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Guideline Summary
Guideline Title
Post-operative pain management. In: Guidelines on pain management.
Bibliographic Source(s)
Post-operative pain management. In: Bader P, Echtle D, Fonteyne V, Livadas K, De Meerleer G, Paez Borda A, Papaioannou EG, Vranken JH. Guidelines on pain management. Arnhem, The Netherlands: European Association of Urology (EAU); 2010 Apr. p. 61-82. [88 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Post-operative pain management. In: Bader P, Echtle D, Fonteyne V, De Meerleer G, Papaioannou EG, Vranken JH. Guidelines on pain management. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 62-82. [79 references]

Scope

Disease/Condition(s)
  • Urologic cancer
  • Postoperative pain
Guideline Category
Evaluation
Management
Prevention
Treatment
Clinical Specialty
Anesthesiology
Critical Care
Geriatrics
Internal Medicine
Oncology
Pediatrics
Pulmonary Medicine
Surgery
Urology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To assist medical professionals in appraising the evidence-based management of pain in urological practice
  • To establish safer and more effective pain management, to introduce proper assessment of pain and planning of pain control techniques, and to promote training of medical and nursing staff in this area
Target Population

Patients requiring pain management following surgery for urological cancer

Interventions and Practices Considered

Treatment/Management

  1. Pre-operative pain assessment
  2. Pre- and post-operative pain management
    • Pre-emptive analgesia
    • Systemic analgesic techniques (e.g., non-steroidal anti-inflammatory drugs [NSAIDs], paracetamol, opioids)
    • Regional analgesic techniques (e.g., epidural analgesia, patient-controlled epidural analgesia)
    • Multi-modal analgesia
    • Analgesia in special populations, including ambulatory, geriatric and obese patients
    • Use of postoperative pain management teams
  3. Specific pain treatment after different urological operations
    • Extracorporeal shock wave lithotripsy (ESWL)
    • Endoscopic procedures (e.g., transurethral, percutaneous, laparoscopic procedures)
    • Open surgery (e.g., minor surgery of the scrotum/penis, transvaginal surgery, perineal surgery, laparotomy surgeries)
  4. Peri-operative pain management in children
    • Preoperative problems
    • Postoperative analgesia
Major Outcomes Considered
  • Pain relief
  • Function
  • Quality of Life
  • Adverse effects of therapy

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The recommendations provided in the current guidelines are based on a systemic literature search using Medline, the Cochrane Central Register of Controlled Trials, and reference lists in publications and review articles.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

1a Evidence obtained from meta-analysis of randomized trials

1b Evidence obtained from at least one randomized trial

2a Evidence obtained from one well-designed controlled study without randomization

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
  • The first step in the European Association of Urology (EAU) guidelines procedure is to define the main topic.
  • The second step is to establish a working group. The working groups comprise about 4-8 members, from several countries. Most of the working group members are academic urologists with a special interest in the topic. Specialists from other medical fields (radiotherapy, oncology, gynaecology, anaesthesiology, etc.) are included as full members of the working groups as needed. In general, general practitioners or patient representatives are not part of the working groups. Each member is appointed for a four-year period, renewable once. A chairman leads each group.
  • The third step is to collect and evaluate the underlying evidence from the published literature.
  • The fourth step is to structure and present the information. All main recommendations are summarized in boxes and the strength of the recommendation is clearly marked in three grades (A-C), depending on the evidence source upon which the recommendation is based. Every possible effort is made to make the linkage between the level of evidence and grade of recommendation as transparent as possible.
Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
  2. Based on well-conducted clinical studies, but without randomized clinical trials
  3. Made despite the absence of directly applicable clinical studies of good quality
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

There is no formal external review prior to publication.

The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to analyse and assess a range of specific attributes contributing to the validity of a specific clinical guideline.

The AGREE instrument, to be used by two to four appraisers, was developed by the AGREE collaboration (www.agreecollaboration.org External Web Site Policy) using referenced sources for the evaluation of specific guidelines.

Recommendations

Major Recommendations

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of the publication date. However, because EAU updates their guidelines frequently, users may wish to consult the EAU Web site External Web Site Policy for the most current version available.

