Optimizing the Management of Bladder Pain Essay

Optimizing the Management of Bladder Pain Essay


Reflex sympathetic dystrophy is a disease that affects the lower limb and it is mainly caused by trauma.  It is not only a stumbling block for recovery but also affects the psychological well-being of a patient. It presents with vasomotor insufficiencies such as cold extremities and very severe pain.  Patients experience pain that is disproportion to the injury and the healing process tends to persist. The main aim of treatment is to relieve pain, psychological stabilization, and restore the function of the limb. Optimizing the Management of Bladder Pain Essay

Analgesics are often used to restore the functioning status and relieve the patient from pain. Health care providers should ensure the drugs administered aids in compliance with tolerable side effects. In this essay, we are discussing the management of a 43-year-old Caucasian male who presented with complex regional pain disorder. In his treatment, three decisions are made regarding the best medication, expected results, and actual outcome. A description of the ethical issues when engaging clients with a complex regional pain disorder and their families will also be provided.


Decision #1

Decision Selected

Start amitriptyline 25mg during bedtime daily then increase by 25mg weekly up to a maximum dose of 200mg.

Reasons for the decision

            Reflex sympathetic dystrophy has a low pain thresh hold due to changes in the central nervous system that makes the patient have increased pain sensitivity because of the neurotransmitter levels in the brain. Amitriptyline is a tricyclic anti-depressant that works by blocking both serotonin and norepinephrine neurotransmitters. It works on the nerve ending to achieve analgesic effects thus relieving pain. Optimizing the Management of Bladder Pain Essay

Amitriptyline, a tricyclic antidepressant is very effective in the treatment of neuropathic pain. It has side effects such as dizziness and drowsiness. Therefore, prescribing this medication for a start might only trigger non-compliance.

Hydrocodone is in the class of opiate or narcotic analgesics. It relieves pain by changing the way the nervous system responds to pain (Al-Singary et al 2020). It relieves pain by decreasing the activity of the brain. Its side effects are chest tightness, difficulty in breathing, anxiety, headache, nausea, vomiting, and constipation. However, the patient disliked the side effects of the drug and could not comply with the medication.

Expected Outcome

The expected outcome after starting the patient on amitriptyline was to reduce the pain to 3 out of 10 on a scale of 1-10, reduction in cramping of extremities, walk unaided, and to improve the depressive mood.

Difference between Expected outcome and Actual Outcome

            The patient visited the clinic four weeks later with crutches. He reports the pain has slightly reduced and he could move around his house without support. On a scale of 1-10, the pain was 6 out of 10 which has greatly reduced from 9 out of 10. Cramping of extremities has reduced to one to two episodes per week. Increasing the dosage of amitriptyline will help to achieve maximum effects in reducing pain and restoring function.

Decision #2

Decision Selected

To increase the dosage of amitriptyline to 125mg bedtime and continue increasing the dosage weekly up to a maximum dose of 200mg. the patient was also advised to take amitriptyline one hour earlier than the time he takes.

Reasons for Selecting This Decision

In the previous visit, the patient reports of pain, walking with support, and cramping of extremities. This happened because the drug was initially administered at a low dose which could not achieve the expected outcome of relieving pain and restoring function. The patient was advised to take the medicine one hour earlier to prevent the effects of drowsiness.

Expected Outcome

Increasing the dosage of amitriptyline, the expected result is a reduction of pain, zero episodes of cramping of extremities, restored function of the limb, and improved depressive mood (Shakshuki, Yeung & Agu, 2020). Taking medicine one hour earlier will suppress the side effects of drowsiness.

Difference between Expected outcome and Actual Outcome

            During the second visit after four weeks, the patient walked in without support, no limping reports that he no longer experience cramping of extremities. The patient noticed to have put on weight after he started his treatment.

Decision #3

Decision Selected

The patient was advised to continue with the current dosage of Elavil of 125mg per day and refer the client to a life coach who will counsel him on good dietary habits and exercise.
Reasons for Selecting This Decision

This patient’s pain has gradually reduced over a period of time. During the first visit, the pain was at a score of 6 out of 10, he was walking with support and reduced cramping of extremities. A gradual increase in the dosage relieved pain and restored function. It will be a good idea to continue with the medication. Nutritionist advice on eating habits and healthy exercise will hell to stop adding weight.

Expected Outcome

The patient is expected to gain full function, to be socially interactive, and can now start working. On a scale of 1-10, the expected result was pain at around 3 out of 10. With nutritional advice, he is expected to lose weight and maintain his usual weight.

