British Journal of Anaesthesia 88 (2): 270±6 (2002)

REVIEW ARTICLE
Analgesia for pelvic brachytherapy
M. D. Smith1, J. G. Todd2 and R. P. Symonds3*
1
Royal Alexandra Hospital, Paisley PA2 9PN, 2Western In®rmary, Glasgow GL1 6NT and
3
University of Leicester, Leicester Royal In®rmary, Leicester LE1 5WW, UK
*Corresponding author

Br J Anaesth 2002; 88: 270±6

Keywords: radiotherapy, pelvic brachytherapy; analgesia; anaesthetics, local
Accepted for publication: May 1, 2001

Radiotherapy is an important and potentially curative
treatment for malignancies of the cervix, endometrium,
vagina, vulva, rectum, anus and penis. Successful treatment
requires a combination of external beam x-ray and brachy-
therapy. Brachytherapy (brachy=short, therapy=treatment)
is the placement of radioactive sources within the body
cavities such as the uterus and vagina (intracavity
brachytherapy), or within the tissues (interstitial brachy-
therapy). It allows an extremely high dose of radiation to
be received by the tumour, with relative sparing of the
surrounding tissues from radiation-induced complications.
The anaesthetist is a vital member of the brachytherapy
team. Many of the patients are medically un®t for surgery.
The radioactive sources are potentially very painful and can
remain in situ for several days. During this time, the patient
is nursed in an isolated room to reduce the radiation
exposure to staff. The use of appropriate analgesic tech-
niques can reduce these treatments from being an ordeal to
slightly unpleasant.
Patients considered un®t for surgery can be treated by
radical radiotherapy with identical cure rates, but lower
morbidity than surgery.17 More advanced stage tumours are
treated by radiotherapy. Since cervical cancer is relatively
slow to metastasize from the pelvis, it is possible to cure
40% of stage 3B tumours (®xed to one or both pelvic side
walls).8 Recently, it has been shown that chemotherapy
given along with pelvic brachytherapy reduces the risk of
death by 30±50% compared to patients treated by radio-
therapy alone.36 This signi®cant advance may increase the
number of patients referred for radiotherapy.
Endometrial cancer
The treatment of choice for most patients with endometrial
cancer is simple hysterectomy, with cure rates of 80±90% if
the tumour is con®ned to the uterus.1 In patients considered
un®t for surgery, intracavity brachytherapy can result in a
5-yr survival of up to 73%.14

Intracavity brachytherapy for cervical and

endometrial cancers
Cervical cancer
Over the last 10 yr, cervical screening programmes and a
rise in the standard of living has led to a fall in both
prevalence and mortality from carcinoma of the cervix. In
1998, there were over 3500 new cases in the UK31 and 13
700 cases in the USA.22 However, it is still extremely
common in the developing world where it is the most
common female cancer.29
Stage 1B tumours (con®ned to cervix) can be treated by
Wertheim's hysterectomy with cure rates of 85±90%.
Intracavity brachytherapy techniques
Manually inserted radiation sources provide `gold standard'
treatment results at the expense of radiation exposure of
staff. To reduce these risks, most centres in Europe now use
remote after-loading systems. Aluminium and nylon
applicators are inserted into the uterus and vagina under
anaesthesia (Figs 1 and 2). Pneumatic hoses are connected
to the applicators postoperatively, allowing stainless steel
pellets (containing caesium in glass) to be moved in and out
of the applicators from a computer-controlled lead safe.
This can reduce the radiation exposure of nursing staff by
30-fold.15

Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2002
 Analgesia for pelvic brachytherapy
After-loading systems deliver radiation at either high
dose rate (HDR) in just a few minutes or at low dose rate
(LDR) over 15±72 h. In 1994, a survey of UK practice found
97% of all departments used LDR but 41% planned to
introduce HDR machines.13 HDR and LDR treatments have
markedly different anaesthetic and analgesic requirements.
High dose rate
HDR treatment can be completed in a few minutes and
performed on an outpatient basis. General anaesthesia,
spinal anaesthesia23 or conscious sedation with fentanyl and
midazolam33 are suf®cient. Once the applicators are with-
drawn, there are no further analgesic requirements.
Fig 1 A±P radiograph of intrauterine/intravaginal insertion using
selectron applicator.
Fig 2 Lateral radiograph of intrauterine/intravaginal selectron insertion.
271
Two methods have been described which avoid repeated
anaesthesia for serial treatments. First, an indwelling
cervical sleeve can be inserted under anaesthesia during
the initial treatment. This can remain in situ to allow
subsequent introduction of uterine applicators without
anaesthesia. However, 26% of patients still experienced
severe uterine pain which was relieved by nitrous oxide.37
Second, osmotic dilators can be introduced to dilate the
cervix 10±12 h before insertion of the applicators.
Discomfort is minimal with fentanyl and midazolam
supplementation.18 Both methods are particularly useful in
medically un®t patients.
Low dose rate
Following anaesthesia for insertion, the applicators remain
inside the uterus and vagina for 15±72 h during LDR
treatment. The postoperative care of these patients is
complicated by many factors:
Patient characteristics
Typical patients presenting for pelvic brachytherapy vary
from younger, ®tter cases of cervical carcinoma (75% ASA
I±II) to older, medically un®t cases of endometrial
carcinoma (83% ASA III±IV).29 The most striking feature
in younger women is the marked anxiety and distress
produced by the nature of the underlying condition.34 In
contrast, a series of 96 endometrial cases noted multiple risk
factors (Table 1),3 with another series noting an average
body mass index of almost 50 kg m±2.24
Type of pain
The cause of considerable discomfort is multifactorial. The
presence of applicator rods in the body of the uterus
stimulates sympathetic autonomic afferents which enter the
spinal cord at the T10±L1 level. This produces poorly
 Smith et al.
Table 1 Incidence of medical risk factors in patients with endometrial
cancer
Risk factor Incidence (%)
Hypertension 50
Age >75 yr 40
Morbid obesity 30
Diabetes mellitus 30
Congestive heart failure 20
Myocardial infarction 10
Thromboembolism 10
Cerebrovascular disease 10
localized, central, lower abdominal pain of a cramping
nature associated with nausea and vomiting. Distension of
the cervix and upper vagina stimulates parasympathetic
autonomic afferents from the pelvic splanchnic nerves of
S2±4 to cause lower back pain. Vaginal packing and its
retaining suture through the labia stimulates somatic
afferents via the pudendal nerves of S2±4. Patients have a
urinary catheter, and a rectal marker is initially present until
the correct position of the applicators is con®rmed by
postoperative x-ray. All these stimuli are considerably
worsened by patient movement. This occurs on transfer
from the operating table to the transfer trolley and bed, on
attachment of pneumatic hoses from the after-loading
device and the removal of applicators some 20 h later.
During this prolonged treatment the patient must lie still in
bed, which can result in considerable pain and stiffness in up
to 80% of cases.12
Postoperative environment
This often comprises an isolated single room. Close
supervision is severely limited by the need to avoid
radiation exposure to staff. Adequate monitoring of pain
