Managing pain in advanced prostate cancer

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Some men with advanced prostate cancer have problems with pain. This page explains what causes pain, what to do if you have pain, and ways to treat and control pain.

If you haven’t been diagnosed with prostate cancer, but want to find out more about what to look out for, you can read our information on signs and symptoms.

Do all men with advanced prostate cancer have pain?

No, not all men with advanced prostate cancer have pain. Men who do have pain experience different levels of pain. Pain is more common in men whose cancer has spread to their bones. If the cancer has spread to several places in your body, you might not get pain in all of these places.

With the right treatment and management, pain can usually be relieved or reduced. Tell your doctor or nurse if you’re in pain or your pain relief isn’t working well.

What causes the pain?

We feel pain when our bones, muscles, organs, nerves or other parts of our bodies are damaged or irritated. Cancer which has spread into these areas might cause pain.

Sometimes pain can be due to cancer treatments. For example, radiotherapy to treat bone pain can sometimes cause your pain to get worse during treatment and for a few days afterwards. But this isn’t very common.

Pain can also be caused by problems not linked to the cancer, such as an infection.

Your doctors and nurses will work with you to find out what is causing your pain and will talk to you about suitable treatments. There are effective ways to treat different types of pain.

Bone pain

If prostate cancer spreads to the bone, it can damage or weaken the bone and may cause pain. But not all men with cancer in their bones will get bone pain. Prostate cancer can spread to any area of bone around the body. It most commonly spreads to the spine. Pain in these areas can sometimes make it painful to walk and move around. The pain might remain in only one area, but over time it can spread to several parts of your body.

Bone pain is a very specific feeling. Some men describe it as feeling similar to a toothache but in the bones, or like a dull aching or stabbing. It can get worse when you move and can make the area tender to touch. Each man’s experience of bone pain will be different. The pain may be constant or it might come and go. How bad it is can also vary and may depend on where the affected bone is.

Nerve (neuropathic) pain

Nerve pain is caused by damage to a nerve, for example if the cancer presses on a nerve. The outer layers of bones contain nerves, and neuropathic pain can be a part of bone pain. The pain can come and go and people have described it as a shooting, stabbing, burning or tingling pain. For some people, the damaged area feels numb.

Sometimes damage to one part of your body is felt as pain in a different area. This is called referred or reflective pain. For example, cancer pressing on a nerve in the spine could be felt as a pain in the chest, arms or legs.

Sciatica is the most common type of referred pain in advanced prostate cancer. It’s caused by damage to one or more of the nerves that start in the spine and run down through the legs. People feel sciatica as pain, numbness, weakness, pins and needles or tingling in the lower back, buttocks, legs or feet. Sciatica can sometimes make it difficult to move the affected leg.

There are more common causes of sciatica – it isn’t only caused by cancer.

Lymphoedema

If the cancer spreads to the lymph nodes it could lead to a condition called lymphoedema – caused by a blockage in the lymphatic system. But this isn’t very common. The lymphatic system is part of your body’s immune system, carrying fluid called lymph around your body. If it is blocked, the fluid can build up and cause swelling (lymphoedema).

Lymphoedema in prostate cancer usually affects the legs, but it can affect other areas, including the penis or scrotum (the skin around your testicles). Some men notice that the part of their body that is affected aches or feels tight or heavy. Prostate cancer itself can cause the blockage, and so can some treatments, such as surgery or radiotherapy. Lymphoedema can occur months or even years after treatment.

If you think you might have lymphoedema, speak to your doctor or nurse. Lymphoedema can cause discomfort or pain, but there are treatments and ways to manage it.

Metastatic spinal cord compression (MSCC)

You might get pain if you have metastatic spinal cord compression (MSCC). This happens when cancer cells grow in or near to the spine and press on the spinal cord.

MSCC isn’t common but it is serious. You need to be aware of the risk if you have advanced prostate cancer.

How much pain might I have?