Levels of evidence (1a-4) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

Post-operative pain is usually underestimated and undertreated. Approximately 70% of surgical patients experience a certain degree (moderate, severe or extreme) of post-operative pain (Level of evidence: 1a).

The results of post-operative pain undertreatment include increased morbidity and mortality, mostly due to respiratory and thromboembolic complications, increased hospital stay, impaired quality of life, and development of chronic pain (Level of evidence: 1a).

The Importance of Effective Post-operative Pain Management

The physiological consequences of post-operative pain are shown in the table below, all of which could delay or impair postoperative recovery and increase the economic cost of surgery as a result of the longer period of hospitalization (Level of evidence: 3). Inadequate post-operative pain control may also lead to the development of chronic pain after surgery (Level of evidence: 2b).

Table: Physiological Consequences of Post-operative Pain

Condition Consequences Level of Evidence
Stress response to surgery
  • Tissue trauma results in release of mediators of inflammation and stress hormones
  • Activation of this 'stress response' leads to:
    • Retention of water and sodium
    • Increase in metabolic rate
2a
Respiratory complications
  • Shallow breathing
  • Cough suppression
  • Lobular collapse
  • Retention of pulmonary secretions
  • Infections
2b
Cardiovascular complications
  • Hypertension
  • Tachycardia
  • Increased myocardial work, which may lead to:
    • Myocardial ischaemia
    • Angina
    • Infarction
  • These are the most common cardiovascular complications after urological surgery
2b
Thromboembolic complications
  • Reduced mobility due to inadequate pain management can lead to thromboembolic episodes
2a
Gastrointestinal complications
  • Gastric stasis
  • Paralytic ileus
  • These occur often, mostly after open urological operations
2b
Musculoskeletal complications
  • Prolonged confinement to bed due to inadequate pain management leads to:
    • Reduced mobility
    • Muscle atrophy
3
Psychological complications
  • Peri-operative pain may provoke fear and anxiety, which can lead to:
    • Anger
    • Resentment
    • Hostility to medical and nursing personnel
  • These symptoms are often accompanied by insomnia.
3

The aims of effective post-operative pain management are to:

  • Improve the comfort and satisfaction of the patient
  • Facilitate recovery and functional ability
  • Reduce morbidity
  • Promote rapid discharge from hospital (Level of evidence: 1a)

Recommendation

Post-operative pain should be treated adequately, to avoid post-operative complications and the development of chronic pain (Grade of Recommendation: B).

Pre- and Post-operative Pain Management Methods

Pre-operative Patient Preparation

  • Patient evaluation
  • Adjustment or continuation of medication in order to avoid abstinence syndrome
  • Premedication as part of multimodal analgesia
  • Behavioral-cognitive interventions for the patient and family with the aim of alleviating anxiety and fear of post-operative pain. This in turn leads to a reduction in the amount of analgesia required postoperatively and better and more efficient pain management (Level of evidence: 1a).

During this phase, patients should be informed about the different options and methods of post-operative analgesia and their benefits and adverse effects. This will enable them to make an informed decision together with their clinicians.

Recommendation

Pre-operative assessment and preparation of the patient allow more effective pain management (Grade of recommendation: A).

Pain Assessment

Careful pain assessment by the surgeon or the acute pain team can lead to more efficient pain control, adequate doses of the correct drugs, and diminished morbidity and mortality (Level of evidence: 2a). Pain should be assessed before and after treatment.

In the post-anaesthesia care unit (PACU), pain should be evaluated, treated and re-evaluated initially every 15 minutes and then every 1-2 hours. After discharge from the PACU to the surgical ward, pain should be assessed every 4-8 hours before and after treatment.

Recommendation

Adequate post-operative pain assessment can lead to more effective pain control and fewer post-operative complications (Grade of recommendation: B).

Pre-emptive Analgesia

Pre-emptive or preventive analgesia is defined as the administration of analgesia before surgical incision to prevent establishment of central sensitization from incision or inflammatory injury in order to achieve optimal post-operative pain control. A variety of pharmacological agents and techniques have been used for this purpose. The results of clinical trials on the efficacy of pre-emptive analgesia are controversial (Level of evidence: 2b).

Systemic Analgesic Techniques

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Table 10 in the original guideline document gives dosage and administration details for NSAIDs.

