The opioid epidemic continues to be a serious public health concern. Many have pointed to prescription drug misuse as a nidus for patients to become addicted to opioids and as such, urologists and other surgical subspecialists must critically define optimal pain management for the various procedures performed within their respective disciplines. Controlling pain following penile prosthesis implantation remains a unique challenge for urologists, given the increased pain patients commonly experience in the postoperative setting. Although most of the existing urological literature focuses on interventions performed in the operating room, there are many studies that examine the role of preoperative adjunctive pain medicine in diminishing postoperative narcotic requirements. There are relatively few studies looking at postoperative strategies for managing pain in prosthetic surgery with follow-up past the immediate hospitalization. This review assess the various strategies employed for managing pain following penile implantation through the lens of the current state of the opioid crisis, thus examining how urologists can responsibly treat pain without contributing to the growing threat of opioid addiction.
Analgesics/therapeutic use* ; Analgesics, Opioid/therapeutic use* ; Anesthetics, Local/therapeutic use* ; Anti-Inflammatory Agents, Non-Steroidal/therapeutic use* ; Cyclooxygenase 2 Inhibitors/therapeutic use* ; Gabapentin/therapeutic use* ; Humans ; Intraoperative Care ; Male ; Nerve Block/methods* ; Opioid Epidemic ; Pain Management/methods* ; Pain, Postoperative/therapy* ; Penile Implantation/methods* ; Pregabalin/therapeutic use* ; Preoperative Care

Dexmedetomidine is a selective α-2 adrenoceptor agonist with anxiolytic, sedative, and analgesic properties that prolongs analgesia and decreases opioid-related side effects when used in neuraxial and perineural areas as a local anesthetics adjuvant. The current study was designed to evaluate the effects of a single perineural administration of dexmedetomidine without local anesthetics on narcotic consumption and pain intensity in patients with femoral shaft fractures undergoing surgery. This prospective randomized single-blind clinical trial was conducted in patients undergoing femoral fracture shaft surgery. Based on block permuted randomization, the patients were randomly divided into intervention and control groups. The intervention group received 100µg dexmedetomidine, for a femoral nerve block without any local anesthetics. Total intraoperative opioid consumption, postoperative opioid consumption, visual analogue score (VAS) for pain, and hemodynamic parameters were recorded and compared. Finally the data from 60 patients with a mean age of 30.4±12.3 were analyzed (90% male). There were no significant differences between the baseline characteristics of the two groups (p>0.05). The mean total consumption of narcotics was reduced during induction and maintenance of anesthesia in the intervention group (p<0.05). The amount of postoperative narcotics required showed a significant difference in the intervention group compared with the control group (p<0.05). It is likely that perineural administration of dexmedetomidine significantly not only reduced intra and postoperative narcotic requirement but also decreased postoperative pain intensity in patients undergoing femoral shaft surgery. Femoral blockade by dexmedetomidine can provide excellent analgesia while minimizing the side-effects of opioids.
Analgesia ; Analgesics, Opioid ; Anesthesia ; Anesthetics, Local ; Dexmedetomidine ; Femoral Fractures ; Femoral Nerve ; Hemodynamics ; Humans ; Narcotics ; Nerve Block ; Pain Management ; Pain, Postoperative ; Propofol ; Prospective Studies ; Random Allocation

A variety of pharmacologic agents have been developed for the treatment of osteoarthritis. At present, however, none of them has been proven to prevent disease progression, and the medications are used only for symptomatic relief. Thus, non-pharmacologic conservative treatment such as education, weight reduction in the obese, and consistent exercise should be recommended first to maintain fitness and tolerance to physical activity. Medication is then indicated to better control symptoms provided non-pharmacologic measures prove inadequate, and a successful strategy most likely would entail a combination of these non-pharmacologic and pharmacologic approaches. Acetaminophen can be tried first because of its efficacy and relatively safe profile, especially in those with mild osteoarthritis. Nonselective non-steroidal anti-inflammatory drugs may be used in patients with moderate to severe pain, but long-term medication requires caution due to the increased risk of gastrointestinal and renal complications. Selective cyclooxygenase-2 inhibitors can be better tolerated, especially in patients with risk factors for gastrointestinal adverse events, but potential cardiac and cerebrovascular thrombotic events should be considered in those with preexisting cardiovascular disease. Tramadol and opioids are more potent analgesics. However, they are not recommended for routine use due to a high incidence of nausea, constipation, and drowsiness. These agents require close monitoring for those adverse effects, especially in a geriatric population. Lastly, the pharmacologic plan should be individualized according to the severity and duration of pain, age and gender of the patient, and concurrent comorbidities to maximize the benefit as well as to minimize the risk of adverse effects from medication.
Acetaminophen ; Analgesics ; Analgesics, Opioid ; Cardiovascular Diseases ; Comorbidity ; Constipation ; Cyclooxygenase 2 Inhibitors ; Disease Progression ; Education ; Humans ; Incidence ; Motor Activity ; Nausea ; Osteoarthritis* ; Risk Factors ; Sleep Stages ; Tramadol ; Weight Loss

