Kevin W. A. Göttgens1 and Stéphanie O. Breukink2
(1)
Surgical Resident, Catharina Hospital Eindhoven, Maastricht, The Netherlands
(2)
Colorectal Consultant, Maastricht University Medical Center, Maastricht, The Netherlands
Stéphanie O. Breukink
Email: s.breukink@mumc.nl
21.1 General Consequences of Diagnosis and Treatment
Colorectal cancer is worldwide the third most common cancer in men and the second most common in women. It accounts for about 10 % of cancer cases. The incidence of anal cancer is much lower, and there is a higher risk in patients with immunodeficiency or infection with HIV and some strains of HPV (human papillomavirus). Diagnosis and subsequent treatment of both colorectal and anal cancer can be considered as major life events, with significant effects on the psycho-sexual functioning of both the patient and the partner (caregiver). Fear, questions, isolation, and uncertainty were preoperatively identified as major issues for patients. A change in family structure and a decrease in family and relationship functioning, social support, and emotional stress were seen in both patients and spouses up to 1 year after diagnosis. It has also been shown that, regarding sexual functioning, both positive and negative changes can occur for the caregiver. Some of the caregivers seem to lose desire, but for others sexual relations seem to intensify due to an increase in bonding with their partner [1].
Treatment for colon cancer consists mainly of surgical resection and is often combined with adjuvant chemotherapy in case of lymph node involvement. Partial colectomies are the normal resections for colon cancer. A stoma is sometimes needed after resection of colon cancer.
Rectal cancer is often neoadjuvantly treated with local radiotherapy or radiochemotherapy, followed by surgery. For rectal cancer, total mesorectal excision of the rectum is performed. In case of a high rectal tumor, a low anterior resection (LAR) is performed. For rectal cancer, a temporary deviating stoma can be used to reduce the consequences of anastomotic leakage, or a definitive stoma is used after a low anterior resection. If the tumor is very distal that the anus cannot be spared, an abdominoperineal resection will be performed. A permanent end colostomy is unavoidable in this operation. Nowadays, the treatment of anal cancer consists mostly of radio(chemo) therapy and sometimes local surgical resections.
The various consequences of the different treatment modalities on sexual function can often not be distinguished, and probably, the combination of these treatments is responsible for disturbances in this area.
21.2 Effects of Radiotherapy
Sexual dysfunction may occur after treatment with radiotherapy in the pelvic area and is often a multifactorial problem, involving fibrosis, vascular toxicity, and neurotoxicity [2]. Radiation damage to the cavernous arteries can cause erectile dysfunction (ED), whereas radiation damage to the seminal vesicles may be a reason for ejaculatory dysfunction (EJD) [3].
In the first year after radiation therapy, sexual functioning was comparable to patients without radiation therapy. Radiation damage takes much time and a significant decline in sexual functioning in males was seen after 24 months. There are also hypotheses regarding the effect of radiotherapy on testicular function. During long-course radiotherapy, the testes can be exposed to direct and/or scattered radiation, possibly resulting in testicular dysfunction with lowered serum testosterone levels compared to pretreatment values and compared to patients treated with surgery only. A decrease in testosterone levels (<8 nmol/L) may precipitate testosterone deficiency leading to specific symptoms like impaired physical, psychological, and sexual function. Female sexual functioning may also be compromised by radiotherapy [4]. Vaginal epithelium is lost following an acute reaction on radiotherapy. This epithelial lining is restored within 3–6 months; however, the histological pattern of this epithelium is different with more hyalinization and collagenization, fibrosis, and obliteration of small vessels and glands. This will result in decreased blood flow in the vagina, less lubrication, loss of elasticity, and dyspareunia.
21.3 Effects of Chemotherapy
Specific effects of chemotherapy on sexual functioning are difficult to investigate and not much data is available. However, it is reasonable to conclude that chemotherapy itself and supporting medication may be associated with a decline in sexual functioning, at least temporarily. In males, ED may occur during chemotherapy cycles, and sexual desire may be temporarily lowered with recovery between the cycles. Some chemotherapy may result in permanent damage to nerves controlling erection and emission.
In women, chemotherapeutic agents may results in permanent or transient amenorrhea. Even when the monthly cycles return, premature ovarian failure may be a long-term result. For both men and women, chemotherapy may cause fatigue, hair loss, and weight changes. Part of the fatigue and loss of sexual desire can also be the result of damage to the gonads and adrenals with accompanying lowering of the androgen levels. All of these effects together can change a person’s sexual response, or change a patient’s motivation and ability to engage in sexual activities. Besides, supporting medication like opioids, antidepressants, antiemetics, and antianxiety medication may cause sexual problems in both men and women (see corresponding chapters).
21.4 Effects of Surgical Resection
The specific effects of surgical resection on sexual functioning are probably the most investigated part of the treatment for colorectal cancer. The confined anatomical space of the pelvis makes rectal surgery more demanding than colon surgery. Similar anatomical challenges can be found in treating anal cancer when a larger resection has to be performed. In males, ED and EJD are well-known problems after total mesorectal excision (TME). These problems are related to surgically induced pelvic autonomic nerve damage.
After TME, ED is found between 11 and 25 % and EJD between 19 and 54 % [5].
