Open Journal of Urology, 2012, 2, 164-172
http://dx.doi.org/10.4236/oju.2012.223031 Published Online October 2012 (http://www.SciRP.org/journal/oju)
Pain Management in Prostate Cancer
Ali Eman1, Serbülent Gökhan Beyaz2*, Hasan Sağlam3, Mustafa Emre Gürcü4
1Department of Anesthesiology, Ipekyolu State Hospital of Van, Van, Republic of Turkey
2Department of Anesthesiology, Sakarya University Medical School, Sakarya, Republic of Turkey
3Department of Urology, Sakarya University Medical School, Sakarya, Republic of Turkey
4Ipekyolu State Hospital of Van, Department of Anesthesiology, Van, Republic of Turkey
Received July 6, 2012; revised August 14, 2012; accepted August 27, 2012
Prostate cancer is the most common urogenital malignity of western communities and is the second leading cause of
cancer-related deaths in this population. Pain is often due to bone metastasis in prostate cancer. For the patient
diagnosed with cancer and for his family, pain is the most feared aspect of cancer following the likelihood of failure to
treat and death. Quality of life is severely impaired together with complaint of pain which arises high rates as 80% in
advanced stage cancers.
Keywords: Prostate; Cancer; Pain; Analgesia
For the patient diagnosed with cancer and for his family,
pain is the most feraed aspect of cancer following the
likelihood of failure to treat and death . In these
patients, factors like primary tumor type, presence of
metastasis, proximity of the tumor to neural structures,
psychological status of the patient play important roles in
development and severity of the pain . Quality of life
is severely impaired together with complaint of pain
which arises high rates as 80% in advanced stage cancers.
Having sufficient knowledge about treatment and control
of pain today and also dying of patients before their pain
is controlled despite advanced techniques and drugs is
disappointing. Treatment is insufficient due to clinicians’
lacking of experience and knowledge about assessment
and treatment of cancer pain despite sufficient knowl-
edge about the treatment of cancer pain. These shortco-
mings include not knowing wide spectrum cancer pain
syndromes, lacking of a certain treatment protocol, worr-
ies about side effects and addiction of opioids among the
nurses and the clinicians (opiophobia), legal restriction of
opioid use, not knowing the pharmacologic properties of
non-opioid analgesics, not inquiring the complaint of
pain sufficiently and properly, not knowing interventio-
nal pain management methods .
2. Prostate Cancer and Pain
Prostate cancer is the most common malignant lesion in
western male population and is the second leading cause
of cancer-related deaths in this population . Pain is
often due to bone metastasis in prostate cancer. It may
also be seen due to perineal pain or obstruction of lower
end of ureter and prostatic urethra as the result of local
invasion of the prostatic pathology.
Osteoporosis which develops as the result of hormonal
treatment and aging increases the risk of bone comp-
lications besides metastasis in patients with prostate can-
cer. Although primary osteoporosis is not common in
males, bone mineral density begins to reduce beginning
from middle age. Thus many men have osteoporosis at
the time of prostate cancer diagnosis. Androgen depriv-
ation, the standard treatment of metastatic prostate cancer,
is known to lead to bone loss and hormonal treatment re-
duces bone mineral density 3% - 5% yearly [5,6].
Prostate cancer metastasis to the bones more frequent-
ly than any other solid tumors and bone metastasis is
seen in approximately 65% - 75% of the patients with
advanced disease [7,8]. Metastasis is frequently seen in
vertebra, bony pelvis and ribs. Skeletal complications
increase in prostate cancer when bony metastasis deve-
lops. Skeletal complications develop in 30.3% of prostate
cancers with bone metastasis and resistant to hormone
and yearly incidence was reported as 12% . Events
related with sceletal system also impair the quality of life
of the patients.
Bone metastasis from prostate cancer usually seen as
pain, pathologic fractures and spinal cord compression.
However pain is not essential in all bone metastasis.
Cause of pain in bone metastasis is structural damage,
mechanic stress, periosteal strain, microfractures, pres-
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A. EMAN ET AL. 165
sure on adjacent nerves and tissues and release of chemi-
cal mediators like prostaglandin and cytokines [10-12].
Pain may be generalized, continuous or intermittent. It is
usually defined as ache, burn sensation or sting. Pain
becomes severe at night or when holding heavy things.