Intravenous (IV) administration of NSAIDs should start 30-60 min before the estimated end of surgery, and oral administration should start as soon as possible. Intramuscular administration of analgesic drugs for post-operative pain control is generally avoided because of the variability of serum drug concentrations and the pain caused by the injection.

Recommendations

  • NSAIDs are not sufficient as the sole analgesic agent after major surgery (Grade of recommendation: B).
  • NSAIDS are often effective after minor or moderate surgery (Grade of recommendation: B).
  • NSAIDs often decrease the need for opioids (Grade of recommendation: B).
  • Avoid long-term use of cyclo-oxygenase (COX) inhibitors in patients with atherosclerotic cardiovascular disease (Grade of recommendation: B).

Paracetamol

Recommendations

  • Paracetamol can be very useful for post-operative pain management as it reduces the consumption of opioids (Grade of recommendation: B).
  • Paracetamol can alleviate mild post-operative pain as a single therapy without major adverse effects (Grade of recommendation: B).

See Table 11 in the original guideline document for dosage and administration of paracetamol/opioid combinations.

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 agranulocytosis. In other countries, it is considered to be a useful analgesic and antipyretic drug for use in moderate pain. Even though data are controversial, long-term use of metamizole is best avoided (Level of evidence: 2b).

Opioids

Opioids are the first-line treatment for severe acute post-operative pain (See Table 12 in the original guideline document for a listing of opioid drugs, dosage and administration). The key principle for their safe and effective use is to titrate the dose against pain relief and to minimize unwanted effects.

Patient-Controlled Analgesia (PCA)

Systemic administration of opioids may follow the 'as needed' schedule or 'around-the-clock' dosing. The most effective mode is patient-controlled analgesia (PCA) (Level of evidence: 1a). Typical PCA dosing schedules are shown in Table 13 of the original guideline document.

Recommendation

Intravenous PCA provides superior post-operative analgesia, improving patient satisfaction and decreasing the risk of respiratory complications (Grade of recommendation: A).

Fentanyl

Fentanyl has been administered transdermally for post-operative pain management, but its use by this route has been limited by the difficulty of titrating the drug levels. The fentanyl HCl iontophoretic transdermal system (fentanyl ITS) is a needle-free patient-controlled system that releases a pre-programmed dose of fentanyl on demand. It is very effective in the management of severe post-operative pain (Level of evidence: 1a).

Regional Analgesic Techniques

Local Anaesthetic Agents

Bupivacaine is considered to be cardiotoxic in high doses. L-bupivacaine and ropivacaine appear to be safer, but the degree of motor blockage they provide is not as good as that of bupivacaine. Ropivacaine has the longest duration of action.

Epidural Analgesia

Epidural analgesia provides excellent post-operative pain relief for extended periods after major surgical operations, reducing post-operative complications and the consumption of opioids (Level of evidence: 1a). Typical epidural dosing schemes are shown in Table 15 of the original guideline document.

Patient-Controlled Epidural Analgesia (PCEA)

Patient-controlled epidural analgesia has become very common because it allows individualization of analgesic requirements, a decrease in the use of drugs, greater patient satisfaction, and superior analgesia. In addition, PCEA seems to provide better analgesia compared with IV PCA (Level of evidence: 1a). Typical PCEA dosing schemes are shown in Table 16 of the original guideline document.

Recommendation

Epidural analgesia, especially PCEA, provides superior post-operative analgesia, reducing complications and improving patient satisfaction. It is therefore preferable to systemic techniques (Grade of recommendation: A).

Neural Blocks

Local anaesthetic blocks (intermittent and continuous) can be used after urological surgical operations to supplement post-operative analgesia (Level of evidence: 2a). Examples of such blocks are shown in Table 17 of the original guideline document. Note that lidocaine is not usually used because of its short duration of action.

Wound Infiltration

Intra-operative wound infiltration with local anaesthetic (usually 10-20 mL of ropivacaine or bupivacaine 0.25-0.5%) can provide some post-operative analgesia and may reduce the requirement for systematic analgesia (Level of evidence: 2b).

