This is the third part of our mini-series about the condition based on our patient booklet “Fast Facts for Patient and Their Supporters: Metastatic Prostate Cancer”.

Bone Pain

Cancer cells that have spread to your bones activate the bone’s osteoblast (builder) and osteoclast (demolisher) cells, which build and recycle bone minerals. In turn, these bone cells activate the cancer cells. This cycle of activity between bone and prostate cancer cells results in abnormal bone production and destruction, which can cause pain.

What Does Bone Pain Feel Like?

Bone pain often starts in the lower back, pelvis or hips. Initially, the pain may be mild. Some men describe it as a dull ache, others a stabbing pain, which gets worse with movement. The bone may be tender to the touch. Over time the pain will increase and eventually become constant. The pain may affect your sleep or may even be incorrectly diagnosed as arthritic pain.

How Is Bone Pain Treated?

Everyone reacts differently to pain, so only you can describe how much pain you are in. Honest open discussions with your doctor are essential.

 

Numeric rating scale

 

With the right treatment, bone pain can usually be reduced or relieved. You should take pain relief regularly (every 3–6 hours), not on demand.

First, your doctor will make sure you are receiving the best possible treatment for your prostate cancer. You will then be prescribed painkillers according to your pain level. Your doctor will review your pain relief often, and adjust and substitute drugs as needed.

Tolerance to painkillers or drug dependency are not a problem for most people, but the side effects of these drugs will need to be managed; for example, constipation or effects on kidney function.

Ladder for cancer pain relief

 

Urinary Problems

Narrowing (stricture) or blockage of the urethra, or the symptoms of distant metastases, can cause:

  • difficulty urinating
  • visible blood in the urine (hematuria)
  • inability to pass urine (urinary retention).

Several small procedures that are not very painful can be carried out to relieve these symptoms. Dilatation usually provides short-term relief. A thin plastic rod is passed into the urethra to stretch it under local anesthetic.

If you have never had surgery or radiotherapy to the prostate, your urologist may propose a transurethral resection of the prostate (TURP). In most cases, this should be done sooner rather than later. An instrument is passed up the urethra to cut out the middle of the prostate, leaving an outer rim or shell. It is not a very painful procedure and most men go through it quite easily.

As long as TURP is carried out before cancer reaches the bladder neck and base, urine flow usually improves rapidly. The need to urinate often may take a few months to subside. Some men have an urgent need to go to the toilet and a burning sensation when urinating, but this usually disappears within a few days or weeks.

If the cancer spreads to the lymph nodes in the pelvis, the drainage tubes from the kidneys to the bladder (ureters) may become blocked, which can lead to kidney failure. In this situation, your urologist may insert a stent. Stents may need to be replaced every few months.

Bowel Problems

You may experience constipation, diarrhea, leakage from your back passage (fecal incontinence), urgency (rushing to the toilet), or stomach or anal pain.

What you can do to relieve: 
Constipation
• Increase the amount of fiber that you eat, including fruit and vegetables
• Drink plenty of water
• Keep as active as you can
• Ask your doctor about taking laxatives
• Speak to your doctor about the medications you are taking; some can cause constipation
Diarrhea
• Cut down on the amount of fiber that you eat
• Avoid alcohol, caffeine and spicy foods
• Speak to your doctor about the medications you are taking; some can cause diarrhea

Fatigue (Extreme Tiredness)

You may experience a decrease in energy, making it difficult to carry out your daily activities. Tiredness will also affect your concentration, emotions and sex drive. This may be caused by:

  • anemia (fewer red blood cells taking oxygen around the body) – this may also make you look pale
  • low testosterone (after hormonal treatment)
  • chemotherapy
  • radiotherapy
  • loss of appetite leading to a low calorie intake
  • substances produced by cancer cells which can affect the normal function of organs such as the liver and bone marrow
  • kidney failure
  • depression (often not diagnosed).

Your urologist will check that there is no reversible or treatable underlying condition causing your fatigue. Blood tests will reveal any problems in your bone marrow, thyroid, liver or kidneys and whether you have the right level of electrolytes and calcium.

To Help Combat Tiredness

  • Eat a well-balanced diet. If you are struggling to eat, nutritional support in the form of high protein drinks can also be of value.
  • Drink plenty of fluids.
  • Take vitamin and mineral supplements for any deficiencies. Vitamin D and calcium may be particularly beneficial.
  • Take gentle, regular exercise.
  • Use complementary therapies such as acupuncture, massage or meditation to make you feel better. (Note: only with the knowledge of your urologist and under the guidance of experienced practitioners in these fields who are aware of your condition).
  • Get enough sleep. If you can’t sleep, talk to your doctor.
  • Plan things you can look forward to, which will give you a lift (e.g. seeing friends, a round of golf, a trip to the theater).

Sexual Problems

Advanced prostate cancer can spread to the nerves and blood vessels that supply the penis, causing erectile dysfunction. Damage to the nerves or blood vessels can also occur during surgery or radiotherapy, although this is less likely in the hands of an experienced surgeon. Hormonal therapy can also cause impotence. Normal testosterone levels are essential for a healthy libido, energy and mood as well as good erections. For this reason, some patients may start on an oral anti-androgen to preserve sexual function.

Swelling of the Legs

Prostate cancer metastases can obstruct lymphatic drainage of the lower limbs, and in advanced cases the penis and scrotum (especially after radiotherapy), resulting in swelling called lymphedema. Too much fluid in the legs may cause pain, making it difficult for you to stay active. The skin can become red and infection can set in.

What You Can Do

  • Take care of your skin with regular cleaning and moisturizing
  • Avoid any pressure to the skin on your legs and feet
  • Report any sign of infection to your doctor and start treatment early
  • Take gentle exercise to help circulation
  • Use compression stockings and massage to reduce the swelling

Blood Clots

Large lymph nodes filled with prostate cancer cells can compress nearby veins that drain the lower limbs. This puts you at high risk of thrombosis (blood clots) in your legs, which can then travel to your lungs. Immediately after surgery, especially after extended lymph node dissection, you will be given anticoagulant injections under the skin. If you are found to have blood clots, you will then be given oral anticoagulants.

Eating Problems

You may feel sick or lose your appetite because of your cancer or the treatment you are having. Your doctor can prescribe anti-sickness drugs, and will be able to refer you to a dietician to help with supportive nutrition.

 

Please check out the other posts of our mini-series here:

 

Information based on Metastatic Prostate Cancer (Karger, 2017).

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