July 27, 2022
As the 2022 monkeypox outbreak continues to accelerate in the United States, the Centers for Disease Control and Prevention (CDC) is learning that a large number of persons presently affected are experiencing anogenital lesions (>70%) as well as mucosal lesions (>40%), which can be anogenital (>65%) or oral (>20%). 1 Clinical providers indicate that these lesions— especially oral, genital, and anal mucosal lesions that may not be overtly visible on initial physical exam—are associated with pain out of proportion to expectation based on clinical experience with sexually transmitted diseases in the same anatomic areas, such as herpes simplex virus and lymphogranuloma venereum.
Proctitis, occasionally with bleeding, has been described, with severe lancinating pain that makes defecation very painful or impossible. Dysuria can limit urination and may require catheterization; severe balanitis and phimosis have also been described. Oropharyngitis has resulted in limited oral intake requiring nasogastric intubation. Pain control has been a common reason for hospital admission.1-3
Relief of pain is an essential part of caregiving. Studies are underway to evaluate antiviral medications to treat monkeypox virus infection, including manifestations of pain. These drugs include tecovirimat (TPOXX®), which is available through an expanded access investigational new drug protocol. CDC and the Food and Drug Administration recently streamlined this protocol to facilitate compassionate use, and with the National Institutes of Health are investigating tecovirimat’s safety and efficacy in humans.4 We hope that these drugs may speed clinical recovery and shorten the duration of patient suffering.5 In the interim, pain management should remain a cornerstone of treatment for monkeypox virus infection.
CDC recommends the following:
- Assess pain in all patients with monkeypox virus infection.
- 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. These can include sitz baths and salt-water gargles, topical steroids and lidocaine, over-the-counter pain relievers (e.g., non- steroidal anti-inflammatory drugs, acetaminophen), and ultimately prescription pain relievers (e.g., gabapentin, opioids) as indicated by need for pain control.
- Seek consultation with pain specialists for refractory cases.
- Use stool softeners for proctitis, especially if opioid analgesia is prescribed.
- Stay in contact with patients to regularly assess their pain control and adjust pain management as indicated.
- Monkeypox treatment6 may be indicated for pain control.
We have much to learn about the novel clinical presentations of monkeypox in the 2022 outbreak. The experiences of healthcare providers on the front lines are critical for building the evidence base to inform optimal approaches to pain management. To this end, CDC encourages providers and researchers to document and report the patient pain experience to determine the incidence of pain, predictive factors for developing pain, and successful methods to control pain associated with monkeypox.
We look forward to working with you to provide the guidance necessary for healthcare providers and clinicians to address this outbreak. No single group can do this alone, and we thank each of you for your effort and commitment to effective patient care.
Rochelle P. Walensky, MD, MPH
- Thornhill JP, Barkati S, Walmsley S, et al. and the SHARE-net Clinical Group. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. 2022 Jul 21. doi: 10.1056/NEJMoa2207323. Epub ahead of print. PMID: 35866746.
- Girometti N, Byrne R, Bracchi M, et al. Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis. Lancet Infect Dis. 2022 Jul 1:S1473-3099(22)00411-X. doi: 10.1016/S1473-3099(22)00411-X. Epub ahead of print. PMID: 35785793.
- Investigation into monkeypox outbreak in England: technical briefing 4 - GOV.UK (www.gov.uk) at https://www.gov.uk/government/publications/monkeypox-outbreak-technical…- monkeypox-outbreak-in-england-technical-briefing-4 (last accessed July 27, 2022)
- https://www.cdc.gov/poxvirus/monkeypox/clinicians/obtaining-tecovirimat… (last accessed July 27, 2022)
- Adler H, Gould S, Hine P et al. and the NHS England High Consequence Infectious Diseases (Airborne) Network. Clinical features and management of human monkeypox: a retrospective observational study in the UK. Lancet Infect Dis. 2022 Aug;22(8):1153-1162. doi: 10.1016/S1473-3099(22)00228-6. Epub 2022 May 24. Erratum in: Lancet Infect Dis. 2022 Jul;22(7):e177. Erratum in: Lancet Infect Dis. 2022 Jul;22(7):e177. PMID: 35623380; PMCID: PMC9300470.
- https://www.cdc.gov/poxvirus/monkeypox/treatment.html (last accessed July 27, 2022)