While the pain is initially mild, it may gradually become
severe as the disease advances. Metastasis-related pain is
usually somatic type but neuropathic pain may also be
added as the result of pressure of tumoral mass on
adjacent neural structures or invasion. In that case, burn
sensation, pressure or paroxysmal pain may arise in the
area of affected nerve. Sensory or motor loss may
accompany this and a pain reflecting to the legs may
develop. Chemotherapy-related neuropathic pain emer-
ges as dysesthesia and peripheric neuropathy or burn
sensation in the hands and the feet.
3. Cancer-Related Pelvic and Perineal Pain
Urologic cancers, rectum cancer and lower genital organ
cancers are among the causes of perineal pain. Pain is
initially visceral and somatic properties are added there-
after. Pain may be resulted from involvement of nerve
root, plexus, nerve corpus or branches, lymphatic or va-
scular system or pressure on those sites.
Pain is seen in perineal region in lower urogenital
system cancers. More than one third of perineal pain ari-
ses from lower genital malignities.
Pelvic, perineal pain may originate from prostate can-
cer in cases with urologic cancers. Pain may be related to
involvement of the organs crossing pelvic and perineal
region. Involvement of genitofemoral, iliohypogastric
and ilioinguinal nerves are the cause of severe pain.
4. Chronic Prostatitis
Interest on chronic prostatitis has increased in recent
years. Quality of life is impaired in correlation with de-
pressive symptoms and severity of pain. Post-ejaculatory
pain is accepted as a finding of poor prognosis.
A men-specific marker was seeked in some studies
about chronic prostatitis however nothing except some
amount of elevation in IL-6 and IL-8 could be found.
Prostatic cultures did not differ between the patients with
or without chronic pelvic pain.
Benefits of technetium-binding ciprofloxacin are men-
tioned. Also, detection of a large prostatic calculi, hyper-
sensitivity of sacral dermatomes to cutaneous stimuli are
also beneficial for diagnosis. Pain development with
intravesical potassium solution is frequently seen in chro-
nic protatitis patients.
Agents like ciprofloxacin, levofloxacin, alpha-agonists,
pentason polysulphate may be used for treatment. Bio-
feedback, prostate ablation using transurethral needle,
electrostimulation are the other techniques used.
5. Assessment of the Patients with Cancer
The main principle for pain assessment is to believe the
complaint of pain. In other words, if the patients says that
“I have pain”, he has pain. Taking an anamnesis enables
to put forward the emotional and psychiatric status of the
patient besides providing data about potential causes and
mechanisms of the pain. A simple treatment plan must be
made for pain while needed tests are being performed.
The following algorithm may be followed for pain
1) Believe the complaint of pain.
2) Take a careful anamnesis of pain: question the pain
in detail together with the location, duration, character-
istic, severity of the pain, factors increasing or decreas-
ing the pain, accompanying symptoms and history of
pain including previous treatment modalities, medical
history, drugs and allergy.
3) Range the complaint of pain according to signifi-
cance if the complaint of pain is more than one.
4) Assess the response to and satisfaction from the
current and previous analgesic therapy.
5) Assess the psychologic status and alcohol or
smoking addiction of the patient.
6) Make a careful medical and neurologic examination
7) Assess the proper diagnostic procedures.
8) Start treatment for the pain in order to facilitate the
9) Provide regular care and control of the patient to
provide patient compliance, to reduce anxiety and to
assess treatment, question the response to pain treatment
again at each time.
10) Talk to the patient and his family about the poten-
tial problems and solutions.
6. Pain Measurement
An objective measurement of pain is not possible as it is
a subjective concept. Scales used to measure the pain
may be uni-dimensional or multi-dimensional (Table 1)
and which scale is to be used differs according to the
patient or health staff. Uni-dimensional scales are focus-
ed on a special parameter like the severity of pain. These
scales are simple and beneficial. Visual analogue scale is
the most sensitive and beneficial one. Multi-dimensional
scales investigate other properties of pain besides its se-
7. Pain Treatment in Patients with Cancer
Plan of pain treatment is divided into two groups as in-
vasive, non-invasive or pharmacologic or non-pharmac-
ologic, the limits beteen treatment methods is unclear and
co-existence of two conditions may be seen frequently .
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A. EMAN ET AL.
Table 1. Scales used for pain measurement.
