Pain Management and Supportive Care

Symptomatic manifestations of monkeypox

Monkeypox can commonly cause severe pain and can affect vulnerable anatomic sites, including the genitals and oropharynx, which can lead to other complications. Genital and mucosal lesions can be associated with pain out of proportion to their appearance.

In a multinational report of patients with monkeypox, 13% of patients were admitted to the hospital, 30% of whom were admitted for pain management 1. In a case series from the United Kingdom, approximately 10% of patients required hospital admission, most commonly for management of rectal pain and penile swelling2. More than 40% of patients have reported mostly anogenital but also oropharyngeal mucosal lesions, resulting in severe pain at these sites1. Genital lesions, perianal lesions, and pain have also been commonly reported in monkeypox surveillance data from the United States23. These reports highlight the need for symptomatic management of pain experienced by patients with monkeypox.

Complications

Local complications of monkeypox include pain and secondary bacterial infection. To the extent possible, with appropriate use of personal protective equipment, thoroughly examine patients to identify sites of infection and assess for secondary complications. You may help prevent severe pain and other complications at vulnerable sites (e.g., proctitis causing severe pain in the rectum) by recognizing mucosal or genital lesions early. Instruct patients to report any evidence of bacterial infection or abscess formation (e.g., increasing erythema, warmth, purulent drainage) due to the risk of secondary bacterial infections of lesions associated with monkeypox, which have been a common cause of morbidity and hospital admissions14.

For treatment considerations for tecovirimat, see Tecovirimat (TPOXX) for Treatment of Monkeypox.

General considerations for pain management

Pain management strategies should be individualized and patient-centered, tailored to the needs and context of an individual patient. Healthcare professionals should assess pain in all patients with monkeypox and recognize that substantial pain may exist from mucosal lesions not evident on physical exam; validation of the pain experience can build trust in the care provider and care plan. Use topical and systemic strategies to manage pain:

• Over-the-counter medications (e.g., acetaminophen, NSAIDs) for general pain control⁵
• Topical steroids and anesthetics such as lidocaine could also be considered for local pain relief5

Use topical lidocaine or other topical anesthetics with caution on broken skin or on open or draining wounds. To minimize the risk of autoinoculation (i.e., transferring virus from a lesion to another site on the body), people with monkeypox and their caregivers should use disposable gloves when applying topical medications to lesions, then dispose of the gloves and practice hand hygiene.

Prescription pain medication

In some circumstances, prescription pain medications such as gabapentin and opioids have been used for short-term management of severe pain not controlled with other treatments including acetaminophen, NSAIDs, and/or topical medications2. Patients should be meaningfully engaged in decisions about whether to start opioid therapy.

• Using opioids for pain control should be balanced against the risk of side effects such as constipation and other risks such as potential for unintended long-term use of opioids, development of an opioid use disorder, and overdose.
• Use prescription pain medication, especially opioids, only with careful consideration of a patient's comorbid medical conditions, concurrent medications, values and preferences related to opioids, and other factors which influence the safety of such medications.
  • Consider these medications only if the benefits of opioid therapy are anticipated to outweigh the risks to the patient.
    
• Prescribe immediate-release opioids at the lowest effective dose for no longer than the expected duration of pain severe enough to require opioids.
• To prevent constipation associated with opioid use, advise patients to increase hydration and fiber intake, maintain or increase physical activity, and use stool softeners or laxatives if needed.

Proctitis

Rectal pain is a common complication of monkeypox, and proctitis has been frequently reported123. Complications of rectal involvement have included rectal perforation and perianal abscess2. Consider:

• Stool softeners for patients with proctitis to reduce pain associated with bowel movements
• Oral acetaminophen or NSAIDs for symptomatic relief
• Topical anesthetics (e.g., topical lidocaine) for symptomatic relief5

Pain from proctitis may be severe and may require prescription medications or sometimes require hospitalization for pain management. Adjunctive pain relief with neuropathic pain agents, such as gabapentin, may provide relief of proctitis symptoms based on anecdotal reports to date.

Warm sitz baths (warm bath made up of water and baking soda or Epsom salt) could be considered for symptomatic relief. While autoinoculation or person-to-person transmission of monkeypox virus has not been associated with sitz baths, we recommend that sitz baths be drained and disinfected immediately after use.

Consider secondary bacterial infections if there are progressive symptoms such as erythema, pain, or swelling, which may indicate abscess formation.

Genital lesions

Genital lesions are commonly reported among people with monkeypox123. Severe penile complications reported have included penile edema, paraphimosis, or phimosis2. Urethral involvement can occur, leading to dysuria, difficulty urinating, or hematuria. Secondary bacterial infections of the penis and scrotum have also been reported2.

While reports of monkeypox among female patients are limited, monkeypox lesions may similarly affect female genitalia, with risk of local complications such as pain, scarring, or urethral involvement678.

Managing genital lesions includes the pain control considerations outlined above and vigilance for secondary bacterial infections. In certain circumstances, you may consider topical steroids to reduce localized swelling; also consider the benefits and risks, including possible viral persistence.

Oropharyngeal lesions

Severe oropharyngeal manifestations of monkeypox virus infection have been reported, including tonsillar edema, peritonsillar abscess, and epiglottitis16. Such symptoms may limit the ability to tolerate oral therapy and maintain hydration and caloric intake.

For management of oropharyngeal symptoms, patients can consider:

• Rinsing the mouth with clean saltwater four times a day5
• Oral antiseptic (e.g., chlorhexidine mouthwash), local anesthetic (e.g., viscous lidocaine), and prescription analgesic mouthwash (sometimes called "magic mouthwash")

Healthcare providers can work with pharmacists to identify optimal ingredients (e.g., antihistamine, anesthetic) for prescription analgesic mouthwash for their patients.

Pruritis/itching

Pruritis associated with monkeypox lesions is another common symptom of the infection. Some relief and symptom improvement may come from use of:

• Oral antihistamines
• Topical agents such as calamine lotion, petroleum jelly, or colloidal oatmeal

Patients who use topical steroids for pre-existing skin conditions should avoid applying steroids to active lesions of monkeypox unless directed to do so by their treating clinician.