Non-opioid Pathways for Pain Management in Reconstructive Urology

By: Sarah Christianson, DO; Jay Simhan, MD, FACS | Posted on: 01 Apr 2021

The United States continues to experience a well-recognized opioid crisis that imposes both societal and financial burdens on our communities. In 2017 alone, there were approximately 2.1 million American adults with an opioid use disorder and 47,600 recorded fatal opioid overdoses.1 A substantial proportion of those who develop opioid dependence have undergone prior surgery, and recent Centers for Disease Control and Prevention data have even indicated that patients undergoing short-stay procedures who take narcotic pain medicine even 7 days postoperatively are at an increased risk to develop narcotics dependence 1 year after surgery.2 As regular prescribers of opioid narcotics, surgeons, general urologists and subspecialists alike bear great responsibility in mitigating unintended downstream consequences associated with postoperative pain control.

Many of the efforts within reconstructive urology in particular to limit narcotic usage have centered predominantly on cancer survivorship patients undergoing prosthetic surgery.3 In the setting of an ongoing opioid epidemic, reconstructive urologists have been encouraged to utilize contemporary multimodal pain management strategies that potentiate several different pathways thereby mitigating pain in an effort to minimize narcotic usage. There have been several recent notable efforts that have incrementally moved the needle to help us understand how effective nonnarcotic pain control can reasonably manage postsurgical patients undergoing reconstructive urology procedures.

Optimal postoperative pain management begins in the preoperative setting. Desensitization of the central and peripheral pain receptors, also known as preventative analgesia, can translate to improved pain management and reduced narcotic usage.4 In 2020, Saleh and associates performed an investigation of 100 patients with posterior urethral stricture undergoing reconstruction randomized to receive single dose 600 mg Gabapentin vs placebo preoperatively. Significant differences in visual analog scale pain scores postsurgery as well a 50% reduction in opioid consumption in the gabapentin group were observed (p <0.001).5 Although there is a paucity of randomized control data demonstrating similar benefits with the incorporation of other agents such as acetaminophen and nonsteroidal anti-inflammatory agents, we have employed a multimodal approach aggressively in our preoperative protocol (see figure) due to the reported theoretical benefits of pain sensitization.

Figure. Multimodal analgesia for pain reduction after reconstructive surgery. Postoperatively patients may receive low quantity, as-needed doses of oxycodone for severe breakthrough pain. *May substitute with other gabapentinoids (eg pregabalin) or NSAIDs depending on institutional availability.

In addition to preoperative interventions, intraoperative anesthetic strategies can synergistically impact postoperative pain perception. As penile discomfort can be specifically challenging after surgical manipulation, many of the recent efforts describing pain recovery have centered on patients undergoing penile implantation. We recently compiled a review that highlighted intraoperative techniques routinely utilized including pudendal, penile ring, dorsal/cural nerve and peri-incisional block among other implant specific manipulation strategies to minimize postoperative pain. Despite the growing body of both prospective and retrospective data on intraoperative analgesia in the implant space, there remains no guideline or consensus regarding an optimal intraoperative analgesic.6

In an effort to decrease opioid usage and improve patient perception of pain, our institution has described a multimodal analgesia (MMA) protocol in penile implant recipients that we have now expanded for all reconstructive procedures performed. This regimen incorporates multiple medications that can be administered throughout the entire perioperative timeframe to target different aspects of the pain pathway. Preoperative administration of long-acting nonsteroidal anti-inflammatory drugs (NSAIDs) as well as acetaminophen are used to inhibit cyclooxygenase and prostaglandins. Gabapentin or pregabalin block voltage dependent calcium channels thereby reducing central nervous system irritability. These medications are given in a single dose preoperatively for preemptive analgesia and continued postoperatively around the clock. We also employ a specific intraoperative regimen that includes pre-incisional penile and pudendal nerve blocks with a 50:50 mixture of 1% lidocaine and 0.5% bupivacaine. Narcotics are made available to patients receiving MMA on an as-needed basis for severe breakthrough pain. Patients receiving MMA had significantly reduced patient pain perception, postoperative opioid use and need for outpatient narcotic refills.2 A multi-institutional assessment of this protocol assessing more than 200 patients demonstrated similar reductions in pain with results that were generalizable across several centers.7

While we can do our part as individual surgeons to curb opioid use, true population-scale reductions in use must occur through multidisciplinary efforts. A recent analysis of opioid prescribing patterns in urology found that while urologists provided narcotic prescription refills for roughly 35% of postoperative patients who required refills, they were only responsible for 20% of all refills provided. Nonurological providers wrote for an alarming majority of opioid refills in this cohort of patients undergoing urological surgery. The importance of open communication with our nonurological colleagues in managing our patients’ postoperative pain is paramount.8

As urologists managing acute postsurgical pain, the burden to develop and implement non-opioid based pain management strategies lies with us. Investigating and employing multimodal analgesia protocols across all perioperative time points along with careful interdisciplinary, collaborative, postoperative management and monitoring are essential to optimize both provider opioid stewardship practices and overall patient care.

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  3. Tong CMC, Lucas J, Shah A et al: Novel multi-modal analgesia protocol significantly decreases opioid requirements in inflatable penile prosthesis patients. J Sex Med 2018; 15: 1187.
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  6. Ellis JL, Pryor JJ, Mendez M et al: Pain management strategies in contemporary penile implant recipients. Curr Urol Rep 2021; 22: 17.
  7. Lucas J, Gross M, Yafi F et al: A multi-institutional assessment of multimodal analgesia in penile implant recipients demonstrates dramatic reduction in pain scores and narcotic usage. J Sex Med 2020; 17: 518.
  8. Ellis JL, Ghiraldi E, Cohn J et al: prescribing trends in post-operative pain management after urologic surgery: a quality care investigation for healthcare providers. Urology 2021; doi: 10.1016/j.urology.2020.11.070.