and vital signs is hampered by the need to interrupt
treatment for recordings, as well as by equipment and
staf®ng levels on the ward.
Analgesia for low dose rate intracavity
brachytherapy
There is little published evidence on analgesic techniques
for LDR pelvic brachytherapy. What mention there is
originates from the oncology literature and this probably
re¯ects the relatively small numbers of patients managed in
any particular unit. In light of the factors complicating
postoperative care, the following analgesic options can be
considered.
Inhalational analgesia
Inhalational analgesia from nitrous oxide is well suited for
the short term discomfort of applicator attachment, patient
movement or applicator removal (where there is a sudden
increase in pain many hours after other modes of analgesia
have ceased to have an effect).37 It is easily administered,
272
well tolerated and effective if used in anticipation of the
stimulus.
Non-steroidal anti-in¯ammatory drugs and simple analgesics
Non-steroidal anti-in¯ammatory drugs (NSAIDs) and sim-
ple analgesics (including codeine phosphate as a routine
constipating agent) contribute to a multimodal approach. In
particular they may ease the cramping central abdominal
pain, which many patients relate to menstrual pain. The use
of NSAIDS may reduce the requirement for systemic
opioids, as seen in other forms of gynaecological surgery.21
Systemic opioids
It is dif®cult to meet the wide variation in dose requirements
via the intramuscular root (morphine requirements in young
patients have exceeded 30 mg in the ®rst 4 h of treatment in
our unit). Such administration consumes a considerable
amount of nursing time, frequently interrupts treatment and
risks signi®cant breakthrough pain. Patient-controlled anal-
gesia (PCA) is a useful alternative in this setting, and its
general advantages have been well described elsewhere.
The degree of control given to the patient is helpful in
enabling them to cope. Having a favourable respiratory
depressant pro®le in comparison with other opioid tech-
niques is a particular advantage in the isolated setting.
Sedation, commonly referred to as a side effect, can be
regarded as bene®cial in such highly anxious patients. PCA
requires regular monitoring assessments which interrupt
treatment, unless remote alarmed monitoring is available.
As pelvic brachytherapy is a form of gynaecological
surgery often performed on young women, it is no surprise
to ®nd that postoperative nausea and vomiting (PONV) can
be problematic in the presence of systemic opioids.
Although prophylactic antiemetics are of value,16 the
incidence of PONV in published series varies from 25 to
50%.4 16 34 It occurs despite the avoidance of opioids and
with the use of topical or regional anaesthesia for applicator
insertion. In a study where systemic opioids were used, up to
47% of patients were not ®t for discharge at the end of
treatment due to PONV, dizziness and unsteadiness.10 In our
unit this is a particular problem when patients who require
large amounts of PCA morphine are mobilized on the
morning following treatment. We believe this to be
exacerbated by perioperative dehydration. Patients are
fasted for anaesthesia, and remain supine and potentially
nauseous during 20 h of treatment, resulting in reduced oral
intake for up to 32 h prior to mobilization. Routine
perioperative i.v. ¯uids are recommended.
Sedation
Sedation, often with fentanyl and midazolam, although not
strictly speaking an analgesic technique, is frequently
utilized in HDR therapy.24 33 In LDR therapy, benzodi-
azepines are often used to alleviate distress and promote
sleep during protracted treatment in younger, more anxious
patients.12 Indeed, 21 h of target-controlled propofol
sedation has been described.26 This technique demanded
 Analgesia for pelvic brachytherapy