Uni-dimensional scales Multi-dimensional scales
Numerical Scales McGill Pain Questionnaire Form
Categorical Scales Wisconsin Brief Pain Inventory
Visual Analogue Scale (VAS) Memorial Pain Identification Card
TermometerVAT) Descriptive Differential Scale
Burford Pain Termometer West Haven-yale Multi-dimensional
Treatment strategy for cancer pain was determined in
detail by World Health Organization (WHO). An algo-
rithm of line therapy was put forward in order to protect
from side effects and to provide an effective treatment
According to this algorithm:
Step 1: Non-opioid analgesics;
Step 2: Weak opioid analgesics + non-opioid analges-
Step 3: Potent opioid analgesics + opioid analgesics.
Adjuvan drugs may be added to each line when needed.
Application and recognization of this line principle is
quite easy and it may provide pain treatment in more
than 80% of patients.
The aim of pain control is painless resting, night sleep
not interrupted by pain, to reduce pain in standing
position and with movements. In other words, the main
goal is to reduce side effects and to improve quality of
8. Cancer Pain Syndromes
Pain syndromes in cancer patients may be gathered under
three major groups according to etiology [2,19-21].
1) Invasion or compression of pain-sensitive structures
by tumor (bone invasion, compression of nerve roots or
nerve plexus, infiltration of nerve tissue and blood
vessels of the tumor.
2) Pain arising during cancer therapy;
Surgical therapy-related pain;
3) Non-cancer pain in cancer patients.
9. Pain Treatment
Pain treatment is done based on analgesic use principles
10. Non-Opioid Analgesics
Acetaminophen and nonsteroidal antiinflammatory drugs
(NSAIDs) are non-opioid analgesics [22,23], they are the
most commonly used analgesics in mild pain alone, they
Table 2. Principles of analgesic use .
Analgesic must be chosen in accordance with line principle according
to severity of pain.
Cause and quality of pain must be taken into consideration for analgesic
Per oral route must be primarily preferred for analgesic use.
Analgesic dose must be individualized.
Analgesics must be taken with certain intervals before the pain begins.
The patient and his family must be informed about potential side
Adjuvan drug use must not be overlooked and must always be keptin
are effective to reduce opioid dose with additive effect in
moderate and severe pain. Ceiling effect, potential side
effects and toxicity in high doses restrict their use.
NSAIDs act through inhibiting cyclooxygenase enzyme
(COX) taking part in prostaglandin synthesis. COX
enzyme has two forms. Of them, COX1 mostly regulate
renal plasma flow, gastric mucosa protection, platelet
aggregation, pain and inflammation and COX2 is respon-
sible for inflammatory cytokine stimulation and hyperal-
gesia in tissue damage [24-26].
Although acetylsalicylic acid is prototype and an
important member of NSAIDs, it is not used in the long
term treatment of cancer pain due to high side effect
Paracetamol inhibits only the prostaglandin in central
nervous system and does not have antiinfalmmatory
property. Therefore it does not have negative peripheral
side effects of NSAIDs. It may reduce opioid dose and
potential side effects when combined with opioid anal-
gesics. It is recomended at every 6 hours and hepatic
toxicty should always be kept in mind in patients who
use more than 4 gr and above paracetamol [27-29].
Metamizol is a drug with poor cyclooxygenase and
antiinflammatory property and strong analgesic and
antipyretic properties. Its analgesic effect is more than
aspirin. It also shows additive effect with opioid analge-
sics like paracetamol. Recommended maximum daily
dose is 5 gram. It is particularly recommended in spas-
motic pain and it may supress bone marrow. Paracetamol
and metamizol are aside from classical NSAIDs .
Naproxen is better tolerated than other NSAIDs and is an
effective drug in cancer pain. Half-life is approximately
14 hours, recommended daily dose is 1100 mg. Piroxi-
cam is an analgesic that may be used as single dose due
to its long half-life (45 hours) .
Adverse effects like reduction in renal blood flow and
micturation, hypertension, thrombocyte dysfunction, as-
thma crisis, bone marow depression, hepatotoxicity be-
sides frequently seen side effects like gastric irritation,
ulcer, bleeding restrict use of NSAIDs .
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A. EMAN ET AL. 167
11. Opioid Analgesics
They are the most potent analgesic agents. They are used
in treatment of moderate and severe cancer pain regard-
less of the mechanism of pain. They act as binding to
specific receptors located in medulla spinalis, brain and
peripheral nerves. They are usuallay used in combination
with NSAIDs at second and third lines recomended by
WHO. They inhibit release of transmitters responsible
for pain transmission in medulla spinalis and pain per-
ception in the brain. They do not have ceiling effect and
maximum doses in a painless individual and they are
classified as potent opioids (morphine, hydromorphon,
metadon, levorphanol, meperidine, fentanyl) and weak
opioids (propoxiphene, codeine, oxycodone, hydroco-
done, tramadol). They are administered via per oral, IM,
IV, subcutaneous, transdermal, rectal and spinalepidural
routes. Side effect and analgesic efficiency balance vary
according to the agent used [31-33].
