Female Sexual Dysfunction and Colorectal Surgery

The occurrence of sexual dysfunction after CRS is a well-recognized phenomenon. Prior studies in men have demonstrated that the incidence of sexual dysfunction is between 20% and 34% in patients undergoing rectal excision, and is related to the extent of the procedure.9 Sexual dysfunction has been attributed to damage of the autonomic nerves, especially during pelvic dissection. Injury to the sympathetic nerves often results in retrograde ejaculation whereas parasympathetic nerve injury can contribute to ED.

In contrast, FSD after CRS is not as well understood. The findings in the literature are controversial; whereas some authors believe that female sexual function does not change or even improves after surgery,10,11 others have reported deteriorated function, despite cure of the disease.6,12 This discrepancy in results may be attributed to the fact that most studies were retrospective, included a small number of female patients, lacked a baseline functional status, and did not use a validated sexual inventory. Therefore, the available literature data warrant cautious evaluation. Table 5-1.5 summarizes the results of 14 studies in women who underwent major colorectal procedures.

After CRS, sexual dysfunction in women may be attributed to disorders of desire, arousal, orgasm, and/or pain. Sexual desire has been shown to maintain or improve in 76% to 80% of women after CRS and is often accompanied by increased frequency in sexual activity and sexual satisfaction.13,14 Such an improvement may be expected, because general health is likely to improve after surgery. However, previous studies have demonstrated that up to 78% of women complain of decreased or complete loss of libido after surgery.15 Factors such as impaired body image, concerns of partner negative reaction, fear of stool leakage, and use of a stoma are known to adversely impact sexual function, and may account for these findings. Among these factors, the negative impact of a stoma has been specifically addressed by several studies. Gloeckner and Starling16 conducted an interview with 40 subjects with a permanent stoma (24 men, 16 women) and found that 60% of the patients had impaired sexuality after surgery. One year after surgery, 67.5% of the patients reported improvement on sexual attractiveness, and this significantly correlated with gender (female vs. male), type of disease (inflammatory bowel disease vs. malignancy), type of stoma (ileostomy vs. other stoma types), duration of disease before surgery (>10 years vs. <10 years), and the ability to manage the stoma (no problems to manage vs. problems to manage). In a study recently published by Engel et al.,17 the long-term quality of life of 329 patients with rectal cancer was prospectively assessed. Overall, patients who underwent an anterior resection had better quality-of-life scores than those who had an abdominoper-ineal resection with a permanent stoma; the effects of the abdominoperineal resection on the patients' quality of life did not improve over time in this series. Patients with stoma had significantly worse quality-of-life scores than patients without stoma; however, quality of life greatly improved for patients whose stoma was reversed. In their study, Sjögren and Poppen14 also demonstrated significant improvement in patients' sexuality after stoma closure.

Table 5-1.5. Female sexual dysfunction after major colorectal surgery

Author, year

Surgery

n

Decreased Desire

Decreased Lubrication

Altered Orgasm

Dyspareunia

Decreased Satisfaction

Williams and Slack,22 1980*

APR

3

1 (33)

Deixonne, 198336

APR

26

12 (46)

11 (42)

8 (31)

Hjortrup, 1984*37

LAR

20

1 (5)

2 (10)

Fegiz et al.,21 1986

LAR - stapled LAR - manual

15 9 17

(70) (24) (44)

(65) (65) (44)

Metcalf et al.,11 1986

Kock pouch

50 50

2 2

(38) (48)

Cirino et al.,151987

APR

18

15 (77)

1 (5)

6 (33)

8 (44)

Wikland et al.,191990

Pouch

71

27

Cunsolo, 199038

APR

8

2 (25)

2 (25)

4 (50)

Öresland et al.,131994

J pouch

20

5 (25)

1 (5)

5 (25)

Sjögren and Poppen,14 1995

S pouch

30

6 (20)

7 (23)

10 (33)

5 (16)

Damgard et al.,101995

J pouch

23

0

0

Bambrick et al.,121996

J pouch

92

16 (18)

22 (26)

13 (15)

22 (26)

21 (26)

Tiainen et al.,181999

J pouch

95

2 (5)

9 (22)

4 (9)

* Prospective studies. APR,abdominoperineal resection; LAR, low anterior resection.

Although patients with a J pouch do not have to deal with the inconvenience of a stoma, 3% to 43% of women fear stool leakage from the pouch, causing a hindrance of sexual activity.18 In addition, special precautions such as emptying the pouch before intercourse are often necessary in these patients.