Continuous Wound Instillation

Continuous post-operative wound instillation of a local anaesthetic via a multihole catheter placed intraoperatively by the surgeon has been proven to provide satisfactory analgesia for moderate to severe post-operative pain, reducing the consumption of systemic analgesics (Level of evidence: 2b).

Multi-modal Analgesia

The concept of multi-modal ('balanced') analgesia is that effective post-operative pain control depends on the use of several different analgesics and routes of administration, which then act in synergy. The combined use of different classes of analgesics and analgesic techniques improves the effectiveness of pain relief after surgery and reduces the maximal dosage and adverse effects (Level of evidence: 2b).

Multi-modal analgesia seems to be more effective when different drugs are administered via different routes than when different drugs are administered via a single route (Level of evidence: 2b).

Recommendation

Multi-modal pain management should be employed whenever possible since it helps to increase efficacy while minimizing adverse effects (Grade of recommendation: B).

Special Populations

Ambulatory Surgical Patients

The main aim of analgesia in these patients is to achieve adequate pain relief so that patients can be discharged from hospital. It also avoids the use of opioids, the side-effects of which can prolong hospital stay (Level of evidence: 2a).

A multi-modal analgesic plan uses a combination of NSAIDs or paracetamol plus local anaesthetics used as peripheral nerve blocks, tissue infiltration, or wound instillation. In this way, ambulatory patients can be given pain relief that does not use opioids (Level of evidence: 2b).

Recommendations

  • For post-operative pain control in out-patients, multi-modal analgesia with a combination of NSAIDs or paracetamol plus local anaesthetics should be used (Grade of recommendation: B).
  • If possible, avoid opioids (Grade of recommendation: B)

Geriatric Patients

Multi-modal post-operative analgesia may be the pain management technique of choice in elderly patients, as the dosages of medication required are lower. However, it is important to be vigilant for adverse reactions, as they tend to increase in number in the geriatric population (Level of evidence: 2b).

Epidural analgesia might diminish the risk of post-operative delirium and respiratory complications in elderly patients (Level of evidence: 2b).

Recommendation

Multi-modal and epidural analgesia are preferable for post-operative pain management in elderly patients because these techniques are associated with fewer complications (Grade of recommendation: B).

Obese Patients

Obese patients appear to be at higher risk for certain post-operative complications, including respiratory (hypoxia, atelectasis, arrest), cardiovascular (ischaemia, arrhythmias, infarction), thromboembolic episodes, and wound infections. Because the administration of opioids to obese patients is associated with sudden respiratory arrest, a combination of NSAIDs or paracetamol with a local anaesthetic epidural might be the safest analgesic solution (Level of evidence: 2b).

Recommendations

  • The postoperative use of opioids should be avoided in obese patients unless absolutely necessary (Grade of recommendation: B)
  • An epidural of local anaesthetic in combination with NSAIDs or paracetamol is preferable (Grade of recommendation: B).

Other Groups

Critically ill or cognitively impaired patients present special difficulties in pain management. Regional or multi-modal analgesia might be more effective in such patients because drug dosages are reduced and behavioral interventions and patient-controlled methods are unsuitable (Level of evidence: 3).

Recommendation

There are no sufficient data to support a specific post-operative pain management plan for critically ill or cognitively impaired patients (Grade of recommendation: C).

Post-operative Pain Management Teams

The importance of efficient post-operative pain management has led to the development of acute post-operative pain management teams. These are multidisciplinary teams, which generally consist of nursing and pharmacy personnel led by an anaesthesiologist. Their aims are post-operative pain assessment and treatment using various methods, including PCAs or PCEAs, and education of medical and nursing staff. Such services have been shown to improve pain relief, decrease analgesic medication-related side-effects (e.g., nausea, vomiting, pruritus, sedation, and respiratory depression), improve patient satisfaction, and decrease overall costs and morbidity rates (Level of evidence: 2b). In addition, improved pain control can lead to a shorter period of hospitalization and fewer unscheduled re-admissions after day-case surgery (Level of evidence: 3).

Specific Pain Treatment after Different Urological Operations

Extracorporeal Shock Wave Lithotripsy (ESWL)

This is a minimally invasive treatment, during and after which between 33% and 59% of patients do not need any analgesia (Level of evidence: 2b). In those patients who do need pain relief, post-treatment pain is unlikely to be severe and oral analgesics are usually sufficient.

