REVIEWSSexual Function, Incontinence, and Wellbeing in Women after Rectal Cancer—A Review of the Evidence
Introduction
Colorectal cancer (CRC) is the second most common cancer in women 1, 2. The median age of diagnosis of CRC in women is 71 years [3]. In 2005, the incidence of CRC in the USA was 40.9 per 100,000 women per year. For colon cancer, the incidence was 31 per 100,000 per year and 9.9 per 100,000 per year for rectal cancer. These rates are calculated for a population standardized to the US population in the year 2000 [4].
Thirty‐two percent of colorectal cancers occur in the rectum [3]. Early detection and improvements in surgical techniques in combination with radiotherapy 5, 6, 7, 8 have increased the life expectancy of individuals with rectal cancer. The estimated 5‐year survival for women with rectal cancer was 66.7% during 2002–2008 [4]. However, compared with a 90.3% 5‐year survival for breast cancer during the same period, the outlook for women with rectal cancer is not equivalent [4]. At diagnosis, the main focus for rectal cancer patients is treatment of their cancer [9]. When treatment has been completed, patients have to come to terms with the impact of their cancer on their quality of life (QoL). These frequently include dealing with urinary and fecal incontinence and sexual dysfunction [10]. Profound and stressful consequences of rectal cancer therapy have been observed, with adverse effects on mental and physical health, and on relationships [9].
There are substantial differences in the morbidities arising from the treatment of rectal vs. colon cancer. Colonic surgery generally does not impinge on other major organs and is usually a one‐stage procedure with end‐to‐end anastomosis of the bowel after excision of the tumor. However, for pelvic (rectal) surgery, other organs as well as the pelvic nerves are very close to the pathology and therefore may be affected by the treatment (both surgery and radiotherapy). Furthermore, rectal cancer surgery is usually a two‐stage procedure with the creation of a stoma when the cancer is removed, which is then closed from weeks to months later, depending on the timing of radiotherapy and chemotherapy. Thus, patients with rectal cancer may have a stoma for several months after their initial surgery. Rectal surgery is further complicated by tissue edema in a restricted space and the high risk of damage to pelvic nerves essential for bladder, bowel, and sexual function. Historically, abdominoperineal surgical resection was employed for rectal cancers close to the anal sphincter [11]. This surgery, which results in a permanent stoma, is still required for approximately 20–25% of rectal cancers because of their anatomical proximity to the anal sphincter. Now gold standard surgery for rectal cancer, when possible, involves removal of the tumor and the mesorectum, which contains the draining lymphatics and vascular tissue, en bloc (total mesorectal excision, TME). TME minimizes local recurrence and improves survival [12]. The overall 5‐year survival of TME is up to 80% [13]. However, a key aim of TME is preservation of anal sphincter, bladder and sexual function thus achieving the best possible QoL for patients. TME requires precise dissection of the tissue (fascia) that envelops the rectum and mesorectum and the parietal fascia overlying the pelvic wall structures. Great surgical care is taken to spare the pelvic nerves controlling bowel, bladder and sexual function which may be intimately associated with the visceral fascia of the mesorectum. The extent to which TME for rectal cancer translates into preservation of urinary and fecal continence and sexual function, and ultimately wellbeing and QoL remains uncertain. The contribution of radiotherapy and chemotherapy is also unclear.
Section snippets
Methods
A systematic search of the literature using Medline (Ovid, 1946–present) and PubMed (1966–2011) for English language studies that included the following search terms: “colorectal cancer,” or “rectal cancer,” or “rectal neoplasm,” and “sexual function,” or “sexual dysfunction,” or “wellbeing,” or “quality of life,” or “urinary or fecal incontinence.” The search was refined using the terms “human,”“female,” and, if sexual function, QoL and bowel and bladder incontinence were measured. The
Female Sexual Function
Although sexual functioning declines with age, sexuality remains important to many men and women well into old age [14]. Sexual dysfunction is a recognized complication in men who undergo pelvic surgery for rectal cancer; however, there is less information about the effect of pelvic surgery on women's sexual function 15, 16. Sexual function remains an important aspect of quality of life for older women [14]. It has been shown in several studies that over 75% of older women consider sex
The Need for Further Research
QoL and sexual function are important ongoing concerns for women after treatment for rectal cancer. The available information about sexual function, incontinence, and QoL after rectal cancer is limited as it is primarily from clinical trials 69, 70, 71. Thus, the research represents a highly select population who undergo intensive follow‐up and thus may not generalize to the general experience of cancer survivors. As the trials are often over a relatively short time, they provide information
Conclusion
In summary, there is a gap in our knowledge of the effects of rectal cancer and its treatment on urinary and fecal continence, sexual function, and QoL in women. There is a need for studies of sufficient size and duration to gain a better understanding of the disease and its management and the long‐term effects on these parameters. This information is needed to develop preventative health care plans for women treated for rectal cancer that target those most at risk for these adverse outcomes.
Conflict of Interest
None.
Category 1
- (a)
Conception and Design
Mary Panjari; Robin J. Bell; Susan R. Davis; Susan Burney; Paul J. McMurrick; Stephen Bell
- (b)
Acquisition of Data
Mary Panjari; Robin J. Bell; Susan R. Davis; Susan Burney; Paul J. McMurrick; Stephen Bell
- (c)
Analysis and Interpretation of Data
Mary Panjari; Robin J. Bell; Susan R. Davis; Susan Burney; Paul J. McMurrick; Stephen Bell
Category 2
- (a)
Drafting the Article
Mary Panjari; Robin J. Bell; Susan R. Davis; Susan Burney; Paul J. McMurrick; Stephen Bell
- (b)
Revising It for Intellectual Content
Mary
References (71)
- et al.
Recurrence and survival after total mesorectal excision for rectal cancer
Lancet
(1986) - et al.
Cancer and sexual problems
J Sex Med
(2010) - et al.
Sex after seventy: A pilot study of sexual function in older persons
J Sex Med
(2007) Sexual dysfunction after surgery for rectal cancer
Lancet
(1999)- et al.
Risk factors for sexual dysfunction after rectal cancer treatment
Eur J Cancer
(2009) - et al.
Late injury of cancer therapy on the female reproductive tract
Int J Radiat Oncol Biol Phys
(1995) - et al.
A prospective study of sexual and urinary function before and after total mesorectal excision with autonomic nerve preservation for rectal cancer
Surgery
(2002) - et al.
Hypoactive sexual desire disorder in menopausal women: A survey of western European women
J Sex Med
(2006) - et al.
Correlates of sexually related personal distress in women with low sexual desire
J Sex Med
(2009) - et al.
Long‐term quality of life in patients with rectal cancer treated with preoperative (chemo)‐radiotherapy within a randomized trial
Cancer Radiother
(2010)