Some men have no pain at all. Men who do have pain experience different levels of pain. Some men only feel mild discomfort and are able to carry out their daily activities as normal, but other men find that the pain affects their daily lives.

Only you can describe how your pain feels. Another man with advanced prostate cancer may not feel pain in the same way. So predicting how much pain you might have is difficult, as it varies from man to man.

How much pain you have will depend on several things, including:

where the pain is
what’s causing the pain
how soon your doctor or nurse can help you manage the pain
finding the right pain relief for you
taking the right amount of pain-relieving drugs at the right times
how tired you feel
how well you feel in general
if you feel anxious
if you feel depressed.

What should I do if I have pain?

Let your doctor or nurse know about any pain you have as soon as possible. The earlier you ask for help, the easier it will be to get your pain under control. With the right treatment and management, your doctor and nurse should be able to help you control your pain.

Don’t think that you are complaining too much or that you should put up with pain. You shouldn’t have to accept pain as a normal part of having cancer. Pain will affect your daily life if it isn’t properly controlled.

As well as treatments, there are things you can do yourself that might help with your pain.

What questions might my doctor or nurse ask about my pain?

Your doctor or nurse will ask you questions about your pain to try to get as much information about it as possible. This will help them work out the best treatment for you. They might ask you the following questions.

Where is your pain?
How bad is it?
What does it feel like? For example, is it a stabbing pain, or a dull ache?
When did the pain start? How often do you get it? How long does it last?
Does it wake you at night?
Does anything help?
Have you tried any pain-relieving medicines? Did they help?
Does anything make it worse?
How does your pain make you feel? For example, do you feel anxious or depressed? Does this affect the pain?
How does the pain affect your daily life?

Your doctor or nurse may also examine you to see if there is an obvious physical reason for your pain. This will help them decide whether you need any tests or scans, such as a blood test, X-ray, bone scan, MRI scan or CT scan. Your doctor or nurse can tell you more about the tests you might need.

Keeping a pain diary

Keeping a diary to record your pain and what medicines you take might help you describe the pain to your doctor or nurse. It may also help them work out what might help manage it. You can use our diary to record your pain.

What treatment can I have?

There are different ways to treat pain. What’s best for you will depend on a number of things, including what’s causing the pain, your general health, how you are feeling emotionally and what sort of things you do in your daily life. Because pain involves all of these things, treating it often means using a few different approaches.

You might need treatment for the pain itself, such as:

pain-relieving drugs
pain-relieving radiotherapy
medicines called bisphosphonates
surgery to support damaged bone
transcutaneous electrical nerve stimulation (TENS)
nerve block

Pain might be a sign that your prostate cancer treatment isn’t working as well as it was. A different treatment for your cancer may help the pain. Possible treatments include:

hormone therapy
steroids
chemotherapy
a type of radiotherapy called radium-223.

There are other things that may also help with pain, including:

complementary therapies
emotional support
treatments for other causes of pain, such as antibiotics to treat infection.

By using a combination of treatments to suit your needs, pain from cancer can usually be managed well.

Pain-relieving drugs

Most men who have pain caused by advanced prostate cancer need to take pain-relieving drugs at some stage. There are different types of pain-relieving drugs. Your health professionals may use a guide called a ‘pain relief ladder’ to decide which drugs will help you. The ladder recommends different types of drugs for each level of pain.

Pain relief ladder

Step 1: for mild pain use mild pain-relieving drugs (paracetamol or non-steroidal anti-inflammatory drugs), with or without other treatment.

Step 2: for moderate pain use weak opioids such as codeine, with or without mild pain-relieving drugs and other treatment.

Step 3: for severe pain use strong opioids such as morphine, with or without mild pain-relieving drugs and other treatment.

By using this approach, your treatment can be moved up to the next stage if your pain is not controlled by one type of drug. Most people find that this helps to control their pain.