Analgesic Plan

  • Pre-operative assessment: see section 5.3.2 in the original guideline document.
  • Intra-operatively: the most experience exists for alfentanil (0.5-1.0 mg/70 kg IV), given on demand during ESWL, either by the urologist or the anaesthesiologist. Nonsteroidal anti-inflammatory drugs (NSAIDs) or midazolam as premedication 30-45 min before treatment reduces the need for opioids during the procedure (Level of evidence: 2b). With a premedication of diclofenac (100 mg rectally), only 18% of patients needed pethidine during the lithotripsy. After a premedication with midazolam (5 mg orally), 70% of patients were completely free of pain during the treatment, and if buprenorphine was added this proportion rose to 87%. After premedication with midazolam (2 mg IV, 5 min before the treatment), diclofenac or tramadol proved to be safe and effective analgesics with fewer side-effects than fentanyl (Level of evidence: 1b). Other effective regimes for intraoperative pain treatment are fentanyl (1 microgram/kg IV) or sufentanil or remifentanil. These drugs are usually given by the anaesthesiologist because of the risk of respiratory depression. The incidence of respiratory depression after the procedure was significantly lower (20% vs. 53%) if remifentanil was used instead of sufentanil (Level of evidence: 1b). There is not enough evidence to prove an advantage for any of the combinations used.
  • Post-operative: most patients will be able to tolerate oral analgesics following this procedure. NSAIDs, metamizole, paracetamol, codeine, and paracetamol combination preparations or tramadol could all be used. These drugs could be prescribed on an 'as needed' or a time-contingent basis. If pain is more severe or persistent, patients usually need to be examined to exclude hydronephrosis or haematoma of the kidney.

See Table 18 in the original guideline document for a listing of the analgesic drug options after ESWL.

The majority of patients for this procedure will be outpatients who have come in just for the day. Upon discharge, they should be provided with a prescription for analgesics and a contingency plan in case the pain worsens. This will reduce the incidence of unplanned hospital readmissions.

Recommendations

  • Analgesics should be given on demand during and after ESWL because not all patients need pain-relief (Grade of recommendation: B).
  • Premedication with NSAIDs or midazolam often decreases the need for opioids during the procedure (Grade of recommendation: B).
  • IV opioids and sedation can be used in combination during ESWL; dosage is limited by respiratory depression (Grade of recommendation: C).
  • Post-ESWL, analgesics with a spasmolytic effect are preferable (Grade of recommendation: C).

Endoscopic Procedures

Transurethral Procedures

These operations are usually performed under spinal anaesthesia (epidural or subarachnoid block) with the patient awake or mildly sedated. These regional anaesthetic techniques will usually provide post-operative analgesia for 4-6 h following surgery.

Much of the post-operative pain is generally caused by the indwelling catheter or the double-J (ureteral stent following ureterorenoscopy), which mimics overactive bladder syndrome. For this reason, drugs with an antimuscarinic effect have been proven to be useful in addition to the opioids (Level of evidence: 1b).

For post-operative pain control, oral or IV analgesia is preferable.

Analgesic Plan

  • Pre-operative assessment: see section 5.3.2 in the original guideline document.
  • Intra-operative: spinal (intrathecal or epidural) anaesthesia will provide intraoperative analgesia and last for 4-6 h post-operatively.
  • Post-operative: after 4-6 h, mild oral analgesics such as NSAIDs or paracetamol +/- codeine, or stronger opioids, also orally, could be used. In the case of bladder discomfort (overactive bladder syndrome) resulting from the indwelling catheter, metamizole (orally or IV), pethidine (IV) or piritramide (IV) would also be effective. In addition, antimuscarinic drugs such as oxybutynin (5 mg orally three times daily) are useful and reduce the need for opioids (Level of evidence: 1b).

See Table 19 in the original guideline document for a listing of the analgesic drug options after transurethral procedures.

Recommendations

  • Post-operative analgesics with a spasmolytic effect or mild opioids are preferable (Grade of recommendation: C).
  • Antimuscarinic drugs could be helpful in reducing discomfort resulting from the indwelling catheter (Grade of recommendation: B).
  • Antimuscarinic drugs may reduce the need for opioids (Grade of recommendation: B).