Intrathecal drug delivery is an effective and safe option for the treatment of chronic pathology refractory to conventional pain therapies. Typical intrathecal administered drugs are opioids, baclofen, local anesthetics and adjuvant medications. Although knowledge about mechanisms of action of intrathecal drugs are every day more clear many doubt remain respect the correct location of intrathecal catheter in order to achieve the best therapeutic result. We analyze the factors that can affect drug distribution within the cerebrospinal fluid. Three categories of variables were identified: drug features, cerebrospinal fluid (CSF) dynamics and patients features. First category includes physicochemical properties and pharmacological features of intrathecal administered drugs with special attention to drug lipophilicity. In the second category, the variables in CSF flow, are considered that can modify the drug distribution within the CSF with special attention to the new theories of liquoral circulation. Last category try to explain inter-individual difference in baclofen response with difference that are specific for each patients such as the anatomical area to treat, patient posture or reaction to inflammatory stimulus. We conclude that a comprehensive evaluation of the patients, including imaging techniques to study the anatomy and physiology of intrathecal environment and CSF dynamics, could become essential in the future to the purpose of optimize the clinical outcome of intrathecal therapy.
Analgesics, Opioid ; Anesthetics, Local ; Baclofen ; Catheters ; Chronic Pain ; Humans ; Posture

BACKGROUND: Opioids are increasingly being administered intrathecally as adjuncts to local anesthetics. They enhance spinal anesthesia without prolonging motor recovery. We evaluated the effect of 10 microgram of fentanyl to bupivacaine on sensory, motor block and side effects. METHODS: Thirty six patients undergoing urologic surgery were randomized into two groups. Control group received bupivacaine 10 mg combined with normal saline 0.2 ml, and Fentanyl group received bupivacaine 10 mg with fentanyl 10 microgram (0.2 ml). RESULTS: There were no significant differences between two groups in the peak level of sensory block, onset of peak level, duration of motor block, and side effects. However, the time of regression from peak level to T10 in Fentanyl group was longer significantly than that of Control group. CONCLUSIONS: Intrathecal small dose fentanyl (10 microgram) on bupivacaine spinal blockade prolonged duration of sensory block and did not augment side effects and provide reliable anesthesia for urologic surgery.
Analgesics, Opioid ; Anesthesia ; Anesthesia, Spinal ; Anesthetics, Local ; Bupivacaine* ; Fentanyl* ; Humans

Cancer pain patients have various diagnosis, stage of disease, response to pain, and treatments and individualized treatment methods are thus needed. Use of Nonopioid analgesics is the first step treatment (according to WHO ladder) for mild to moderate pain, and may be useful for second or third step treatments when combined with weak or strong opioids to reduce side effects of opioids and to create synergy between the two drugs. Acetaminophen and nonsteroidal antiinflammatory drugs(NSAIDs) are also nonopioid analgesics. NSAIDs have a ceiling effect, along with antipyretic, analgesic and antiinflammatory effects, while not producing physical and psychological dependence. Adverse effects of NSAIDs include gastrointestinal hemorrhage, coagulopathy, and deterioration of renal function.
Acetaminophen ; Analgesics ; Analgesics, Non-Narcotic ; Analgesics, Opioid ; Anti-Inflammatory Agents, Non-Steroidal ; Gastrointestinal Hemorrhage ; Humans ; Resin Cements

BACKGROUND: There have been many attempts to alleviate pain after surgery, but there is no common approach to the control of postoperative pain. The use of epidural opioids, with local anesthetics, has been a widely employed formula to date. Ketamine, an N-methyl-d-aspartate receptor antagonist, has an excellent analgesic effect. Although there have been many reports on the dose and route of administrating analgesics, there have been few concerning the continuous epidural infusion of ketamine with fentanyl. We designed this study to find the effects of ketamine compared to those of epidurally injected bupivacaine and fentanyl, and used this trial to study any potential side effects. METHODS: In a double blind trial, 55 patients received either fentanyl, 0.3microgram/kg/h (Group F), or fentanyl, 0.3microgram/kg/h, and ketamine, 0.1 mg/kg/h (Group FK), added to 0.125% bupivacaine, at rates as high as 2 ml/h, for patient controlled epidural analgesia (PCEA) following a transabdominal hysterectomy. Ten minutes before the operation, patients received 10 ml of 0.125% bupivacaine, with either 0.5 mg/kg ketamine or the same amount of normal saline with 50microgram fentanyl added. The pain scores and the side effects were recorded at 1, 3, 6 and 24 hour post operation. RESULTS: There were no differences in the pain scores or side effects between the two groups. CONCLUSIONS: We failed to find any effect of the addition of epidural ketamine compared to the that of the bupivacaine and fentanyl formula. However, it is suggested that further investigations will be required on the dose and route of administration.
Analgesia, Epidural ; Analgesics ; Analgesics, Opioid ; Anesthetics, Local ; Bupivacaine* ; Fentanyl* ; Humans ; Hysterectomy* ; Ketamine* ; N-Methylaspartate ; Pain, Postoperative

