Management of urinary tract symptoms
Vesicovaginal or Ureterovaginal fistulae
The classic management of these fistulae have included diversion to bowel conduits or complicated repairs, neither of which is appropriate in palliative care settings with gynaecological cancers.
Options include the use of urethral catheters or percutaneous nephrostomies (25). Of these, the preferred management would be a urethral catheter if it is able to functionally manage output and eliminate most of the vaginal discharge.Urinary retention
While both indwelling catheters and repeated catheterization may treat retention, practically the less management that is required in palliative end of life care the better. Hence, indwelling catheters are the most commonly used technique for relief of symptoms from retention. For individuals with cancer blocking the urethra (e.g. vulvovaginal cancers), consideration of a suprapubic catheter placement are warranted as a urethral catheter may be both difficult to place and also cause unwanted additional bleeding and local pain. It is important to note that while indwelling catheters are accompanied by colonization of the bladder, suppressive antibiotics are not indicated and even treatment for true infections should be based on symptoms.
Ureteral obstruction and renal failure
Acute and chronic ureteral obstruction leading to renal failure is common in late-stage gynaecological malignancies. While these can mechanically be relieved with ureteral stents or percutaneous nephrostomies, the benefit of relief and improvement of renal function needs to be considered in the context of their disease progress and overall comfort. Chronic renal failure and uraemia add symptoms that can increase the burden of symptoms to be palliated, for example, increased neuropathy, sensory changes and obtundation, increased musculoskeletal cramping and even seizures, fluid retention, and nausea with abnormal electrolytes.
The benefit and risks of an intervention have to be weighed against the anticipated survival of individual patients. If it is a few weeks, there is little benefit from relief of the obstruction during that small window, and potential harm with enhanced pain sensation. Furthermore, dialysis is rarely warranted even for other acute causes of renal failure without obstruction. The only exception would be an acute, reversible event in a patient for whom a single episode of dialysis might treat the underlying renal injury and who would benefit symptomatically from that relief.Urinary tract infections (acute, chronic)
Urinary tract infections (UTIs) can be secondary to many of the entities previously discussed—retention, obstruction, fistula, as well as prior history and other comorbidities. When to treat in the palliative care setting is an important question and revolves around comfort and goals of care. If the patient is having symptoms directly referable to a UTI, then a simple dipstick can confirm the source of the new pain symptoms and antibiotic therapy considered if it will improve pain and overall quality of life. If a woman has an asymptomatic UTI found in the course of other activities, it should not be treated—just as it should not be treated in older women with no other symptoms (26).
Pelvic bleeding and symptoms
Pelvic bleeding can be a major source of anxiety for the patient and her family. Fears of ‘letting her bleed to death' or not knowing any way to manage a haemorrhage if it occurs can overwhelm patients and care givers. In fact, one option for pelvic bleeding in the setting of end of life palliative care is local management (pads) alone if it is low volume. Heavy or repeated bleeding can be limited with a short course of antihaemorrhagic medication, such as tran- examic acid. Other interventions for major haemorrhage depend on the goals of treatment and overall quality of life and survival if the haemorrhage is treated. These discussions can be very difficult as the very human fear of bleeding doesn't disappear simply with the horizon to death being close. Local pelvic packing with haemostatic agents is always a consideration particularly if it might be both effective and short in duration given the pelvic pressure and associated pain. If, however, bleeding is not relieved with this, is causing significant quality of life issues, and the time to death is likely to be prolonged, consideration for pelvic vessel embolization is an option. Finally, high-dose, short-interval radiation for palliation of bleeding can be attempted even in the setting of prior pelvic radiation (given that the long-term effects of radiation are not a consideration).