Up to now, regarding sexual dysfunction, no significant differences were found between laparoscopic or open surgery [6]. Some studies report more dysfunction after open resection, but others after laparoscopic resection. This phenomenon could be explained by the fact that laparoscopic surgery may lead to more nerve damage if the surgeon is still in his learning curve, as laparoscopic surgery is technically more demanding than open surgery. After abdominal-perineal resection (APR), sexual function seems more compromised compared to lower anterior resection (LAR); this could be explained by the more extended resection with APR [7].
Another fact to take into account is the use of preoperative radiotherapy. As explained before, radiotherapy can result in fibrosis with inclusion of the mentioned nerves, but also vascular damage and neurotoxicity. Dissection is often more difficult after radiotherapy, with increased risk of nerve damage. In women, damage to autonomic nerves in the pelvis is likely to cause sexual dysfunction after rectal surgery. The parasympathetic nerves are responsible for the increase in blood flow to vagina and vulva (with vaginal lubrication and swelling of the labia and clitoris). Emission and rhythmic contractions of the genital ducts and organs during orgasm are caused by sympathetic nerves. When the nerve-sparing TME was introduced, this resulted in preserved female sexual functioning, proving the importance of the mentioned nerves [8]. Besides nerve damage, another important issue may be the scarring and fibrosis around the vagina after treatment. This could contribute to dissatisfaction during or avoidance of sexual intercourse. Low dissection with full mobilization through the rectovaginal septum may be the cause of this scarring. Several studies show that women feel their vagina as inelastic and too short during intercourse. Sometimes, it may be necessary to remove the whole or part of the vagina. It is possible to do a vaginal reconstruction, and this option should be provided to all patients after adequate preoperative counseling. Perioperative counseling and follow-up by an experienced professional (sexology, gynecologist, surgery or nursing) is needed. Expectations by the patient of this surgery need to be adequately discussed preoperatively.
Regarding surgery for anal cancer is less known. As previously explained, large anorectal resections are nowadays rarely performed, and mostly, the disease is treated with radio(chemo) therapy. However, smaller tumors can be treated with local radical resection. Specific data regarding sexual functioning after these resections is not available. It would, although, be reasonable that resections around the anus and anal canal can influence bodily image. This might specifically account for patients having anal intercourse. Besides body image issues, anal intercourse could be problematic due to stenosis, scarring, pain, and sensibility issues and because of nerve damage.
Specific effects of higher parts of colon cancer surgery on sexual function are rare. Mostly, patients with colon cancer reporting sexual dysfunction have issues because of effects of radiotherapy and/or chemotherapy, or having a stoma.
21.5 Specific Effects of a Stoma
A stoma is by many patients seen as a bodily mutilation. Next to requiring daily care, accidents and leakage may occur, skin irritation can be a problem, and flatulence happens completely without control. If a stoma is not constructed at the ideal location, as sometimes has to be done during acute operations, leakage and skin irritation can be more prevalent. Long-term problems like stoma prolapse and parastomal herniation are also seen. This, and the stoma itself, can have a negative influence on physical attractiveness. In studies, patients showed significantly altered bodily image, and they reported a decrease in attractiveness [9]. However, body image seems to restore over time. This restored body image may be attributed to the initial negative influence of the cancer diagnosis and pending stoma, and a rise after the actual operation. Moreover, beneficial to the acceptance and overall body image are coping and acceptance with the situation after surgery. Using humor can be an important strategy as well as emphasizing positive effects of a stoma (relief of symptoms, control over bowel function, possibility of continuity surgery, having undergone curative treatment, etc.). Some patients have left or were left by their partner because of the stoma. In general, however, partners were supportive and acceptant towards the stoma. Specifically towards sexual functioning, patients, or their partners, reported a lack of desire because of the stoma. Many patients continued intimate and sexual relations, although often after a long period of inactivity.
Preoperative education of the patient and adequate marking of the stoma site are important for postoperative acceptance and to lower anxiety. A good relationship with the ostomy nurse allows openly discussion regarding sexual function and can be beneficial. Some useful tips to give to patients with stomas are to empty the stoma bag before intercourse. It is sometimes wise to tightly fold the new stoma bag and tape it to the skin to reduce flatulence and to avoid filling of the bag, since after orgasm the colon tends to react with peristalsis. This could be caused by the oxytocin increase during high arousal and orgasm, which is known to stimulate colonic activity [10]. Often patients ask about what positions are safe; one could inform them that when the stoma bag has been emptied and folded every position should be possible and safe. Touching the stoma should not be a problem when fully healed after the operation. Using the stoma for penetration is not to be recommended. This could cause damage to the mucosa and laceration between the stoma and the skin.
21.6 Counseling
An important part of the treatment of colorectal and anal cancer is perioperative counseling, as has been mentioned already briefly. Patients need to be counseled on treatment and outcome of the malignancy, but they must be well-informed on factors like postoperative quality of life, living with a stoma, sexual function after treatment, and changes in any of these that might be expected in the long term. Whereas most patients in the beginning of their treatment process mainly focus on the cancer, it is important that their practitioners provide the necessary information about the treatment process and ensure that enough postoperative counselling is available.
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