Palliative Care

Gynaecological Symptoms

Lalit Krishna
Senior Consultant
Division of Palliative
30 May
Medicine
2016
Pelvic
Pain
Pelvic Pain

Multifactorial

- what is the structure involved?

- what is the pathological process?

Consider
GU tract:

- males: ureters, bladder, prostate, urethra,

penis, testis

- females: ureters, bladder, urethra, ovaries,

uterus, vagina

Perineum

GI tract: distal colon, rectum, anus

Bones: sacrum, pelvis

Consider

Cancer

- tumor related/ local invasion/ metastasis

- nociceptive (visceral or somatic)/ neuropathic

Non-cancer disease

- eg UTI, constipation

Iatrogenic

- post radiotherapy/ surgery

Evaluation of Pain

Detailed medical history

Psychosocial assessment

Physical examination
Pain types
Visceral pain

- spasm of smooth muscle of hollow organs/ distension of

capsule of solid organs/ inflammation/ compression of

pelvic viscera

- pain usually poorly localised

- dull aching, pressure-like, deep squeezing

Somatic ( superficial cutaneous or deep musculoskeletal)

- sharp and localized

- local tenderness

- eg. pelvic bone metastasis, pathological fracture

post surgical incisional pain

Neuropathic pain
Paroxysms of: pins & needles, electric shock, burning pain, tingling, pricking, shooting +/-
radiation +/- allodynia, bowel/ bladder dysfunction

Lumbosacral plexopathy commonly caused by retroperitoneal lymph node metastasis

Upper plexus: back, lower abdo, iliac crest or anteo-lateral thigh pain

Lower plexus: buttock, perineum, postero-lateral thigh

Treatment

Non-pharmacological

- positioning (perineal pain)

Pharmacological

- adjuvant analgesia: TCA, anti-convulsants, corticosteroids

- opioid
Interventional management

a) Neurolytic sympathetic plexus block

- superior hypogastric plexus

- ganglion impar

b) Epidural block

- disadvantage: infection, high care need

Per
Vaginal
Bleeding
Per Vaginal (PV) bleeding

- Common consequence of advanced cervical cancer

- Can be life-threatening

- Immediate cause of death in 6% of women with cervical cancer

- Important to rule out coagulopathy/ PR bleeding or urinary tract origin.

Cochrane Database of Systematic Reviews 2015

Management- Tranexamic acid
- oral or IV

- used to control mild to mod vaginal bleed

- antifibrinolytic agent that competitively blocks the conversion of plasminogen to plasmin,

thereby reducing fibrinolysis

- contraindication: history or acute thromboembolic events, haematuria

Other options

Vaginal packing with simple gauze rolls +/- haemostatic agent eg formalin,
Monsels solution

- can be painful and distressing

Palliative Radiotherapy

Ligation of bilateral internal iliac arteries

- may not be appropriate in pall setting

Cochrane Database of Systematic Reviews 2015

Treatment choice

Extent of disease, severity of bleed, goal of care/ patients preferences

For excessive bleeding at end-of-life, ensure comfort with anxiolytics and analgesics.
Deep Venous
Thrombosis
Deep Venous Thrombosis

Association between venous thromboembolism (VTE) and cancer has been

recognised since 19th century.

hypercoagulable state

Prevalence: up to 15% of cancer patients

Higher risk in pelvic malignancy due to compression of iliac vein

S Noble. Postgrad med J 2007;83:671-674

Assessment

History

Physical examination

Investigation Ultrasound, D-dimer

(pretest probability: Wells score)

Treatment

LMWH

Warfarin
LMWH vs Warfarin

LMWH Warfarin
Dose is calculated according to body Needs frequent monitoring/ blood test
weight, no need to monitor
anticoagulation

SC injection Oral route

Not affected by absorption problems Affected by absorption problems

Efficacy not altered by other medicine Presence of drug-drug interactions

Studies have shown that treatment with warfarin
(vs LMWH) in cancer patients
- higher risk of major bleeding

- higher rate of recurrent VTE

Lee AY, Levine M, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous
thromboembolism in patients with cancer. N Engl J Med 2003;349:14653

Meyer G, Marjanovic Z, Valcke J, et al. Comparison of low-molecular-weight heparin and warfarin for the secondary
prevention of venous thromboembolism in patients with cancer. Arch Intern Med 2002;162:172935

Hull RD, Pineo GF, Mah AF, for the LITE Study Investigators. Long-term low molecular-weight heparin versus usual care in
proximal-vein thrombosis patients with cancer. Am J Med 2006;119:106272
Challenges of managing VTE in palliative care
setting

