Wim Meinhardt1
(1)
Former Urologist Netherlands Cancer Institute, Amstelveen, The Netherlands
Wim Meinhardt
Email: wmeinhardt@ziggo.nl
18.1 The Disease
Bladder cancer may be superficial or infiltrating in the bladder wall. Age-specific incidence rates rise gradually from around age 50–54 in both males and females, with a sharper rise in males from age 60–64, to peak in both sexes in the 85+ age group. Only 5 % of patients are younger than 50 years old. The prognosis, the treatment modalities, and the sexual consequences are very different for superficial and infiltrating bladder cancers, so it is practical to discuss them separately.
Superficial bladder cancer does have troublesome recurrences and patients need checkups for several years. For the majority of patients, the prognosis is good. The several treatments and the follow-up checks are with techniques through the urethra, posing stress in some people, especially for people with sexual abuse experience. Symptoms such as blood in the urine and urge to pass urine or even urge incontinence do influence sex life; however, these symptoms ought to respond well to urologic treatment. Ideas about contagiousness of this cancer may inhibit sexual activity. So this aspect needs proper education and information.
Bladder cancer infiltrating the bladder wall is a serious threat to the life of patients. Even when no metastases are discovered at the first examinations, half of the patients may not survive 5 years. This has led to aggressive treatment proposals, with radical surgery or external radiotherapy in combination with multidrug chemotherapy. So the psychological effects of the knowledge of this prognosis can precede and accompany the serious side effects of the treatment.
18.2 The Treatment
Chemotherapy has immediate effects such as gastrointestinal upsets, vulnerability for infections, inflammation of mucous linings of the mouth and genitalia. Long-term side effects such as fatigue and hormonal disturbances have repercussions on the sexual life of patients, e.g., arousal disorders. Damage to nerves and blood vessels may cause sexual dysfunctions such as vaginal dryness and erectile dysfunction. Women in the fertile age may become menopausal after combination chemotherapy.
Operations for infiltrating bladder cancer involve removal of the bladder (cystectomy) and pelvic lymph nodes. In males, the prostate is removed and sometimes even the urethra. This means infertility, erectile dysfunction, and absence of ejaculation. In females, the urethra, part of the vaginal wall, and the uterus are removed together with the bladder. This causes infertility, vaginal dryness, dyspareunia, and an altered orgasm. On top of this, the majority of patients will get a urinary deviation with a stoma on the abdominal wall. Several innovations have been developed to alleviate this. First, let us consider the neobladder. From a segment of the intestines, a reservoir is constructed and attached to the urethra, in order to avoid a stoma and improve body image. For medical reasons, this may be suitable for about half of the cystectomy candidates. (However, data collected of 133,000 patients from several European countries and the USA showed that neobladder diversion was performed in <15 %. In pioneering centers, this was 75 % [1]). For males and females, nerve-sparing techniques have been developed. This may preserve erectile function in 30 % in selected male cases (According to age, reviewing their results in 101 patients, Walsh et al. saw recovery of sexual function in 62 % of males of 20–29 years, and only 20 % recovery in males of 70–79 years old [2]). Females may have less problems with disturbances of lubrication and orgasm. Evaluation of this type of improvements in surgical technique is challenging and the nerve-sparing techniques are not universally employed. Another development is to spare the prostate and seminal vesicles in males. (Describing 120 cases, we found erectile function preserved in 90 % of men, and antegrade ejaculation in 35.5 % [3]). In women, the uterus, the urethra, and the vaginal wall may be preserved. This will not only preserve sexual function, even pregnancies after radical surgery have been described [4]. The main drawback of this approach is the oncological side of the problem. Many urologists are not convinced that the present imaging techniques are accurate enough for a safe patient selection for this type of sexuality-preserving surgery [5].
Radiotherapy is by nature an organ-preserving option. However, function is not always preserved. Urge and blood in the urine are to be expected. Sexual function may deteriorate as well. In half of the male patients, complaints of erectile dysfunction will develop in the first year after external beam radiation. Ejaculation will be less and the ejaculate becomes a watery discharge. Fertility is lost is males and in females. When the vagina is radiated as well, some radiotherapists advise daily dilating the vagina with cones and a lubricant from the start of the radiation. However, the vaginal mucosa responds to the radiotherapy with inflammation and pain. It seems more logical to start this treatment when the acute radiation effects wear off (6–12 weeks after the end of the therapy). Since the pain should be much less after this period, compliance will be better. The main drawback of external radiotherapy for bladder cancer is the bigger risk of local recurrence.