You might be offered a combination of drugs, because they work in different ways. And you might take pain-relieving drugs along with other pain-relieving treatments such as radiotherapy. If your pain improves after these treatments, your doctor or nurse may be able to reduce your medication. This shouldn’t be done suddenly and you should always discuss it with your doctor or nurse.

It’s important to take your drugs regularly, as prescribed by your doctor or nurse. This will give you more constant pain control. Don’t put off taking your drugs. If you wait until the pain comes back, you will have a gap where your pain is not properly controlled, and it might get worse. It can then be more difficult to get it under control.

Pain can come on unexpectedly and you might need to try different treatments to see what works. Doctors and nurses need feedback from you to get your pain relief right.

A personal experience

If your pain comes back before your next dose is due, let your doctor or nurse know. The dose might need changing.

You might find your pain doesn’t go away straight away when you take pain-relieving drugs. This is because they can take a while to be absorbed by the body and start working.

All medicines can cause side effects. We describe the most common side effects of pain-relieving drugs below. But you might not get all or any of these. If you do get side effects that won’t settle down, your doctor can change the amount or the type of drugs you take.

For more information about side effects, check the patient information leaflet included with your medicines or speak to your doctor or nurse at the hospital, or your GP.

Non-opioid drugs

These are mainly mild pain-relieving drugs. They include paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen. You can use them together with stronger pain-relieving drugs.

NSAIDs can help reduce inflammation that may be causing your pain. You should only take NSAIDs regularly if they’ve been prescribed for you. This is because taking them for a long time can cause side effects such as stomach irritation, stomach ulcers, kidney problems, and heart problems. You may not be able to take NSAIDs if you already have problems with your stomach, kidneys or heart.

Your doctor or nurse might prescribe medicines to reduce the risk of side effects from NSAIDs. Taking NSAIDs after food will also help to reduce stomach irritation. You should avoid smoking and drinking large amounts of alcohol, as these can increase the risk of stomach ulcers. Your doctor or nurse can give you more information about this.

Opioid drugs

You might need stronger pain-relieving drugs called opioids. These include strong opioids such as morphine and weaker opioids such as codeine and tramadol. You can take opioids in tablet and liquid form. You may be able to take slow-release opioids so that you don’t have to take them so often. If these aren’t suitable, some opioids such as fentanyl or buprenorphine are also available as a skin patch.

If you find it hard to swallow tablets or liquids, your doctor or nurse might suggest a continuous dose of opioids through a needle under the skin. This uses a small machine called a syringe pump or syringe driver. It means the drug stays at a constant level in your body so it doesn’t wear off. Syringe pumps can be used in hospital or in your home.

It’s possible to get sudden pain even if you’re already taking pain-relieving drugs. This is called breakthrough pain. If you experience this, your doctor or nurse may suggest a fast-acting opioid to help reduce the pain quickly.

Like all medicines, opioids can cause side effects.

Difficulty emptying your bowels (constipation). Most people get this side effect of opioids, which can be very uncomfortable. Your doctor should give you medicines to make it easier to empty your bowels (laxatives). Drinking plenty of water, eating a high fibre diet and exercising, if possible, might also help to prevent constipation. If it doesn’t get better, speak to your doctor – but don’t stop taking the pain-relieving drugs.

Sickness. You might feel sick or be sick for the first few days of taking opioids, but this usually improves. If you feel sick, your doctor can prescribe anti-sickness tablets to stop this or give you a different pain-relieving drug if the sickness doesn’t improve.

Drowsiness. When you first start taking opioids you might feel drowsy or find it hard to concentrate. This usually improves after a few days, as your body gets used to the drug. Ask your doctor or nurse whether it is safe for you to drive when you are taking opioids.

A dry mouth. Sipping cold water throughout the day can help. You can also try chewing gum or sucking boiled sweets or ice cubes.

Some men worry about becoming addicted to stronger opioids such as morphine. But if you’re taking morphine to relieve pain, it’s unlikely you’ll become addicted. You might not start with the strongest type of opioid, and the dose will be carefully controlled by your doctor. If you’re worried about taking opioids, speak to your doctor or nurse.