It is effective on moderate-severe pain. Its combination
with adjuvant and non-opioid analgesics is effective on
cancer pain. Codeine does not cause a significant toler-
ance and physical addiction besides providing an effec-
tive analgesia. It is used via per oral route and may rarely
cause nausea, sedation, allergic reaction and dizziness in
Recommended daily dose for codeine which is in the
second line of analgesic therapy is 15 - 60 mg at every 4
- 6 hours depending on the severity of pain, adjuvant and
Its onset time and duration of action is 75 - 125 fold
greater than morphine due to higher lipid solubility. It is
recommended via epidural-spinal and transmucosal
routes in combination with local anesthetics in the third
line of WHO’s line therapy. Transdermal form is parti-
cularly beneficial in the patients who have trouble with
per oral route and the bands are as 72-h forms, onset time
is 4 - 12 hours and stable effect develops at 12 - 24 hours,
analgesic effect continues 12 hours more after the trans-
dermal band is removed. Side effects may be reversed
with naloxone. Transmucosal form is recommended in
treatment of breakthrough pain in cancer patients which
is seen as sudden pain peaks during the normal course of
Its potency is one tenth of morphine. It is not used for
treatment of chronic pain due to its metabolite, norme-
peridine, which has short duration of action and may
cause convulsions, it is administered for only a few days
in treatment of acute pain.
Morphine is accepted as the gold standard among opioid
drugs, on the contrary to a belief, it is accepted as the
easiest applicable and controllable opioid drug. It may be
used via per oral, rectal, intravenous, intrathecal, epidural
routes and it may provide a long term analgesia in
intrathecal use due to its hydrophillic property. Its active
metabolite morphine 6 glucorinide has a more potent
analgesic property and thus it is recommended to use
carefully in the patients with hepatic and renal insuf-
Per oral route: It may be used as 10 - 60 mg quid, slow
releasing tablets may be used 10 - 60 mg bid.
Rectal route: 10 - 20 mg at every 4 hours.
Intravenous route: It may be used 2.5 - 15 mg slowly.
Subcutaneous and intramuscular doses are the same as
It is used as the first line therapy in line therapy of WHO.
Its opioid receptor affinity is low and it also inhibits
noradrenaline and serotonin reuptake. It is a proper
alternative in treatment of cancer pain due to minimal
central nervous system side effects, not causing respir-
atory depression and low addiction potential, showing
additive effect with NSAIDs. Its active metabolite is
more potent than itself and this causes dose limitation. It
has less side effects than typical opioid agonists. The
most common side effects include dizziness, nausea,
vomiting, sedation, nonspecific central nervous system
irritation and coordination disorder and convulsion may
occur in high doses. Its half life is approximately 6 hours
and it was detected to be safe and effective in max 600
mg daily dose. It may be used via per oral, intravenous,
intramuscular, subcutanous routes.
18. Adjuvant Drugs
Drugs which are not pharmacologically analgesic but
increase the effects of analgesics or used in treatment of
symptoms accompanying the pain are named as adjuvant
drugs or co-analgesics.
These drugs include topical local anesthetics, neurol-
eptics, antihistamines, benzodiazepines, anticonvulsants
and antidepressant drugs .
While carbamazepine and phenytoin were the corner-
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A. EMAN ET AL.
stones of neuropathic pain treatment until recently,
severe side effects restricted the benefits of these drugs.
Those side effects include severe cognitive effects which
may lead to negative and harmful conditions especially
in the elderly, thus patient compliance significantly
increased with development of second generation anti-
convulsants which are tolerated better and significant
improvements occured in treatment options of neuropa-
Gabapentin is initially an antiepileptic drug and a stru-
ctural analogue of gamma-aminobutyric acid (GABA). It
is bound to α2-δ protein subunit of voltage-dependent
calcium channels wich are located widespread in central
and peripheral nervous system. This inhibits calcium
influx and reduces excitatory neurotransmitters released
from pain pathways .
