Cancer, Intimacy and Sexuality

12. The Sexual Consequences of Cancer Surgery

Marjan Traa^{1, 2} , Harm Rutten^{3, 4} and Brenda den Oudsten¹

(1)

CoRPS – Center of Research on Psychology in Somatic Diseases, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands

(2)

Department of Medical Psychology, St. Elisabeth Hospital, Tilburg, The Netherlands

(3)

Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands

(4)

GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands

Marjan Traa (Corresponding author)

Email: M.J.Traa@uvt.nl

Brenda den Oudsten

Email: B.L.denOudsten@uvt.nl

Sexual problems can be present before being diagnosed with cancer but can also develop or aggravate after diagnosis (see Chap. 9), during treatment (see Chaps. 10, 11, 12 and 13), or after treatment. Sexual problems can develop even if the reproductive organs are not involved in treatment. For most cancer types or stages, surgery is an important part of the multidisciplinary treatment. In order to increase the probability that a radical resection can be performed, and sometimes even allow more limited surgery, radiotherapy and/or chemotherapy can precede surgery. After surgery, some patients require additional chemotherapy in order to reduce the risk of developing a local occurrence or metastatic disease. This chapter provides a general overview of the sexual consequences of cancer surgery across time. Some examples are shown in Table 12.1, though a more detailed description of cancer-type-specific consequences are presented in Chaps. 15, 16, 17, 18, 19, 20, 21, 22 and 23.

Table 12.1

Examples of potential sexual consequences of cancer surgery

12.1 Direct Effects of Cancer Surgery on Sexual Function

Surgery can directly compromise sexual function, that is the physical ability to adequately engage in the various phases of the sexual response cycle (desire, excitement, orgasm, and resolution). The extent to which this occurs depends on the tumor site and type of surgery. Sexual function can be particularly harmed when the tumor is located in the pelvis. In the pelvic cavity the nerves involved in sexual function are closely related to the organs (e.g., prostate, uterus, cervix, and rectum) and lymph nodes. Dissecting the tumor and, if needed, the associated lymph nodes can cause damage to these nerves. For men, nerves in the pelvic area control the blood flow to the penis and the ejaculation process. Nerve damage can therefore lead to disturbed erectile and/or ejaculatory function (e.g., retrograde ejaculation – in which the ejaculate ends in the urinary bladder) [1, 2]. In addition, damage to the anatomical structure, for instance, after penile cancer, can cause painful erections. For women, surgical nerve damage, for example, after a radical hysterectomy, can impede lubrication or cause dyspareunia [1, 3]. In addition, gynaecological or bladder cancer surgery can lead to shortening of the vagina and bladder-, gynaecological, and rectum cancer surgery can cause narrowing of the vagina due to a loss of elasticity, which can affect lubrication or lead to a genitopelvic pain/penetration disorder [1, 3].

12.2 Indirect Effects of Cancer Surgery on Sexual Function

Cancer surgery can also have indirect effects on sexual function [1–3]. First, the uncertainty whether surgery will be successful in a potentially fatal disease, the fear for the surgery itself, and/or questions about function loss after treatment can negatively interfere with sexual function and behavior. In addition, local surgical complications, such as pain, bleeding, and infection, may interfere with the ability to engage in sexual activities. Surgery can also cause disfigurement, such as scarring or a stoma, which can cause both practical and psychological barriers for intimacy. Loss of an erogenous zone, for instance, after the amputation of a breast, can impede pleasurable sexual activities due to decreased sexual stimulation. In some cases, the amputation of a limb is needed, which can hinder the capability to adequately engage in sexual activities. Furthermore, urinary- or fecal incontinence may occur after pelvic surgery. Incontinence can complicate sexual activities by demanding scheduling, but might also make couples more reluctant to engage freely in sexual activities. Potentially equally intrusive can be an altered saliva production after head and neck cancer or shortness of breath after lung cancer surgery. Lymphedema (i.e., fluid retention and tissue swelling common after lymph node removal) can cause functional problems and pain. Especially pain has the potential to spoil enjoyment of sexual activities. For women, treatment for most gynaecological cancers and for some types of bladder cancer requires removal of the ovaries. This castration will result in hormonal changes and will induce early menopause in premenopausal women. This premature ovarian failure can affect sexual desire and arousability. For men, bilateral orchiectomy for testicular cancer results in testosterone deprivation, which (without testosterone replacement) will cause loss of sexual desire and other hypogonadal complaints.