1. Recognition of VTE

- asymptomatic VTE

- under appreciation of associated risks of cancer with VTE

among physicians

- many conditions may mimic VTE:

unilateral leg swelling- cellulitis, lymphoedema

bilateral- hypoalbuminaemia, pelvic disease causing

reduced venous outflow
Challenges of managing VTE in palliative care
setting

2. Confirmation of VTE

- D-dimers: highly sensitive indicator for VTE but non specific

(high in infection & malignancy)

- Doppler US: widely available, cheap, non invasive

but poor sensitivity for asymptomatic disease,

difficult in diagnosing DVT recurrence

Challenges of managing VTE in palliative care
setting

3. Treatment of VTE

- higher risk of bleeding from oral anticoagulation among cancer patients

- high recurrence rate despite warfarin

Challenges of managing VTE in palliative care
setting

4. Duration of anticoagulation

- Prothrombotic tendency in advanced cancer patients is indefinite

- no clinical trials were continued past 6 months so far

- need to weigh benefit of treatment and QOL/goal of care

Fistula
Fistula
Communication between 2 hollow viscera or viscera and body surface

Eg vesicovaginal, vesicoenteric fistula

Common in advanced cancer

Previous RT to pelvis

Extremely -ve impact on QOL (odour)

General management:

- meticulous skin protection eg barrier cream (zinc, castor oil)

cavilon or sudoderm

lutrol gel

- water absorbent pads or tampons

- treatment of odour: metronidazole

charcoal dressings
Vesicoenteric fistula
- between bladder and segment of bowel

- pneumaturia, foul odour to urine, recurrent UTI, faecal material in urine

- Investigations: cystoscopy, contrast cystography, intestinal barium studies

- Management: ideally surgery (removal of segment involved/ bypass procedure with

stoma)
Vesicovaginal fistula

- between bladder and vagina

- continuous leakage of urine from vagina

- management: surgical excision

urinary diversion eg ileal conduit

Lymphoedema
Lymphoedema

Failure of physiological lymphatic drainage in the interstitial tissue

Common in patients with terminal cancer, especially those undergone resection

and/or irradiation of lymph node bed

Upper limb: breast cancer

Lower limb: prostate, uterine cancer, lymphoma, melanoma

Manifestations: heaviness ,fullness, reduced mobility, and psychological distress

Treatment
- Aim: reduce swelling and improve function

- Goal standard: complete decongestive therapy (CDT)

a.) skin care

b.) exercise/ physiotherapy **

c.) manual lymphatic drainage (MLD)

d.) compression therapy

Manual Lymphatic Drainage
Clemens et al performed a study to evaluate the effectiveness of MLD for advanced cancer patients with lymphoedema (LE)

208 patients with LE were included (90 with symptoms)

94% of patients with pain reported a clinically-relevant reduction of pain intensity

73.9% of patients with dyspnoea had significant relief of symptom

18.9% of the patients reported LE reduction as little; 64.4% as moderate, and 16.7% as good.

Clemens KE, Jaspers B, Klaschik E, Nieland P: Evaluation of the clinical effectiveness of physiotherapeutic management of lymphoedema in
palliative care patients. Jpn J Clin Oncol 2010;40:10681072.
Closed-controlled Subcutaneous Drainage
First reported by Clein and Pugachev in 2004

placing subcutaneous needles in the swollen legs, which drained into an enclosed bag, for a
period of 12 hours to 1 week, depending on the volume of drainage

Results:

- 7 out of 8 patients had objective improvement (volume

drained)

- no adverse effects eg infection

- all patients died in comfort

- limitation: objective limb volume assessment tools were not used

Many subsequent studies also showed similar +ve results

Marcia Beck, Ausanee Wanchai, Bob R. Stewart, Janice N. Cormier, Jane M. Armer. Palliative Care for Cancer-Related Lymphedema: A Systematic Review. J palliat
medicine June2012; 15(7):821-7
Compression Therapy

Multi-layer banding
- In 2007, Pyszora et al conducted a case study (n = 1)

- Tx regime: multi-layer compression bandaging, limb elevation and skin

care

- Result: oedema was reduced by about 35% in both limbs

Compression Therapy

Kinesio taping
- A second case study was conducted by Pyszora et al in 2010

- Kinesio tap applied on lower limb for 3 days

- Swelling, pain, and the feeling of heaviness decreased.

Thank You