Clinical Considerations for Pain Management of Monkeypox

Who this is for: Healthcare professionals providing care for people with monkeypox.

What this is for: Considerations for pain management in people with monkeypox.

How to use: This information is intended as an aid for healthcare facilities and healthcare professionals developing plans for monkeypox treatment.

Key Points

  • Pain is a common symptom of monkeypox virus infection, and specific considerations regarding management of pain as well as specific sites or complications of disease (e.g., proctitis) are reviewed.

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.

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 swelling (2). Mucosal lesions have been reported in more than 40% of patients, predominantly anogenital but also oropharyngeal, resulting in severe pain at these sites (1). Genital lesions, perianal lesions, and pain have also been commonly reported in monkeypox surveillance data from the United States (23). Genital and mucosal lesions can be associated with pain out of proportion to their appearance. These reports highlight the need for symptomatic management of pain experienced by patients with monkeypox.

Complications of monkeypox

Local complications of monkeypox include pain and secondary bacterial infection. To the extent possible, with appropriate use of personal protective equipment, patients should be examined thoroughly to identify sites of infection and assess for secondary complications. Early recognition of mucosal or genital lesions may help prevent severe pain and other complications at vulnerable sites (e.g., proctitis causing severe pain in the rectum). Patients should also be instructed 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 admission (1, 4).

For treatment considerations for tecovirimat, see Guidance for Tecovirimat Use Under Expanded Access Investigational New Drug Protocol during 2022 U.S. Monkeypox Cases.

General Considerations for Pain Management

Healthcare professionals should assess pain in all patients with monkeypox virus infection 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. Topical and systemic strategies should be used to manage pain. Pain management strategies should be individualized and patient-centered, tailored to the needs and context of an individual patient.

Over-the-counter medications (e.g., acetaminophen, NSAIDs) are recommended for general pain control for patients with monkeypox (5). Topical steroids and anesthetics such as lidocaine could also be considered for local pain relief (5). Topical lidocaine or other topical anesthetics should be used 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), persons with monkeypox virus infection or their caregivers should use disposable gloves when applying topical medications to lesions, then dispose of the gloves and practice hand hygiene.

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 medications (2). Use of 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 of prescription pain medication, especially opioids, should be undertaken 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, and should be considered only if the benefits of opioid therapy are anticipated to outweigh the risks to the patient. Patients should be meaningfully engaged in decisions about whether to start opioid therapy. If opioids are prescribed, immediate-release opioids at the lowest effective dose should be prescribed for no longer than the expected duration of pain severe enough to require opioids. To prevent constipation associated with opioid use, patients should be advised to increase hydration and fiber intake and to maintain or increase physical activity; stool softeners or laxatives might be needed. See CDC’s Opioid Prescribing Guideline Resources.

Proctitis

Rectal pain is a common complication of monkeypox infection, and proctitis has been frequently reported (1-3). Complications of rectal involvement have included rectal perforation and perianal abscess (2).

Stool softeners should be considered for patients with proctitis to reduce pain associated with bowel movements. Oral acetaminophen or NSAIDs can provide symptomatic relief. Topical anesthetics (e.g., topical lidocaine) may offer symptomatic relief (5). 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 (see Disinfecting Home and Other Non-Healthcare Settings).

Secondary bacterial infections have been reported and should be considered 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 monkeypox (1-3). Severe penile complications reported have included penile edema, paraphimosis, or phimosis (2). Urethral involvement can occur, leading to dysuria, difficulty urinating, or hematuria. Secondary bacterial infections of the penis and scrotum have also been reported (2).

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 involvement (6–8).

Management of genital lesions includes general pain control considerations outlined above, and vigilance for secondary bacterial infections. In certain circumstances, topical steroids could be considered for reduction in localized swelling, although the benefits and risks, including possible viral persistence, should be considered.

Oropharyngeal lesions

Severe oropharyngeal manifestations of monkeypox virus infection have been reported, including tonsillar edema, peritonsillar abscess, and epiglottitis (1, 6). 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 day (5). Oral antiseptic (e.g., chlorhexidine mouthwash), local anesthetic (e.g., viscous lidocaine), and prescription analgesic mouthwash (sometimes called “magic mouthwash”) can also be considered. There are different potential ingredients (e.g., antihistamine, anesthetic) for prescription analgesic mouthwash; healthcare professionals can work with pharmacists to identify the optimal ingredients for their patients.

Pruritis / Itching

Oral antihistamines may provide some relief of pruritis associated with monkeypox lesions. Topical agents such as calamine lotion, petroleum jelly, or colloidal oatmeal may also improve symptoms.

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.

References
  1. Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries – April-June 2022 [published online ahead of print, 2022 Jul 21]. N Engl J Med. 2022;10.1056/NEJMoa2207323.
  2. Patel A, Bilinska J, Tam J C H, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ2022;378:e072410.
  3. Philpott D, Hughes CM, Alroy KA, et al. Epidemiologic and Clinical Characteristics of Monkeypox Cases — United States, May 17–July 22, 2022. MMWR Morb Mortal Rep. ePub: 5 August 2022.
  4. Moschese D, Giacomelli A, Beltrami M, et al. Hospitalisation for monkeypox in Milan, Italy [published online ahead of print, 2022 Aug 4]. Travel Med Infect Dis. 2022;49:102417.
  5. World Health Organization. Clinical management and infection prevention and control for monkeypox: Interim rapid response Guidance. https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1. Accessed July 18, 2022.
  6. UK Health Security Agency. Monkeypox outbreak: technical briefings. Available at: https://www.gov.uk/government/publications/monkeypox-outbreak-technical-briefings. Accessed August 9, 2022.
  7. Rehlan V, Sahay RR, Shete AM, et al. Clinical presentation, viral kinetics and management of human monkeypox cases from New Delhi, India 2022, 24 August 2022, PREPRINT. [https://doi.org/10.21203/rs.3.rs-1986039/v1].
  8. Ogoina D, James IH. (2022).  (2022). Monkeypox among linked heterosexual casual partners in Bayelsa, Nigeria. 24 August 2022, PREPRINT. [https://doi.org/10.32388/2Z4ZH4.2].