Percutaneous Endoscopic Procedures

These include:

  • Percutaneous nephrolithotomy
  • Percutaneous endopyelotomy
  • Percutaneous resection of pyelocaliceal tumours
  • Antegrade ureteroscopy

The analgesic plan is the same as that for transurethral procedures, but with the additional complexity caused by the skin having been breached, which could mean that additional analgesia is required. Local anaesthetic could be infiltrated locally into the skin, e.g., 10 mL of 0.5% bupivacaine.

General anaesthesia is usually required for the procedure because of the uncomfortable decubitus (prone position) and the prolonged duration of the operation.

Laparoscopic Procedures

These include:

  • Laparoscopic lymph node dissection
  • Diagnostic laparoscopy
  • Laparoscopic removal of organ or tumour

These procedures are usually performed under general anaesthesia, and so patients cannot take oral medication for at least 4-6 h post-operatively. It is therefore necessary to use IV analgesia (or intramuscular [IM] or subcutaneous [SC] as second choice options) during this period.

After this time, analgesia can be given orally or systemically, depending on bowel motility.

Most data concerning post-operative pain exist for laparoscopic cholecystectomy. A particular consideration after this procedure is the development of pain in the shoulder as a result of diaphragmatic irritation following the pneumoperitoneum. This problem seems to be dependent on the intra-abdominal pressure used during the procedure, as reduced carbon dioxide insufflation reduces postoperative shoulder pain (Level of evidence: 1b).

See Table 20 in the original guideline document for a listing of the analgesic drug options after laparoscopic procedures.

Recommendations

  • Low intraabdominal pressure and good desufflation at the end of the procedure reduces post-operative pain (Grade of recommendation: A).
  • NSAIDS are often sufficient for post-operative pain control (Grade of recommendation: B).
  • NSAIDs decrease the need for opioids (Grade of recommendation: B).

Open Surgery

Minor Operations of the Scrotum/Penis and the Inguinal Approach

These two types of surgical operations are relatively minor and nearly all patients will be able to take oral analgesia following the operation. The operation is often performed as an ambulatory procedure under local anaesthesia or with the aid of an ilioinguinal or iliohypogastric nerve block.

See Table 21 in the original guideline document for a listing of the analgesic drug options after scrotum/penis and the inguinal region.

Recommendations

  • For post-operative pain control, multimodal analgesia with a combination of NSAIDs or paracetamol plus local anaesthetics should be used (Grade of recommendation: B).
  • If possible, avoid opioids for outpatients (Grade of recommendation: C).

Transvaginal Surgery

These procedures would include:

  • Pelvic floor surgery
  • Stress incontinence surgery

Local or regional anaesthesia can be used for these operations.

See Table 22 in the original guideline document for a listing of the analgesic drug options after transvaginal urological surgery.

Recommendations

  • NSAIDS are often sufficiently effective after minor or moderate surgery (Grade of recommendation: B).
  • NSAIDs decrease the need for opioids (Grade of recommendation: B).

Perineal Open Surgery

These procedures include:

  • Perineal radical prostatectomy (PRPE)
  • Posterior urethroplasty

See Table 23 in the original guideline document for a listing of the analgesic drug options after major perineal open surgery.

Transperitoneal Laparotomy

These include:

  • Retroperitoneal lymph node dissection (RLND)
  • Radical nephrectomy -/+ caval thrombectomy
  • Cystectomy + urinary diversion

Post-operatively, patients are usually managed in an intermediate or intensive care unit. A combined general anaesthetic and regional technique is usually used.

Recommendations

  • The most effective method for systemic administration of opioids is PCA (see section above on Patient-Controlled Analgesia above and in the original guideline document), which improves patient satisfaction and decreases the risk of respiratory complications (Grade of recommendation: A).
  • Epidural analgesia, especially patient-controlled epidural analgesia (PCEA), provides superior post-operative analgesia, reducing complications and improving patient satisfaction. It is therefore preferable to systemic techniques (See the sections above on Epidural Analgesia and Patient-Controlled Epidural Analgesia (PCEA) above and in the original guideline document). (Grade of recommendation: A).

