will rectal cancer treatment affect my sexuality?

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Sex After Rectal Cancer Part of Fight Colorectal Cancer’s Monthly Patient Webinar Series

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Dr. Joel Tepper, MD, PhDHector MacLean Distinguished Professor

of Cancer Research in Radiation Oncology 

Rectal Cancer: Sexual Dysfunction

Joel E. Tepper, MD

Department of Radiation Oncology

UNC Lineberger Comprehensive Cancer Center

Rectal Cancer

• Occurs in pelvis close to many components of the reproductive system

• Organs, nerves and vasculature are at risk from tumor and therapy

• Can be effected by surgery, radiation therapy and chemotherapy

Anatomy of the Female Pelvis

Pelvic Nerve Anatomy

Sexual Dysfunction- Tumor

• Rectal cancer does not commonly directly effect the reproductive system or its functions

• Invasion of vagina, uterus, ovaries, prostate all can occur– Vaginal involvement most common site of

invasion in rectal cancer– Proximity of anterior rectal wall to the posterior

vaginal wall

Rectal Cancer

• Baseline sexual activity is variable• One study showed that 80% of male

patients and 50% of female patients were sexually active at the time of diagnosis– Age is the strongest factor

• A high percentage of female patients are post-menopausal, so reproductive capability is not important

Sexual Function

• Can be effected by emotional factors as well as physical factors– Reduced self esteem– Lessened body image– Fatigue– Depression– Change in inter-personal relationships

Sexual activity of (A) male and (B) female patients who were sexually active preoperatively.

Marijnen C A et al. JCO 2005

Males

• 1/3 of male patients did not become sexually active after therapy

• Primary sexual issues are erectile dysfunction and ejaculatory problems

• Strongly associated with older age and developing an anastomotic leak– Peri-operative blood loss also related

• Worsening of erectile function is common

Females

• Approximately 60% sexual dysfunction after therapy (surgery, RT, chemo)

• Dyspareunia and vaginal dryness most prominent symptoms

• Decreased libido, altered orgasms• Vaginal stenosis• Loss of ovarian function

Surgery

• Tumors located lower in the pelvis are more likely to have post-surgical SD

• Surgical resection of pelvic organs can occur for an extensive tumor, but this is uncommon– Vagina, uterus, prostate

• Organ resection and nerve injury are the most likely surgical causes of sexual dysfunction

• TME produces less surgical toxicity than prior operations

MRI-Phased Array Coil

T3N1Beets-Tan, Lancet-2001

LAR Specimen Assessment

Shiny Visceral

Mesorectal Fascia

A. Cohen, Univ of Kentucky

Surgery- Males

• Erectile dysfunction• Ejaculation disorders

Radiation Therapy

• Studies in the literature have focused heavily on radiation effects

• Known impact of radiation therapy on multiple areas that could impact sexual function

Classical AP-PA field

Classical lateral fields

Radiation Therapy- Females

• Cessation of ovarian function in young patients

• Incompetent uterus for child-bearing• Vaginal dryness• Vaginal stenosis

Radiation Therapy- Males

• Difficulties with erection• Decreased sperm count• Decreased semen production• Altered testosterone production• Ejaculatory difficulties

Chemotherapy

• Difficult to sort out independent role of chemotherapy in treatment as almost all patients have received both radiation therapy and surgery

• Oxaliplatin can cause testicular dysfunction• Temporary or permanent loss of menstruation• Early ovarian failure• Supportive medications can impact sexual

function

Prevention of SD

• Defining appropriate therapy- don’t over-treat

• Have surgery done by an experienced colorectal surgeon

• Use radiation therapy when needed, by an experienced radiation oncologist

Management of SD

• Erectile dysfunction can be helped by medications

• Mechanical devices for ED• Vaginal lubricants• Low dose vaginal estrogens• Vaginal dilators

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