Analgesic effect of gabapentin was widely investi-
gated by the surgical community before and it was
reported as the result of these studies to have analgesic
effect on postoperative pain [36-39]. It was also found to
be quite effective in treatment of non-cancer neuropa-
thic pain and cancer-related neuropathic pain. Initial dose
of gabapentin is 100 - 300 mg daily and the dose is in-
creased at every three days. Maximum dose is usually
3600 mg daily and the maximum tolerable dose is reach-
ed within 1 - 2 weeks. The most common side effects are
somnolence and dizziness. Although it is usually well
tolerated with a careful titration, somnolence may lead to
termination of therapy especially in deteroirated patients.
Pregabalin is a lipophillic GABA analogue which has
analgesic, anticonvulsant, anxiolytic, sleep modulation
opioid sparing effects. It was reported to be effective in
many conditions like many neuropathic pain models [40,
41], incisional injury  and inflammatory conditions
 as the successor of gabapentin. In recent studies,
there is a gradually increasing interest as it is a part of
multimodal analgesia in pain control. Although its me-
chanism of action is similar to that of gabapentin, its
pharmacologic profile is more superior.
Its reducing opioid need, hinder and reduce opioid
tolerance, improve the quality of opioid analgesia, reduce
respiratory depression, eliminating anxiety and gastric
sparing effects make this agent attractive.
Pregabalin has a similar effect to gabapentin. It should
be used carefully in the elderly and susceptible indivi-
duals. It may be well tolerated if the dose reaches to 75
mg bid by gradually increasing from 75 mg daily at the
end of the first week. Patients rarely wish to exceed 150
mg bid dose due to blurred vision and edema in addition
to frequent side effects of anticonvulsants. Gabapentin
and pregabalin must certainly be used after renal func-
tions had been checked, preferably after creatinine clear-
ance had been calculated as they are excreted from the
kidneys. Pregabalin may be preferred due to less com-
plex titration schedule and possible lower side effect pro-
Tapentadol affects centrally with its µ receptor agonist
effect and inhibition of noradrenaline reuptake [45-47]. It
is 2 - 3 fold less effective than morphine despite 18 fold
greater affinity to µ opioid receptors compared to mor-
phine. It was developed as the result of studies aiming at
reducing tolerance seen with opioid doses causing equal
analgesic effect. Tapentadol is a novel analgesic with
central effect and side effect incidence is lower than that
of opioids. It was initially formulated as immediate—
release preparation and approved as potent Schedule II
analgesic by the US Food and Drug Administration
(FDA). It is also the first analgesic developed since the
recent 25 years for management of moderate and severe
acute pain .
Tapentadol has two different forms of which one is
tapentadol immediate-release 50, 75 and 100 mg tablets
and they provide an analgesia lasting for 4 - 6 hours. Ta-
pentadol was accepted to have an equal analgesic po-
tency with hydrocodone and oxycodone, between tra-
madol and morphine. Tapentadol was seen to provide a
similar analgesia with immediate-release oxycodone .
It was also found as effective as oxycodone in the
patients suffering from osteoarthritis and chronic low
back pain . Besides, its analgesic efficacy was shown
in inflammatory, somatic and neuropathic pain and it was
reported to have a better gastrointestinal tolerability than
opioids (nausea, vomiting, constipation) [35,50].
The second form is tapentadol extended-relase which
may be effective for about 12 hours for the patients 18
years and above with moderate or severe pain. It is used
twice daily. Tolerance begins slowly in chronic use and it
significantly delays the beginning of tolerance compared
to morphine . It is contraindicated in the patients
with severe asthma, paralytic ileus and who use monoa-
Steroids inhibit prostaglandin synthesis, reduce tumor-
related edema and inflammation. They have special use
areas like inflammation control, antiemetic effect, improv-
ement of anorexia and cachexia in pain management and
paliative care. They are particularly indicated in the pain
related with bone metastasis, increased intracranial
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A. EMAN ET AL. 169
pressure, spinal cord compression, liver metastasis, soft
tissue infiltration . Usually low dose corticosteroid
regimen is applied (prednisone 10 - 30 mg or deaxame-
thasone 2 - 4 mg daily).
Most steroids primarily act as reducing inflammatory
mediators when used systemically. Usually a depot
steroid is used in intraarticular injections, localized
myofascial and trigger point injections. These approaches
enable higher local doses without causing systemic side
effects. Depot steroids are typically used together with
local anesthetics for various nerve blocks.
Patients must be assessed in detail, age, physcial
condition, hepatic and renal functions of the patients,
accompanying diseases, drug interactions must be consi-
dered and the patients must be followed up carefully.
Myopathy, hyperglycemia, weight gain and dysphoria
may develop as the result of long term steroid treatment.