Sjögren and Poppen14 evaluated 30 women who underwent total proctocolectomy with S pouch and found that 13.3% of the patients had dyspareunia and 10% complained of vaginal dryness, which could not be explained by estrogen deficiency. In a larger series including 92 patients who underwent restorative total proctocolectomy, Bambrick et al.12 found that 22 patients (26.8%) had dys-pareunia, of whom 30.5% experienced decreased sexual pleasure, and 22 patients (26.5%) had vaginal dryness, 7% of whom experienced this 75% or more of the time.

Few factors have been postulated to cause dyspareunia in women after rectal excision. It has been suggested that neurovascular damage during dissection interrupts the physiologic response of arousal, leading to decreased lubrication and dyspareunia. In patients with rectal cancer, radiation therapy can cause damage to the small vessels and induce fibrosis with loss of elasticity of the vaginal canal, resulting in arousal impairment.

Anatomic changes after rectal excision and pelvic floor closure have also been postulated to cause sexual discomfort or dyspareunia. Metcalf et al.11 compared sexual dysfunction between 50 patients who had a Kock pouch (continent stoma) and 50 patients who had an ileoanal anastomosis. Although the overall rate of dyspareunia decreased in both groups after surgery, patients with a

Kock pouch had significantly more persistent dyspareunia and excessive positional vaginal discharge, than patients who underwent ileoanal anastomosis.

Wikland et al.19 evaluated the anatomic changes of the genital tract in women after proctocolectomy. The authors performed a gynecologic examination in 71 women and compared physical findings to the gynecologic complaints. Of the 71 women, 35 (49%) had a distressing vaginal discharge after proctocolectomy, compared with 6 (9%) before surgery. Dyspareunia was reported by 8 women (12%) before surgery and 18 (27%) after surgery. In 44 patients (61%), gynecologic examination revealed caudal fixation and dilatation of the posterior vaginal fornix. Thirty (68%) of these 44 women had heavy vaginal secretion (upper thirds of the vagina filled with fluid, cervix identified after washout) associated with the anatomic changes. In a subsequent study, some of these women underwent vaginography, which confirmed anatomic changes assessed by physical examination.20 Öresland and associates13 from the same institution demonstrated that such abnormalities are not present when a bowel reconstruction is performed. Twenty-one women who underwent restorative proctocolectomy underwent gynecologic examination and vaginography after surgery. Five experienced occasional dyspareunia and one complained of vaginal discharge. Gynecologic examination demonstrated unaltered vaginal position and angulation in all patients, which was also proven by the vaginography. Corroborating these findings, Sjögren and Poppen14 found normal vaginal anatomy in 29 (96.6%) of 30 patients who underwent proctocolectomy with pouch formation. These data suggest that the interposed pelvic pouch prevents its dorsal displacement in contrast to proctocolectomy and permanent stoma.

Orgasmic function can potentially be affected by changes in the pelvic floor muscles after radical pelvic and colorectal surgery. In a study performed by Fegiz and asso-ciates,21 orgasmic function was more affected in patients after abdominoperineal resection (70%) than patients who underwent colorectal hand-sewn (65%) or stapled anastomosis (44%). The majority of the studies, however, have shown that most women maintain the ability to achieve orgasm after surgery.22 This may be explained by the fact that the pudendal nerve supply to the pelvic floor muscles, which is considered essential for female orgasmic response, remains intact.

At the Cleveland Clinic Florida, a recent study looked at the incidence of changes in sexual function in women who underwent CRS as a result of rectal cancer and benign diseases.23 A survey was sent to 225 patients, and 74 (32.8%) returned the questionnaire; 31 had rectal cancer and 43 had benign diseases. The mean age was 54 years in the patients with rectal cancer and 36 years in the group with benign disease (P < 0.01). The mean time of follow-up postsurgery was 41.3 (18-93) months. Forty-five patients (60.8%) were married, and 48 (74.9%) continued their education beyond high school. Fifty women (67.5%) indicated being sexually active at the time of surgery. Of these, 32 patients (64%) reported worse sexual function after surgery, and 16 (55%) sought help. Fourteen patients (43.7%) expressed an interest in receiving treatment for FSD, which was more likely in women younger than 60 years of age (P = 0.012). Sixteen patients (32%) reported no difference, and only 1 (2%) indicated improved sexual function after surgery. Interestingly, 65 patients (87.8%) indicated that their physician never discussed the risk of postsurgical sexual dysfunction before surgery. However, only 24 patients (typically younger women) reported that they would have wanted to discuss such issues preopera-tively (P = 0.001). There was no statistically significant association between the desire to discuss sexual matters and level of education, marital status, diagnosis, or the presence of a stoma. This study suggests that CRS may significantly and adversely impact a woman's sexual function and her sexuality, and, therefore, all women should be preoperatively counseled regarding the potential for sexual dysfunction after surgery.

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