The Benefits and Harms of Pharmacological Treatment for Postradiation Pelvic Pain: A Systematic Review by the European Association of Urology Chronic Pelvic Pain Panel with Recommendations for Clinical Practice

Valentin Zumstein; Brian A Parsons; Saeed Dabestani; Andrew P Baranowski; Victoria Tidman; Bary Berghmans; Jan Borovicka; Angela M Cottrell; Paolo Dinis-Oliveira; Sohier Elneil; John Hughes; Bert E J Messelink; Pedro Abreu-Mendes; Benjamin Sacks; Yuhong Yuan; Daniel S Engeler

doi:10.1016/j.euros.2023.08.009

The Benefits and Harms of Pharmacological Treatment for Postradiation Pelvic Pain: A Systematic Review by the European Association of Urology Chronic Pelvic Pain Panel with Recommendations for Clinical Practice

Eur Urol Open Sci. 2023 Sep 9:56:29-38. doi: 10.1016/j.euros.2023.08.009. eCollection 2023 Oct.

Authors

Valentin Zumstein¹, Brian A Parsons², Saeed Dabestani³, Andrew P Baranowski⁴, Victoria Tidman⁴, Bary Berghmans⁵, Jan Borovicka⁶, Angela M Cottrell⁷, Paolo Dinis-Oliveira⁸, Sohier Elneil⁹, John Hughes¹⁰, Bert E J Messelink¹¹, Pedro Abreu-Mendes⁸, Benjamin Sacks¹², Yuhong Yuan¹³, Daniel S Engeler¹

Affiliations

¹ Department of Urology, Cantonal Hospital of St. Gallen, School of Medicine, University of St. Gallen, St. Gallen, Switzerland.
² Royal Devon and Exeter Hospital, Exeter, UK.
³ Department of Translational Medicine, Division of Urological Cancers, Lund University, Kristianstad Central Hospital, Lund, Sweden.
⁴ University College London and the National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation Trust, London, UK.
⁵ Pelvic Care Centre Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.
⁶ Department of Gastroenterology/Hepatology, Cantonal Hospital of St. Gallen, School of Medicine, University of St. Gallen, St. Gallen, Switzerland.
⁷ East of England Deanery, London, UK.
⁸ Department of Urology, Hospital de Sao Joao, University of Porto Faculty of Medicine, Porto, Portugal.
⁹ University College Hospital and the Hospital for Neurology and Neurosurgery, London, UK.
¹⁰ The James Cook University Hospital, Middlesbrough, UK.
¹¹ Department of Urology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
¹² University College London Hospital, London, UK.
¹³ Department of Medicine, McMaster University, Hamilton, ON, Canada.

Abstract

Context: Radiotherapy of the pelvis is a widely used method for the treatment of malignancies, and local complications including pain following pelvic radiation therapy are acknowledged complications.

Objective: The primary objective is to assess the clinical effectiveness and safety of pharmacological therapies on postradiation pelvic pain.

Evidence acquisition: A systematic review of the use of different pharmacological treatments in the management of post-radiation pelvic pain was conducted (PROSPERO-ID: CRD42021249026). Comprehensive searches of EMBASE, Medline, and Cochrane library were performed for publications between January 1980 and April 2021. The primary outcomes were improvement in pain and adverse events following treatment. The secondary outcomes included quality of life, bowel function, and urinary function.

Evidence synthesis: After screening 1514 abstracts, four randomised controlled trials were identified, enrolling 355 patients with bladder and anorectal subtypes of postradiotherapy chronic pelvic pain (CPP). A narrative synthesis was performed as heterogeneity of included studies precluded a meta-analysis. A single study reported a significant reduction in pain after 6 mo in patients with bladder pain syndrome treated with hyaluronic acid or hyperbaric oxygen. Anorectal pain was reported to be reduced by the application of 4% formalin, but the use of hyperbaric oxygen in postradiotherapy anorectal pain remains controversial. Adverse event reporting was generally poor. Studies looking at medications used routinely in guidelines for neuropathic pain, such as gabapentin, pregabalin, amitriptyline, and duloxetine, were absent or of poor quality when it came to postradiation pelvic pain.

Conclusions: Beneficial effects of hyperbaric oxygen or formalin on pain, quality of life, and functional symptoms were seen in patients with certain CPP subtypes, but the current evidence level is too weak to allow recommendations about the use of any pharmacological treatment for postradiation pelvic pain.

Patient summary: Different pharmacological treatments are used to treat pain after radiotherapy, but current studies are of insufficient quality to determine whether these should be recommended and many chronic pelvic pain subtypes are not covered. Further research is needed.

Keywords: Chronic painful radiation-induced neuropathy; Chronic pelvic pain; Chronic post cancer treatment pain; Chronic post radiotherapy pain; Pelvic radiation disease; Postradiation; Radiotherapy.

Publication types

Review