Risk of peptic uler increases when used together with
Biphosphonates reduce bone resorption through inhibit-
ing osteoclastic activity in the patients with bone meta-
stasis-related pain. They were detected to reduce pain
development and pathologic fractures when used regu-
larly. The third generation biphosphonate, zolendronic
acid was reported to have the potential to prevent bone
complications of prostate cancer but to be insufficient for
control of bone pain .
25. Hormonal Therapy
Androgen deprivation is the first choice of treatment
modality in painful bone metastasis of androgen-sensi-
tive prostate cancer however resistance may develop
against hormone therapy 2 - 3 years later.
Radiotherapy is the mainstay in treatment of bone meta-
stasis, prevention of spinal cord and nerve root com-
pression. External beam radiotherapy is seen to be very
effective in paliation of pain in bone metastasis. Radi-
otherapy is considered to relieve pain by inhibiting
release of chemical pain mediators and reducing tumor
mass. In treatment of bone metastasis, while response is
obtained in more than 80% of patients with radiotherapy,
full response could not be obtained in 15% - 40%. Its
effect begins mean approximately three weeks and con-
tinues for 13 - 24 weeks [54,55].
Systemic radiopharmaceuticals uptaken in the bone are
known to have effects on palliation and delaying emerg-
ence of new symptomatic sites in the patients who have
widespread symptomatic bone metastasis. The most wide-
ly used radiopharmaceutical is strontium-89 in the pa-
tients with hormone-resistant prostate cancer who have
uncontrollable painful bone metastasis in both sides of
diaphragm [56,57]. Samarium 153 is another radiophar-
maceutical agent which was shown to be effective in
control of bone metastasis-related pain.
28. Interventional Methods Used in
Treatment of Cancer Pain
There is the indication for invasive therapy if pain conti-
nues despite proper doses of analgesics or side effects of
drugs cannot be tolerated. Patient selection must be done
carefully and the procedures must be applied by expe-
rienced specialists as invasive methods have severe side
effects. These methods can mainly be classified as
anesthetic and surgical methods [58-60].
29. Nerve Blocks
Response to therapy must certainly be evaluated with
repeated local anesthetic blocks before permanent neuro-
lytic blocks are done besides general rules valid for
interventional methods. Celiac plexus block and superior
hypogastric block may be beneficial in urologic mali-
Celiac plexus block provides an effective pain control
in upper abdominal pain and low back pain, reduces
analgesic need, facilitates the treatment of constipation, a
frequent complication of opioid use by increasing bowel
movements. Superior hypogastric block is a quite effec-
tive and beneficial method for elimination of pain and
tenesmus due to rectum and lower urogenital tract malig-
30. Percutaneous Cordotomy
Analgesia may be provided on the contralateral body half
by making a destruction in spinothalamic tract using
31. Neuroaxial Catheter Applications
This may be considered as the 4th line following potent
opioid use in analgesic line therapy of WHO. Opioids
provide a longer analgesia when administered via epi-
dural or intrathecal route [61,62]. They are mainly admi-
nistered in three ways: In the first method, a subcu-
taneous tunnel is opened after the epidural catheter had
been placed to a proper site for the pain, the catheter is
used by inserting a bacteria filter. In the second method,
the aforementioned tunnel is extended to axillary line, it
is inserted to a port placed subcutaneously instead of the
bacteria filter, injections are done via this port when
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A. EMAN ET AL.
needed. Small devices which provide automatic doses are
used instead of port in the third method. Which method
will be used is decided according to the patient. Anal-
gesia via catheter is usually provided with morphine, both
morphine dose and the pain developing with movements
reduce by adding a local anesthetic to morphine. Fibrosis
developing on the tip of the epidural catheter makes
injections from the catheter very difficult in some cases,
and accompanying burn sensation may cause severe
disturbance in the patients. On the other hand, it has
advantages like less infection risk, providing dermatomal
Opioid-related urinary retention, nausea, vomiting,
itching, respiratory depression, local anesthetic-related
motor-sensory block, orthostatic hypotension may deve-
lop. The most severe side effect is infection. Obstruction,
break and CSF leakage may develop.
Extended release epidural morphine (EREM) that can
be administered in a single dose and we consider to be
beneficial in cancer patients was put on the market.
EREM was formulated so as to be administered to epi-
dural region at lumbar level. It was reported to provide a
long standing analgesia in a few studies .
In conclusion, the aim in prostate cancer patients will
be to achieve the best possible analgesia with minimum
drug dose, minimum side effect and minimally invasive
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