See Table 24 in the original guideline document for a listing of the analgesic drug options after transperitoneal surgery.

Suprapubic/Retropubic Extraperitoneal Laparotomy

These procedures include:

  • Open prostatectomy
  • Radical retropubic prostatectomy

Post-operatively, patients are usually managed in an intermediate or intensive care unit. A combined general anaesthetic and regional technique is usually used. It will be possible to use the oral route for analgesia sooner than after a transperitoneal procedure. Oral opioids, metamizole and/or paracetamol +/- NSAIDs could be used.

See Table 25 in the original guideline document for a listing of the analgesic drug options after suprapubic/retropubic extraperitoneal laparotomy.

Retroperitoneal Approach – Flank Incision – Thoracoabdominal Approach

These procedures include:

  • Nephrectomy
  • Pyeloplasty
  • Pyelonephrolithotomy

Post-operatively, patients are usually managed in an intermediate or intensive care unit. A combined general anaesthetic and regional technique is usually used.

Recommendation

Epidural analgesia, especially PCEA, provides superior post-operative analgesia, reducing complications and improving patient satisfaction. It is therefore preferable to systemic techniques (See the sections above on Epidural Analgesia and Patient-Controlled Epidural Analgesia [PCEA] and in the original guideline document). (Grade of recommendation: A).

See Table 26 in the original guideline document for a listing of the analgesic drug options after retroperitoneal approach – flank incision.

Peri-operative Pain Management in Children

Pre-operative Problems

The main pre-operative problems concerning children are fear of surgery, anxiety of separation from their parents, and pain caused by interventional procedures, mostly venipuncture. Contrary to popular belief, the presence of parents during anaesthesia induction does not alleviate children's anxiety before surgery (Level of evidence: 1a). The pre-operative use of morphine sulfate, 0.1 mg/kg, can help to prevent crying in children and thereby reduce oxygen consumption and pulmonary vasoconstriction. Table 31 in the original guideline document lists the drugs given most often for pre-operative sedation and separation anxiety in children. The prior application of emulsion of lidocaine and prilocaine (EMLA) (lidocaine 2.5%, prilocaine 2.5%) cream helps to reduce the pain of venipuncture (Level of evidence: 1a). Atropine, 0.01-0.02 mg/kg IV, IM, orally or rectally, prevents bradycardia during anaesthesia induction.

Recommendation

EMLA local application alleviates significantly venipuncture pain in children (Grade of recommendation: A).

Postoperative Analgesia

The use of COX-2 inhibitors in children post-operatively is still controversial. Patient-controlled analgesia (PCA) can be used safely in children older 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. The most common drugs used are bupivacaine and ropivacaine (See Table 33 in the original guideline document). Higher volumes of lower drug concentrations appear to be more effective than lower volumes of higher concentrations (Level of evidence: 1a). The addition of opioids, ketamine or clonidine increases the duration of pain relief and reduces the need for rescue analgesia, so providing more effective pain relief than local anaesthesia alone in caudal analgesia (Level of evidence: 1a).

Definitions:

Level of Evidence

1a Evidence obtained from meta-analysis of randomized trials

1b Evidence obtained from at least one randomized trial

2a Evidence obtained from at least one well-designed controlled study without randomization

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Grade of Recommendation

  1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
  2. Based on well-conducted clinical studies, but without randomized clinical studies
  3. Made despite the absence of directly applicable clinical studies of good quality
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for some of the recommendations (see "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate pain management for patients that includes:

  • Prolonged survival
  • Optimal comfort
  • Optimal function
  • Relief of pain
Potential Harms
  • General analgesic medication-related side-effects include nausea, vomiting, pruritus, sedation, and respiratory depression.
  • The main adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) are:
    • Gastric irritation, ulcer formation, bleeding
    • Renal impairment
    • Bronchospasm, deterioration of asthma
    • Platelet dysfunction, inhibition of thromboxane A2
    • Peri-operative bleeding
    • Inhibition of bone healing and osteogenesis
  • Caution should be used when administering paracetamol to patients with chronic alcoholism or hepatic failure. A dose >6 g/24 h can cause acute renal failure.
  • Apart from single sporadic cases of neutropenia and agranulocytosis, metamizole can cause minor side effects such as nausea, light hypotension, and allergic reactions. Allergic reactions and the rare complication of agranulocytosis have been described only after direct intravenous (IV) administration, and so IV metamizole should therefore be administered as a drip (1 g in 100 mL normal saline).
  • Post-operative delirium in the elderly is a fairly common complication and is often multifactorial. It may be associated with the administration of pethidine.
  • Bupivacaine is considered to be cardiotoxic in high doses.
  • The main adverse effects of fentanyl are:
    • Respiratory depression, apnoea
    • Sedation
    • Nausea, vomiting
    • Pruritus
    • Constipation
    • Hypotension