considerable monitoring and staf®ng resources (comprising

an anaesthetist with remote monitoring, continuously pre-
sent in an adjoining room), which were only deemed
justi®able in an exceptional case. There is a balance to be
struck between opioid and benzodiazepine use which
re¯ects individual patient requirements. Oncology nurses
are particularly experienced in making this judgement.

Local anaesthesia
Paracervical block is mentioned in only a few cases with no
real indication of its effectiveness.18 20 The topical place-
ment of 10% lidocaine 4 ml on the cervix and vagina has
been evaluated in HDR therapy.13 The reduction in visual
analogue scores from 60 mm (SD 24.8) to 49. 9 mm (24.1)
was signi®cant. However, moderate pain still remained and
the effects would not be of suf®cient duration for LDR
therapy.
Caudal epidural block
This is used in our unit. A standard approach with 0.375%
bupivacaine 20 ml is well tolerated and produces minimal
leg weakness. We are currently evaluating the contribution
of the block due to the frequent requirement for supple-
mental opioids. This may be due to several factors. From the
innervation of the structures involved, we expect analgesia
of the cervix and vagina to be produced, but not suf®cient to
tolerate the presence of applicator rods in the body of the
uterus. The block may be dif®cult to perform in obese
patients and the failure rate is known to increase with age.7
Classical sacral anomalies are well described and have been
con®rmed recently by magnetic resonance imaging.5
Finally, the block may well be of insuf®cient duration
(which may be due to the dose of bupivacaine used), despite
the majority of analgesic demand occurring in the ®rst 4 h of
treatment.
Lumbar epidural block
This would seem ideally suited to the treatment of pain
produced by LDR therapy. A low concentration local
anaesthetic/opioid infusion, as is popular in many obstetric
units, should provide excellent postoperative analgesia and
could be topped up for applicator removal at the end of
treatment. The use of such a technique has been described,
albeit indirectly, in a recent study.11 Twenty pelvic
brachytherapy patients were given epidural anaesthesia for
applicator insertion, followed by postoperative infusion of
0.125% bupivacaine with fentanyl 3 mg ml±1. Patients were
only assessed twice daily for block height and motor
weakness. Although precise details were not given, all
patients received adequate pain relief with minimal sys-
temic opioids. The otherwise infrequent mention of epidural
use in the literature,10 16 20 may support our concerns over
its safety for high risk cases in an isolated setting with
limited supervision and monitoring.
Fig 3 Plastic template stitched to peri-anal skin holding eight hollow
afterloading needles containing iridium wire.
Interstitial brachytherapy for anal, low
rectal, vaginal, vulval and penile cancers
Anal and low rectal cancers
In the last decade, it has been clearly shown that anal cancer
can be treated at least as well by radiotherapy as by the
much more radical treatment of abdomino-perineal resec-
tion. Squamous carcinomas up to 5 cm have a 3-yr survival
of 93% following radiotherapy.35 Surgery is the treatment of
choice for adenocarcinomas of the low rectum impinging on
the anus. However, radiotherapy can treat tumours extend-
ing to 8 cm beyond the anal margin. The 3-yr survival in
patients who either refused surgery, or were judged
inoperable on technical or medical grounds, was 57%.35
The technique involves implantation of up to eight hollow
stainless steel needles, of up to 10 cm in length, around the
anal canal. They are secured in a horse-shoe shaped, rigid
plastic template to ensure near perfect geometrical distri-
bution of radiation dose (Figs 3 and 4). Iridium wire is cut to
size and inserted into the needles 1±2 h after the implant has
been sited under anaesthesia.
Vaginal and vulval cancers
Vaginal cancer is becoming more common, often following
successful treatment of cervical lesions. Tumours in the
lower and middle thirds of the vagina can be treated in a
similar fashion to anal cancer. The vulva tolerates radiation
poorly, but localized iridium needles implanted for up to 7
days are useful for incompletely excised or inoperable
tumours.
Penile cancer
The use of radiotherapy can avoid amputation of the penis
for tumours of up to 4 cm. External beam radiotherapy
provides an 80% cure rate,27 but many patients develop