How Ethical Considerations Might Impact Treatment plan and Communication with Clients

Medical ethics are principles that govern the practice of medicine. They defend and protect human dignity. The most important for this patient is non-maleficence, informed consent, beneficence, and autonomy (Shakshuki, Yeung & Agu, 2020). The health practitioner should seek informed consent before prescribing treatment to a patient. Enlighten them about the drug expected side effects and outcomes anticipated. Ensure the treatment is given for the patient’s best interest. Let the patient decide to take the medicine.


Pain management in patients with reflex sympathetic dystrophy needs assessment of patient’s needs to make a conscious decision for the best medicine. The drug of choice is amitriptyline for pain management. It has minimum side effects like tachycardia and weight gain. The maximum effect of this drug is achieved after 1-2 weeks after the first dose.  Optimizing the Management of Bladder Pain Essay

Pain can greatly influence an individual’s quality of life, as uncontrolled pain negatively impacts mood, concentration, and the overall physical and mental well-being of clients. Although pain can often be controlled with medications, the process of assessing and treating clients can be challenging because pain is such a subjective experience. Only the person experiencing the pain truly knows the intensity of the pain and whether there is a need for medication therapies. Sometimes, beliefs about pain and treatments for pain can have an adverse effect on the provider-client relationship. For this Assignment, as you examine the interactive case study consider how you might assess and treat clients presenting with pain. Students will: Assess client factors and history to develop personalized therapy plans for clients with pain Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for pain Evaluate efficacy of treatment plans for clients presenting for pain therapy Analyze ethical and legal implications related to prescribing therapy for clients with pain To prepare for this Assignment: Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for pain and sleep/wake disorders. The Assignment Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. At each decision point stop to complete the following: Which decision did you select? Why did you select this decision? Support your response with evidence and references to the Learning Resources. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Explain any difference between what you expected to achieve with Decision (#1,2,3) and the results of the decision. Why were they different? BACKGROUND This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.” SUBJECTIVE The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). Optimizing the Management of Bladder Pain Essay


He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!” The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.” He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.” During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain. MENTAL STATUS EXAM The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented. Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy) Decision 1: Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day RESULTS OF DECISION POINT ONE: Client returns to clinic in four weeks Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning Client’s pain level is currently a 6 out of 10. The PMHNP questions the client on what would be an acceptable pain level. He states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.” He states that his pain level normally hovers around a 9 out of 10 on most days of the week before the amitriptyline was started. The PMHNP asks what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 6?” Optimizing the Management of Bladder Pain Essay

The client states, “I’m able to go to the bathroom or to the kitchen without using my crutches all the time. The achiness is less and my toes do not curl as often as they did before.” The client is also asked what would need to happen to get his pain from a current level of 6 to an acceptable level of 3. He states, “Well, that is kind of hard to answer. I guess I would like the achiness and throbbing in my right leg to not happen every day or at least not several times a day. I also could do without my toes curling in like they do. That really hurts.” Client denies suicidal/homicidal ideation and is still future oriented Decision 2: Continue current medication and increase dose to 125 mg at BEDTIME this week continuing towards the goal dose of 200 mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning RESULTS OF DECISION POINT TWO: Client returns to clinic in four weeks The change in administration time seemed to help. The client states he is not as groggy in the morning and is able to start his day sooner than before Client’s current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime. Client’s has noticed that he is putting on a little weight. When asked, the client states that he has gained 5 pounds since he started taking this medication. He currently weighs in at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother him nearly as much as it used to and his toes have only “cramped up” twice in the past month. He states that he is able to get around his apartment without his crutches and that he has even started seeing someone he met at the grocery store. The weight gain seems to bother him a lot and he is asking if there is a way to avoid it Decision 3: Continue the current dose of Elavil of 125 mg per day, refer the client to a life coach who can counsel him on good dietary habits and exercise Guidance to Student At this point, the client is almost at his goal pain control and increased functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish. Optimizing the Management of Bladder Pain Essay


Al-Singary, W.Patel, Sarkar, & Patel,(2020). Optimising the management of bladder pain syndrome. Journal of Clinical Urology,  2051415820954738.

Rahman, M. M., Azam, M. G., Garcia-Ballestas, E., Agrawal, A., Moscote-Salazar, L. R., & Khan, R. A. (2020). Letter to the Editor: Pain Management Strategy in Neurosurgical Patients During the Coronavirus Pandemic. World Neurosurgery141, 577.

Shakshuki, Yeung, & Agu, 2020). Compounded  topical amitriptyline for neuropathic pain: in vitro release from compounding bases and potential correlation with clinical efficacy. The Canadian journal of hospital pharmacy73(2), 133. Optimizing the Management of Bladder Pain Essay

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