Other drugs for relieving pain

There are other types of drugs that can also be used to help treat pain. Which ones you are prescribed will depend on what is causing your pain.

Your doctor might suggest drugs that can also be used to treat other health problems. For example, drugs that can be used to manage epilepsy (such as gabapentin or pregabalin) or depression (such as amitriptyline) can help with nerve pain. If your doctor prescribes anti-depressants or anti-epileptics for your pain, it doesn’t mean they think you are depressed or have epilepsy. Different doses of these drugs are usually needed to treat depression or epilepsy.

A type of cream called capsaicin cream can also be used to help with nerve pain if you find it difficult to take tablets. A pain-numbing skin patch, such as a lidocaine patch, can also be used on painful areas.

Antibiotics can be prescribed if your pain is caused by an infection.

Muscle relaxants (such as diazepam) can also be used if you have muscle spasms. Muscle spasms can be painful or make other pain worse.

Talk to your doctor, nurse, or pharmacist about possible side effects before you start taking any new medicines.

Steroids

If your cancer has spread to the bones it could cause swelling and press on the nerves in the bone, causing pain. Steroids can help to reduce swelling around the cancer, and so reduce the pain. You might be able to take steroids in combination with pain-relieving drugs and other types of treatment. Lower doses of steroids can also be used to treat the cancer itself.

Like most medicines, steroids can cause side effects. Read more about steroids, including the possible side effects.

Other pain-relieving treatments

Pain-relieving radiotherapy

Pain-relieving radiotherapy can shrink the cancer cells in the bones and stop them pressing on nerves and causing pain. It can also sometimes slow the growth of cancer cells, giving your bones time to repair and strengthen.

Radiotherapy can be given externally, where high-energy X-ray beams are directed at the area of pain from outside the body, or internally, where a small amount of radioactive liquid is injected into your blood.

A radiographer usually gives pain-relieving radiotherapy. It is usually only used in men whose pain can’t be controlled with pain-relieving drugs.

Most men who have pain-relieving radiotherapy find that it helps control their pain. If your pain comes back, you may be able to have more radiotherapy to the same area. This will depend on the dose you've already had and how long ago you had it. Speak to your doctor or nurse about your own situation.

Bisphosphonates

Bisphosphonates, such as zoledronic acid (Zometa^®), are drugs that can help treat or prevent further bone pain. They bind to damaged areas of bone and can help to prevent and slow down further damage. This helps relieve pain and may lower the risk of broken bones and other bone problems. They are sometimes used if other treatments, such as pain-relieving drugs and radiotherapy, aren’t controlling your pain. You may be offered another drug called denosumab instead of bisphosphonates.

Surgery to support damaged bone

If there is an area of bone that has been badly damaged by cancer, surgery might be an option, although this isn’t very common. A metal pin or plate can be inserted into the bone under general anaesthetic to strengthen and stabilise the area of affected bone and reduce the risk of it breaking. Or, a type of cement can be used to fill the damaged area. This makes the bone stronger and less painful. You might have radiotherapy after the operation to help prevent the cancer growing back in that area.

Transcutaneous electrical nerve stimulation (TENS)

Some NHS pain clinics and hospitals offer TENS to help manage pain. TENS uses a machine to send small electrical currents to nerves in your body through pads placed on your skin. Doctors think that the currents may block the pain signals caused by the cancer. Small studies have found that TENS could help some people with bone pain. But we need more research before we can say for certain whether TENS can help. As the TENS machine is small enough to fit in your pocket, it can be carried around with you so you don’t need to stay in hospital.

Nerve block

This is an injection which changes what you feel in a particular part of the body. It can reduce pain in that area. Nerve block is sometimes an option for men who only have pain in one or two areas, and who aren’t able to have other treatments or aren’t responding well to other treatments.

Nerve blocks aren’t widely used and aren’t available in all treatment centres.

