Pain is a very common symptom and can affect 70–90 % of patients with advanced prostate cancer [11]. It has a profound effect on a patient’s quality of life and treatment of pain can be difficult to achieve.

Dame Cicely Saunders introduced the concept of ‘total pain’ which encompasses the physical, psychological, spiritual and social pain a patient may be experiencing (see Fig. 15.2). Not all patients will experience all of these facets of pain, however to treat one without addressing the other issues will not result in adequate control of symptoms. For example, if a patient is psychologically distressed it may be very difficult to control their physical pain until the psychological distress is established and efforts made to address it. This requires a multidisciplinary approach to care to ensure there is simultaneous focus on all the facets of pain. The multidisciplinary team may include doctors, specialist nurses, physiotherapists, occupational therapists, counsellors, social workers, psychiatrists and dieticians, as well as other allied healthcare professionals. It is also important to remember that the pain a patient has may not be related to their cancer and may be of another cause for example longstanding osteo-arthritis.

The key to the effective pharmacological treatment is to establish the cause of the pain. This will guide the type of analgesia that will be most effective. We focus on some of the causes of pain below.

Once the cause has been established, the medication used can be tailored to the patient. Wherever possible oral analgesics should be used as first line. There will be occasions where this is not possible for example the patient is nil by mouth or too frail to manage oral medication.

Oral analgesics should be instituted using the World Health Organisation (WHO) analgesic ladder (See Fig. 15.3).

The aim is to establish pain control using the simplest regime possible. Pain is a subjective experience and patients can start at any point on the ladder in accordance to the level of pain they are experiencing. Analgesia should then be titrated up or down in accordance with response to treatment and side effects. For example, if a patient is at step 2 of the ladder and their pain is not controlled they should be moved to step 3. If a patient is as step 2 and they undergo a treatment that may reduce their pain (e.g. radiotherapy to a bone metastases) it may be possible to reduce their analgesia with careful observation.

It is important to note that many patients will develop side effects from mild and strong opioids. Often these side effects can be managed effectively allowing a patient to continue taking the analgesia they need. There may be incomplete cross tolerance when starting opioids, which means that a patient may become tolerant to the side effects associated with the opioid but the analgesic effects persist, this is particularly true of opioid associated nausea. It is therefore important to warn patients of the side effects they may experience in order to increase compliance with a new medication. For example, when starting a strong opioid it is important to start a laxative at the same time as constipation occurs in almost all patients. The patient can be warned of this common side effect and advised to inform their doctor or nurse if it is becoming an issue so the laxatives may be increased. If a patient has uncontrollable or intolerable side effects with a medication it should be changed to another medication from the same class, for example opioid switching from morphine sulphate to oxycodone. However, there is little evidence that oxycodone has fewer side effects than morphine sulphate, though individual patients may tolerate one better than the other [12].

The use of adjuvants with opioid-based analgesia is an effective way of managing pain and minimising the dose of opioids needed, thereby reducing side effects. Adjuvants that may be considered include non-steroidal anti-inflammatory drugs (NSAID), corticosteroids, neuropathic pain medication and bisphosphonates, all of which have their own side effects and contraindications.

Non-pharmacological techniques may also be useful in some patients. For example, use of transcutaneous electrical nerve stimulations (TENS) or cognitive behavioural therapy (CBT). Disease modifying therapies such as chemotherapy and radiotherapy also have a role in the management of pain.

Within the UK, NICE defines MSCC as ‘spinal cord or cauda equina compression by direct pressure and/or induction of vertebral collapse or instability by metastatic spread or direct extension of malignancy that threatens or causes neurological disability’ [18]. In 2008 [18], NICE produced guidelines on the ‘diagnosis and management of adults at risk of and with MSCC’. MSCC is common and is an oncological emergency. Delay in diagnosis and treatment can cause huge morbidity and distress. It affects 1–12 % of patients with metastatic prostate cancer, though can occur in any patient with boney metastatic disease affecting the spine [19] which would include many of the urological cancers.

MSCC can present in a number of ways. The earliest symptoms are pain in the back and spinal tenderness. It can cause a number of other neurological signs and symptoms, however once these are evident the MSCC may already have been present for a period of time, which can make functional recovery less likely. Early detection and diagnosis are vital to retaining function.

In the UK, if a patient has a suspected MSCC they must be discussed with the local MSCC co-ordinater within 24 h of presentation. This is to ensure prompt assessment and treatment, which takes into account the patient’s functional level and preferences. The imaging of choice is magnetic resonance imaging, unless contraindicated, of the whole spine as there are often multiple levels of compression [18].

If a patient has suspected MSCC they should be nursed flat if there are any signs of spinal instability. High dose steroids should be initiated as soon as possible and will often precede imaging [18]. Once MSCC has been demonstrated on imaging, choice of treatment will be determined by patient preference and performance status. The options include radiotherapy or spinal surgery to decompress the spinal cord. There is strong evidence that surgery followed by radiotherapy provides a better functional outcome than radiotherapy alone. In a study of 101 patients with MSCC who were randomly assigned to radiotherapy alone or decompressive surgery followed by radiotherapy, significantly more patients were able to walk after the combined therapy (84 %) than after radiotherapy alone (54 %) [20].