With the poor prognosis of infiltrating bladder cancer, combination therapies are increasingly employed. This will improve survival but sexual side effects will also be on the increase.
18.3 Intervention
Since patients with superficial bladder cancer need regular checkups, there is plenty of opportunity to not only ask about urinary complaints but also about sexual dysfunction. The patient is inclined to see the biological aspects of the treatment as the cause of the problem. However, a pathophysiologic explanation is seldom obvious. In case of sexual dysfunction in patients with superficial bladder cancer, referral for sexological exploration is advised to get insight in the cause of the problem and to have the couple properly counseled.
Patients with infiltrating bladder cancer are often overwhelmed by the information on the prognosis and the drastic treatment proposals. Even so sexual function prior to the treatment should be documented and potential sexual side effects of the treatment have to be mentioned. Doing this the patient and his or her partner will realize that after recovery sexuality is an item to be discussed with the doctor or nurse. Stomal therapy nurses are in a unique position to give advice, e.g., on dealing with feeling of shame about the disfigurements. Practical advice on clothing, special small stoma appliances, and coital postures usually can only be accepted when given by a trusted care provider without time constraints. PDE5-Is are useful in patients after radiotherapy or chemotherapy, and are most effective when started at the first sign of dysfunction. After “non-nerve-sparing operations” or combination therapies, PDE5-Is are seldom effective. To treat erectile dysfunction, the self-injection therapy, a vacuum device, or a penile prosthesis can be employed. Prophylactic PDE5-I use after nerve-sparing operations and after radiotherapy is investigated for the treatment of prostate cancer. The hypothesis was that more patients would regain spontaneous erectile function [6, 7]. This has not been the case. But obviously more patients using PDE5-Is had sufficient erectile function using the drug, compared to the patients on placebo. So in analogy for patients after nerve-sparing cystoprostatectomy or radiotherapy for bladder cancer, PDE5-Is can be tried, but when not effective there is no rationale to prescribe the drugs for months in the hope that the chances for recovery will improve. (For more information on sexual rehabilitation, see Chaps. 26 and 27). There is no effective treatment for ejaculation disorders. Acceptance will be facilitated when the patient is warned beforehand. In case of female dyspareunia, a physical examination is needed to exclude a stenosis or a local recurrence of the cancer. Many patients give up on coitus after the bladder cancer treatment. This may not be an excuse to avoid the subject, since one does not know beforehand which patients will do so. Irrespective of age or marital status, we never met a patient who was offended when the question of sexual function was raised.
References
1.
Hautmann RE, Abol Enein H, Lee CT. Urinary diversion: how experts divert. Urology. 2015;85:233–8.CrossRefPubMed
2.
Schoenberg MP, Walsh PC, Breazeale DR, et al. Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10 years follow-up. J Urol. 1996;155:490–4.CrossRefPubMed
3.
Mertens LS, Meyer RP, de Vries RR, et al. Prostate sparing cystectomy for bladder cancer: 20 years single centre experience. J Urol. 2014;191:1250–5.CrossRefPubMed
4.
Nunnunk CJ, de Vries RR, Meinhardt W, et al. Pregnancy following sexuality preserving cystectomy for bladder cancer (Dutch). Ned Tijdschr Geneeskd. 2011;155:A2820.
5.
Hautmann RE, Stein JP. Neobladder with prostate capsule and seminal sparing cystectomy for bladder cancer: a step in the wrong direction. Rev Urol Clin North Am. 2005;32:177–85.CrossRef
6.
Pisansky TM, Pugh SL, Greenberg RE, et al. Tadalafil for prevention of erectile dysfunction after radiotherapy for prostate cancer: the Radiation Therapy Oncology Group [0831] randomized clinical trial. JAMA. 2014;311:1300–7.CrossRefPubMedPubMedCentral
7.
Montorsi F, Brock G, Stolzenburg JU, et al. Effects of tadalafil treatment on erectile function recovery following bilateral nerve-sparing radical prostatectomy: a randomised placebo-controlled study (REACTT). Eur Urol. 2014;65:587–96.CrossRefPubMed