief medication.

For mild to moderate pain, a non-opioid analgesic is usually initiated first, and its effectiveness assessed. Other supplementary medications, such as antidepressants may also be considered at this point. If the non-opioid medications do not adequately control your pain, your doctor may then consider prescribing you an opioid for moderate pain. The supplementary medications may be continued as necessary.

If this is no longer effective, your doctor may then prescribe an opioid for moderate to severe pain such as morphine, oxycodone or hydromorphone.

Medications

  1. Non-opioid analgesics
    Non-steroidal anti-inflammatories (NSAIDS) are effective against tissue inflammation and injury, either alone or in combination with an opioid. NSAIDs should not be used for patients with an allergy to this class of drugs and should be used with caution in those at risk of gastrointestinal bleeding, decreased kidney function, heart failure or bleeding. The elderly are particularly susceptible.
    Paracetamol is less effective than NSAIDs. But may be an alternative if you are unable to take NSAIDs for any reason.
  2. Opioids
    Opioids are usually added to an NSAID or paracetamol. Some people may experience nausea and vomiting, especially at the beginning of treatment, however your doctor can prescribe medication to minimise this. Constipation is a common problem that persists while taking an opioid. This can also be treated by your doctor with laxatives. Other possible adverse effects include sedation, hallucinations, sweating and itching.Addiction is rarely a problem when used for this type of pain, however physical dependence is common, therefore an opioid should never be abruptly ceased due to the risk of withdrawal effects. In addition, tolerance may develop, however your doctor will have methods to deal with this if it is an issue.
  3. Other medications
    Your doctor may prescribe antidepressants for depression as well as nerve pain. Anticonvulsant medication, commonly used to treat epilepsy, can also be effective against nerve pain. Biphosphonates can help treat or prevent further bone pain by binding to damaged areas of bone and slowing down further damage.Corticosteroids may be prescribed with your treatment to reduce fluid build-up, inflammation and to stabilise nerve membranes. They may also alleviate nausea and increase mood and appetite. Ketamine is sometimes given to patients who are experiencing tolerance or an increased sensitivity to pain.

Non-medicated pain management options
There are numerous methods to reduce pain that do not involve taking medication, however each person will respond differently to these.

  • Radiation therapy
    Pain-relieving radiotherapy may help by shrinking the tumour and stopping it from pressing on the nerve and causing pain. It may also slow the growth of the cancer, thus giving the bone time to repair. It can be given either externally or internally.
  • Surgery
    If a bone has been damaged badly, an option may be to have surgery. A pin or plate may be inserted to stabilise the affected bone. Alternatively, a type of cement may be used to fill the affected area.
  • Transcutaneous electrical nerve stimulation
    This involves using a device that transmits mild, safe electrical signals over the pain affected area.
  • Spinal cord stimulation
    This procedure also uses mild, safe electrical signals transmitted via an electrode that has been implanted near the spinal cord.
  • Complementary therapies
    This includes a variety of options such as acupuncture, reflexology, ice/heat, aromatherapy, massage, guided imagery and biofeedback, which may be worth exploring and trying for some additional relief.

It is important that you discuss any symptoms, side effects or concerns that you have with your doctor, for you to receive the most effective pain management. They will be able to advise you on the best treatment options. Treatment is dependent on many different factors such as the cause of the pain, your general health and your emotional wellbeing.

The pain may also be a sign that your cancer treatment is not working effectively, so your doctor may need to look at alternative treatments. You could also benefit from additional treatments such as complementary therapy, emotional support or treatment for other causes of pain such as an infection.

It is possible to manage your prostate cancer pain effectively and still enjoy a good quality of life.

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