Treatments to help control your cancer

If your prostate cancer treatment isn’t working as well as it was, trying a different treatment for your cancer may help the pain. These treatments can all cause side effects. Ask your doctor or nurse about the possible side effects or read more about them in our other fact sheets and booklets. You can also speak to our Specialist Nurses.

Hormone therapy

Lots of men with advanced prostate cancer are on hormone therapy. Hormone therapy shrinks or slows down the growth and spread of the cancer. This can prevent or relieve your pain.

There are different types of hormone therapy. They can be given by injection, implants, tablets or surgery. Read more about hormone therapy.

If your first hormone therapy is no longer controlling your cancer as well as it was, there are other treatments available to control the cancer and reduce pain and other symptoms. These include different types of hormone therapy. Read more about treatment options after your first hormone therapy.

Steroids

If treatments such as hormone therapy are no longer working so well, you might be offered a low dose of steroids to treat your prostate cancer. Higher doses can also be used to reduce pain. Read more about steroids.

Chemotherapy

Chemotherapy uses anti-cancer drugs to kill cancer cells, wherever they are in the body. The aim is to shrink the cancer and slow down its growth. This can help with symptoms, including pain. Read more about chemotherapy.

Radium-223 (Xofigo^®)

This is a new treatment for men whose prostate cancer has spread to the bones and is causing pain. It is injected into a vein in your arm. It collects in bones that have been damaged by prostate cancer and kills cancer cells. It helps some men to live longer. It can also delay some symptoms, such as bone fractures, and can help to reduce bone pain. Read more about radium-223.

What else can I do to help control my pain?

As well as treatments, some of the following ideas may help you to feel more comfortable and help you manage your pain.

Generally looking after yourself might help you to feel better – for example by eating healthily or taking regular gentle exercise.
Rest when you feel tired and try to get a good night’s sleep. Talk to your doctor or nurse if there’s something that might be affecting your sleep. This could be anything from urinary problems to worries that are keeping you awake.
Change your position frequently to stay as comfortable as possible and prevent stiffness.
Hot or cold packs may help to relieve some types of pain. Wrap them in a towel so that they don’t hurt your skin. Hot water bottles can also be helpful.
Do something to take your mind off the pain such as listening to music, reading, watching television or chatting with a friend or family member. As simple as it sounds, it really can help.
Try relaxation techniques such as deep breathing, listening to relaxation tapes or having a bath. These can help you to feel more comfortable and take your mind off the pain.

Complementary therapies

Some people with pain find complementary therapies helpful. Some people say they feel more in control because they are actively doing something to improve their health. And some people find they feel more relaxed and better about themselves. We need more research to know whether complementary therapies can relieve the pain itself.

Complementary therapies are used alongside conventional treatments, rather than instead of them. Tell your doctor or nurse about any complementary therapy you are using or are thinking of using. Some complementary therapies have side effects and some may interfere with your cancer treatment. You should also tell your complementary therapist about any cancer treatments you are having, as this can affect what therapies are safe and suitable for you.

There are many different complementary therapies available. The following are some of the more common ones.

Acupuncture - This is where very thin needles are inserted into the skin at specific points on the body. Acupuncture is sometimes available on the NHS and can be prescribed alongside other treatments. Acupuncture might not be suitable if you have lymphoedema.

Reflexology - This is a form of massage to specific areas of the hands or feet which are believed to be linked to other areas of the body. It might help you feel more relaxed and less anxious.

Aromatherapy - This is where natural oils from plants are added to baths, inhaled with steam or used in massage, such as a gentle hand massage. Different oils are said to have different effects, such as helping you feel calm, relaxed, or energetic.

Gentle massage - This can help you to relax, relieve stress, improve blood flow and improve your mood. It’s important not to put deep pressure on any areas that are affected by cancer, particularly areas that are sore or tender or where you are having radiotherapy.

Hypnotherapy - This is where a therapist talks to you and helps you to feel very relaxed and calm. It could help you to cope with some of the effects of cancer and treatment.