12.3 Effects of Cancer Surgery on the Sexual Identity

Changes in the sexual identity can influence patients’ willingness to engage in sexual activity (i.e., sexual withdrawal), but may also decrease feelings of desire or arousal. A patient’s sexual identity can be affected in several ways. The most reported effects are changed sense of masculinity and femininity, changes in body image, and reproductive issues [4, 5]. A patient may feel less feminine or masculine if surgery entailed removal of sex organs, if surgery caused sexual dysfunction, or due to other physical alterations such as scarring or a stoma. The way patients perceive their physical appearance (i.e., their body image) is highly subjective and can be influenced not only by the above-described physical alterations, but also by psychosocial influences, such as depressive or anxious symptoms and/or an altered relationship with the partner (e.g., decreased intimacy). These psychosocial factors may even influence body image to a larger extent than the changes in physical appearance. Moreover, surgery for gynaecological, bladder-, or testicular cancer can reduce fertility. Becoming incapable to conceive a child can be a general stressor with major influence on the sexual identity.

12.4 Effects of Surgery on the (Sexual) Relationship

When discussing the consequences of cancer surgery on sexuality, it is important to keep in mind that these consequences not only affect the patient but also the partner and potentially the (sexual) relationship [6–8]. The extent to which the sexual consequences of surgery will become problematic depends not only on the couples’ sex life prior to diagnosis and their general relationship functioning, but also on an (in) compatible degree of interest in continuing or redefining the sexual relationship. Reestablishing a satisfactory sexual relationship after cancer surgery may be challenging. Even if patients are physically able to engage in sexual activities, patients and partners may still deliberately avoid sexual intimacy. Couples need to address several issues (e.g., a partner’s fear to hurt the patient, patient’s altered body image, and changed roles within the (sexual) relationship). If sexual intercourse is no longer possible, then couples may explore or increase alternative ways to maintain intimacy such as hugging, kissing, or caressing. Although couples often report that being faced with cancer has brought them closer together in general, a phenomenon known as posttraumatic growth, some couples may still need psychosexual care to find a new satisfactory status quo in their (sexual) relationship [9]. In Chap. 25, more detailed information is provided on the way couples cope with the sexual consequences of cancer, how they deal with potential problems, and the potential role of psychosexual (couples) counseling.

12.5 Concluding Remarks and Recommendations for Practice

This chapter described the direct and indirect effects on sexual function, the sexual identity, and the sexual relationship separately. However, effects may influence each other. Changes in the sexual identity or (sexual) relationship can have an indirect influence on sexual function, while the (in) direct effects on sexual function can also influence the sexual identity and the (sexual) relationship. Another important note concerns the fact that most patients diagnosed with cancer receive multidisciplinary treatment. Combined treatment effects make it difficult to determine the unique sexual consequences of a particular treatment modality, such as surgery. Moreover, even if the impact of surgery on sexuality is known, it remains difficult to determine the actual consequences on a patient’s/couples’ sexual life as this depends not only on medical but also on psychological and interpersonal factors [10]. Psychological and interpersonal factors, such as fear of recurrence, depressive symptoms, and relationship dynamics should not be overlooked as major influences on sexuality. Regardless, the sexual concerns that can arise after cancer surgery postulate the need to further develop strategies that (i) minimize sexual dysfunction caused by surgical treatment (e.g., laparoscopic surgery, nerve-sparing techniques, and fertility-preserving techniques) and (ii) provide adequate psychosexual care to patients and partners, if needed (see Chap. 25).

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