Sildenafil for the Management of Refractory Malignant Ischemic Pain and Edema: A Case Report.

Abstract

Unresectable metastatic urothelial carcinoma presenting with mixed arterio-venous occlusion poses a severe therapeutic challenge, often resulting in limb-threatening ischemia and refractory pain. A 50-year-old Hispanic woman with stage IVB urothelial carcinoma developed severe right lower extremity ischemic pain and edema secondary to tumor encasement of the pelvic vasculature. Following progressive exacerbations, the patient suffered with refractory of pain despite aggressive escalation of opioid with adjuvant regimen, radiation therapy with systemic steroid, and lumbar epidural injection. She was successfully treated with off-label oral sildenafil. The targeted application of sildenafil (a phosphodiesterase type 5 inhibitor) leveraged localized hemodynamic physiology to reduce arteriolar inflow resistance and widen the arteriovenous pressure gradient. This approach achieved rapid symptom resolution and facilitated significant opioid de- escalation, highlighting the potential for precision, physiology-based palliative care in complex malignant pain syndromes.