Finding a complementary therapist

Some hospitals, cancer clinics and hospices offer complementary therapies. If you choose your own therapist, make sure they are properly qualified and belong to a professional organisation. The Complementary and Natural Healthcare Council has advice about finding a therapist. Macmillan Cancer Support and Cancer Research UK have more information about different types of therapies and important safety issues to consider.

Dealing with pain and prostate cancer

Until your pain is under control it may be very difficult to think clearly or believe that the pain will go away. Coping with any type of pain, whether it is constant or comes and goes, can be tiring and frightening. Pain can affect your daily activities, your relationships with other people, your sleep, and your ability to enjoy life.

Pain can also affect your thoughts and feelings. There’s no right way that you’re supposed to feel and everyone reacts in their own way. You might feel scared, worried, stressed, helpless or even angry. Some people with pain say they feel angry or depressed. And some men worry that their pain is a sign that their cancer is getting worse.

Your feelings can also affect your pain – anxiety can make it worse, and feeling low can make you more aware of your pain. It might be useful to get some extra help if you’re feeling down, for example by talking to a counsellor.

Tiredness can also be a big problem if you’re living with pain. If you’re feeling very tired, speak to your GP or your doctor or nurse at the hospital. They can give you advice and support. Read more about extreme tiredness (fatigue) or find out about our fatigue support service.

There are things you can do to help yourself and people who can help.

Families and close friends often say it can be difficult to watch a loved one in pain. They may find it hard to know how to help and may also need emotional or practical support. If you’re a partner, family member or friend of someone with prostate cancer, you may like to read our information for people who are close to a man with prostate cancer.

Who can help?

Your medical team

It could be useful to speak to your nurse, doctor, GP or someone else in your medical team. They can explain your diagnosis, the cause of your pain, treatment and side effects. They can listen to your concerns, and put you in touch with other people who can help.

Getting help at night or at the weekend (out of hours), or in an emergency

Make sure you and your family know who to contact if your pain suddenly gets worse. If you’re unsure, ask your doctor or nurse and keep the instructions somewhere close.

If you’re in a lot of pain it can be difficult to think straight, so it may help to bring someone to the hospital with you to help talk to the doctor or nurse and to make notes for you.

Knowing how to get out of hours medical care is really important. It’s something you need to have thought about before any pain emergency happens.

A personal experience

Support from hospices

You may be able to get support from your local hospice or community palliative care team. These teams don’t just provide care for people at the end of their life. They provide a range of services, including treatment to manage pain. They can also offer emotional and spiritual support, practical and financial advice, and support for families. Some hospices provide day centres with services such as complementary therapy. Or you might be able to stay at the hospice for a short time while they get your pain under control.

The community palliative care team can usually come and visit you at home if you prefer. Both teams will have doctors and nurses who can adjust the dose of your pain-relieving drugs and help get your pain under control.

Your GP, doctor or nurse at the hospital, or district nurse can refer you to a hospice service or community palliative care team. They will continue to work closely with these teams to support you.

Trained counsellors

Counsellors are trained to listen and can help you find your own ways to deal with things. Many hospitals have counsellors or psychologists who specialise in helping people with cancer – ask your doctor or nurse at the hospital if this is available. Your GP may also be able to refer you to a counsellor, or you can see a private counsellor. To find out more, contact the British Association for Counselling & Psychotherapy.

Other people who can help

Other things that might help include:

Questions to ask your doctor or nurse

You may find it helpful to keep a note of any questions you have, to take to your next appointment.

What is causing my pain?
Do I need to see a pain specialist?
Are there pain-relieving drugs that might help me?
What are the side effects of pain-relieving drugs?
What other treatments can I have to help manage my pain?
What else can I do to help with my pain?
Who else can I talk to about my pain?
Who should I contact if my pain gets worse?
Who should I contact at night or at weekends (out of hours)?

References

Updated: May 2017 | Due for review: May 2019

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