Bladder and Ureteric Spasm/Pain
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Appropriate assessment to identify cause and severity symptoms
Consider disease-specific palliative therapy
Explanation to patient and family
Institute non-pharmacological interventions
Prescribe appropriate first-line treatment
Consider adjuvant/second-line treatment
Review assessment and management
Appropriate assessment to identify cause and severity of symptoms
Bladder spasms: transient, often excruciating sensations felt in the suprapubic region and urethra. They are generally secondary to irritation or hyper-excitability of the trigone. It often relates to local cancer, radiation fibrosis, infective cystitis, indwelling catheter or anxiety.
Bladder pain: more constant pain, from a dull ache in UTI to acute disabling pain and may be a sign of obstruction and retention.
Correct reversible factors
Reassess the indwelling catheter where applicable as mechanical irritation can be caused by the catheter balloon - change catheter/ reduce volume of the balloon
Catheter sludging with partial retention – bladder washouts or continuous bladder irrigation as described in the UTI section
Blood clots/haematuria: relating to bladder cancer/ chronic radiation cystitis
Consider disease-specific palliative therapy
- Treat UTI
- Relieve obstruction/instability – especially related to catheter
- Tumour ablation
- Remove foreign body (catheter or stones) if obstructing bladder outlet
- Inflammatory causes
Explanation to patient and family
Explain the cause of the spasms and pain and the steps the care team will be taking to manage this distressing symptom
Institute non-pharmacological interventions
- Regular toileting
- Good fluid intake if possible
- Avoiding caffeine and alcohol
- Cranberry juice
Prescribe appropriate first-line treatment
Treat bladder spasms and pain symptomatically with the following treatment options:
- Hyoscine Butylbromide 10-20 mg po, IVI, IMI or S/C tds. Maximum of 100mg per day – avoid if in retention
- WHO pain ladder
Consider adjuvant/second-line treatment
Intravesical morphine and bupivacaine tds (morphine 10-20mg and 0.5% bupivacan 10ml diluted in 0.9% saline to 20 ml), instil through an indwelling catheter and clamp for 30 min.
Spinal analgesia, e.g. epidural morphine and 0,5% bupivacaine
Review assessment and management
Review catheter care, assess for possible infection, obstruction and retention
At all stages of management consider
Involvement of interdisciplinary team – ensure that appropriate treatment regimes for pain management are adhered to and involve the nursing staff to assist in adherence support. Relieve patient anxiety through support from counsellors and social worker involvement.
Referral to appropriate service/more experienced clinician
Refer to Urologists where necessary for additional interventions such as dilatation of urinary stricture, retention, complicated pyelonephritis and enlarged prostate. The following tests may be required to confirm diagnosis:
MSU, Ultrasound, CT scan and MRI if contrast contra-indicated.