BACKGROUND: caudal anesthesia is a safe and reliable technique for surgical anesthesia as well as an alternative to narcotics for postoperative analgesia for procedure below umbilicus. Onset time and duration of local anesthetics had been influenced by local anesthetics with combined drugs. We wanted that the time required for the onset of local anesthesia should be short and long enough to allow time for the contemplated surgery. METHOD: To investigated the effect of lidocaine with combined drugs, 120 ASA physical status I, II patients who underwent perianal surgery with caudal anethesia. The patients were diveded into 5 groups : control group received 1.5% lidocaine 27ml, group I received lidocaine with epinephrine (1:200,000), group II received lidocaine with morphine 2mg, group III received lidocaine with fentanyl 50 g, group IV received lidocaine with clonidine 75 g. We have compared the onset time and duration of analgesia of 5 groups. RESULTS: 1. The onset time of analgesia for pin prick test were not significantly changes between groups. 2. The duration of analgesia was significantly more prolonged in group II(863.8 222.1 min) than other three group I, III, IV. 3. The most common side effect was urinary retention(20 cases, 16.7%) in all groups(n=120). 6 cases(24%) in group II(n=25), 2 cases(8%) in group III(n=25) were complained of pruritus. Bradycardia and hypotension were observed in group IV(n=20) (each 1 cases, 5%). CONCLUSIONS: It is suggested from the above results that the morhine group during caudal anesthesia can produce more prolonged duration of analgesia.
Analgesia ; Analgesics ; Anesthesia ; Anesthesia, Caudal* ; Anesthesia, Local ; Anesthetics, Local ; Bradycardia ; Clonidine ; Epinephrine ; Fentanyl ; Humans ; Hypotension ; Lidocaine* ; Morphine ; Narcotics ; Pruritus ; Umbilicus

CoX-2 or prostaglandin GH synthetase-2 is an enzyme which has induction, especially in the inflamatory reactions. The inflamatory stimulations activate the CoX-2 of monocytes, macrophages, cells of synovial membrane to synthesize prostaglandin which induce the inflamatory reactions. The non- steroid anti- inflamatory drugs inhibit the CoX-2 so they have anti- inflamatory effects. However, they also inhibit CoX-1 which induce some side effects such as gastrointestinal and kidney accidents, haemorrhage and hypersensitivities. The selective CoX-2 inhibitors have some properties: long half elimination life, easier uptake by oral; the same pharmacokinetics in both elderly and children and uncommon side effects (0.1 -1% treated cases).
Anti-Inflammatory Agents, Non-Steroidal ; Pharmaceutical Preparations ; Cyclooxygenase 2 Inhibitors

It has been known that more than 5% of cancer patients experience severe pain refractory to medical treatments. So it is necessary to use epidural or intrathecal analgesia with opioids and local anesthetics when systemic trial has failed. Although intrathecal catheter placement and drug infusion has some risks, it shows better pain control with least amount of analgesics. The authors managed a patient who had suffered from intractable cancer pain due to metastatic pancreatic cancer. His pain was spreading to his upper body area including chest wall and interscapular region as well as original abdomen and back pain. Pain severity became extreme reaching VAS (visual analogue scale) score to above 9. Cervical epidural catheterization and continuous drug infusion was not effective in this case. So the authors chose to give analgesics intrathecally, and placed the intrathecal catheter on 5th cervical vertebral level and connected it to subcutaneous port so that drugs could be infused continuously. The effect was dramatic by 5 mg/day morphine and 20 mg/day lidocaine, VAS score decreased to below 3 without any possible complications.
Abdomen ; Analgesia ; Analgesics ; Analgesics, Opioid ; Anesthetics, Local ; Back Pain ; Catheterization ; Catheters ; Humans ; Lidocaine ; Morphine ; Pain Management ; Pancreatic Neoplasms ; Thoracic Wall