Contraindications

Contraindications

Cyclo-oxygenase-2 (COX-2) inhibitors are contraindicated for long-term use in patients with cardiovascular problems, such as myocardial infarction, angina pectoris, hypertension, and atherosclerosis.

Qualifying Statements

Qualifying Statements
  • These guidelines include general advice on pain assessment, with a focus on treatment strategies relating to common medical conditions and painful procedures. No attempts have been made to exhaustingly cover the topic of pain.
  • It has to be emphasized that the current guidelines contain information for the treatment of an individual patient according to a standardized general approach.

Implementation of the Guideline

Description of Implementation Strategy

The European Association of Urology (EAU) Guidelines long version (containing all 19 guidelines) is reprinted annually in one book. Each text is dated. This means that if the latest edition of the book is read, one will know that this is the most updated version available. The same text is also made available on a CD (with hyperlinks to PubMed for most references) and posted on the EAU Uroweb website (http://www.uroweb.org/guidelines/online-guidelines External Web Site Policy).

Condensed pocket versions, containing mainly flow-charts and summaries, are also printed annually. All these publications are distributed free of charge to all (more than 10,000) members of the Association. Abridged versions of the guidelines are published in European Urology as original papers. Furthermore, many important websites list links to the relevant EAU guidelines sections on the association websites and all, or individual, guidelines have been translated to some 15 languages.

Implementation Tools
Foreign Language Translations
Mobile Device Resources
Pocket Guide/Reference Cards
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Post-operative pain management. In: Bader P, Echtle D, Fonteyne V, Livadas K, De Meerleer G, Paez Borda A, Papaioannou EG, Vranken JH. Guidelines on pain management. Arnhem, The Netherlands: European Association of Urology (EAU); 2010 Apr. p. 61-82. [88 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Mar (revised 2010 Apr)
Guideline Developer(s)
European Association of Urology - Medical Specialty Society
Source(s) of Funding

European Association of Urology

Guideline Committee

The European Association of Urology (EAU) Guidelines Group for Pain Management

Composition of Group That Authored the Guideline

Primary Authors: P. Bader (Chair), D. Echtle, V. Fonteyne, K. Livadas, G. De Meerleer, A. Paez Borda, E.G. Papaioannou, J.H. Vranken

Financial Disclosures/Conflicts of Interest

All members of the General Pain Management Guidelines writing panel have provided disclosure statements on all relationships that they have and that might be perceived to be a potential source of conflict of interest. This information is kept on file in the European Association of Urology (EAU) Central Office database. This guidelines document was developed with the financial support of the EAU. No external sources of funding and support have been involved. The EAU is a non-profit organization and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have been provided.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Post-operative pain management. In: Bader P, Echtle D, Fonteyne V, De Meerleer G, Papaioannou EG, Vranken JH. Guidelines on pain management. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 62-82. [79 references]

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Availability of Companion Documents

The following is available:

  • Guidelines on pain management in urology. Pocket guideline. Arnhem, The Netherlands: European Association of Urology (EAU); 2010 Apr. 13 p. Electronic copies: Available in English, Russian, Portuguese, and Spanish from the EAU Web site External Web Site Policy. The English version is also available as a handheld resource from the EAU Web site External Web Site Policy.

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 28, 2010. This NGC summary was updated by ECRI Institute on September 23, 2010. The updated information was verified by the guideline developer on October 20, 2010. This summary was updated by ECRI Institute on March 16, 2011 following the U.S. Food and Drug Administration advisory on acetaminophen-containing prescription products. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Downloads are restricted to one download and print per user, no commercial usage or dissemination by third parties is allowed.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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