273
 Smith et al.
Fig 4 A±P radiograph of palisade of hollow afterloading needles
surrounding the anus and lower rectum.
complications such as ®brosis of the penile shaft, erectile
dysfunction and urethral strictures. However, implanting the
tumour-bearing area with iridium reduces the incidence of
complications19 (Fig. 5).
Analgesia for interstitial brachytherapy
General or regional anaesthesia is required to site pelvic
interstitial implants. Postoperative analgesia is greatly
enhanced by appropriate selection of the following tech-
niques.
Caudal epidural block
This provides excellent postoperative analgesia for patients
having anal, vaginal, vulval or penile implants. The
pudendal nerve (S2±4) supplies the perineum and pelvic
¯oor through the inferior haemorrhoidal and perineal
branches, and the penis or clitoris through their corres-
ponding dorsal nerve branches. However, the pudendal
nerve is not the only sensory nerve to the perineum. The
labia majora, base of penis and the scrotum receive mixed
sensory innervation from the terminal branches of the
ilioinguinal (L1) and genitofemoral (L1±2) nerves. The
injection of 0.375% bupivacaine 20 ml through the sacral
hiatus, would be expected to provide a sensory block to a
maximum height of L1.25 More commonly, the block only
reaches the lower lumbar roots, resulting in inadequate
analgesia in a small number of patients whose tumour
extends outwith the distribution of the pudendal nerve.
Spinal `saddle' block
Spinal `saddle' block with 0.5% hyperbaric bupivacaine 1.0
ml in the sitting position, is a useful alternative to caudal
block when the sacral hiatus cannot be identi®ed or the area
of overlying skin is highly in¯amed following recent
external beam radiotherapy.
274
Fig 5 Afterloading template iridium implant for carcinoma of penis.
Penile nerve block
This is highly suitable for operations on the shaft, glans and
foreskin of the penis. Since the penile urethra is supplied
throughout its length by the perineal branch of the pudendal
nerve, block of the dorsal nerve of the penis does not
provide anaesthesia for catheterization or surgery for
tumour involving the urethra. The dorsal nerve is easily
blocked with 0.5% bupivacaine 20 ml at the route of the
penis, as it emerges through the perineal membrane below
the lower border of the pubic symphysis. Several techniques
have been described, including medial or bilateral injections
at the penile root, with an average block duration of 10 h.33
Continuous dorsal nerve anaesthesia has also been
described.9
Local anaesthetic in®ltration
Patients with low rectal adenocarcinomas undergoing
intraluminal irradiation do not need any form of analgesia
and the treatment is performed in the outpatient department.
If an iridium implant is used to give a booster dose to the
tumour bed, then local anaesthetic in®ltration is required.28
Sedation
External beam radiation in the palliation of rectal cancer can
be combined with laser therapy, to control local symptoms
by debulking the intraluminal growth. Photocoagulation of
the lesion is painful and patients require sedation with
opioids and benzodiazepines.2
Pre-emptive analgesia
The use of local anaesthetic blocks for interstitial
brachytherapy in our unit has produced some interesting
®ndings. Postoperative pain in anal cancer treatment can be
markedly reduced for up to 2±3 days after implant insertion,
by a single caudal injection. Analgesia lasting far beyond
the expected duration of the block is also seen in patients
with penile cancer who, following dorsal nerve block, have
required no analgesia for the entire 7 days of implant
 Analgesia for pelvic brachytherapy
insertion. This contrasts greatly with patients not receiving
local anaesthesia, who seldom achieve adequate pain relief
despite repeated systemic opioids.
The precise mechanisms involved in these observations
are unclear. Decreased activation of nociceptive afferents
may occur if the insertion of interstitial needles releases
fewer in¯ammatory mediators (e.g. prostaglandins, brady-
kinin, histamine) than a standard skin incision with subse-
quent suturing and wound tension. The reduced peripheral
sensitization of nociceptive nerve endings would lessen any
degree of primary hyperalgesia. Penile, vulval and anal
implants receive few C-®bre autonomic afferents and the
somatic afferents are effectively blocked by local anaes-
thetic techniques. This may be suf®cient to prevent central
sensitization in the spinal cord and avoid the development of
secondary hyperalgesia during implant insertion. In more
major surgery, however, the clinical trials investigating pre-
emptive analgesia have been disappointing because the
analgesic regimen are perhaps not profound or prolonged
enough to prevent central sensitization in the spinal cord.6
Summary
Pelvic brachytherapy presents the anaesthetist with
numerous challenges. Patients vary from highly distressed
young adults, to the elderly with coincidental disease severe
enough to preclude surgery. The painful radioactive
implants remain in place for a number of days. Treatment
in isolated rooms reduces radiation exposure to staff, but
makes close postoperative monitoring dif®cult, so the
analgesic technique should involve minimum risk to the
patient. Although there is very little published evidence of
speci®c analgesic techniques in this area, knowledge of
these problems allows the anaesthetist to select appropriate
systemic analgesics and regional blocks to provide safe and
effective pain relief.
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