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Fundamentals of Rectal Cancer SurgeryFundamentals of Rectal Cancer Surgery

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Long-Term Complications - Sexual Dysfunction and Its Management

Long-Term Complications - Sexual Dysfunction and Its Management is a topic covered in the Fundamentals of Rectal Cancer Surgery.

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Sexual dysfunction is an important long-term risk of rectal cancer treatment, affecting both men and women. Autonomic nerve injury is a major contributing factor. Autonomic neuropathy can cause urinary dysfunction, erectile dysfunction in men, as well as retrograde ejaculation. Rates of these problems vary widely between studies, but most studies have found that erectile dysfunction is the most common autonomic nerve-related morbidity for men.[1]

Both sympathetic and parasympathetic nerve injury can result from proctectomy surgery. Sympathetic neuropathy caused by injury to the pelvic autonomic plexus at the sacral promontory causes ejaculatory dysfunction, usually manifested as retrograde ejaculation. This can be avoided by preserving the hypogastric nerve trunks, and by minimizing traction on the inferior mesenteric artery (IMA) pedicle and trying to leave a 1-cm margin at the root of the IMA during its division.

Parasympathetic injury, due to excessively lateral dissection along the lateral stalks or injury to the peri-prostatic plexus, can cause erectile dysfunction in up to 30% of men. With the anterior dissection during TME, except when resecting an anteriorly based tumor, it is important to preserve the integrity of Denonvillier’s fascia that is invested by the periprostatic plexus; injury to this plexus can cause additional parasympathetic injury and erectile dysfunction. Prior to the advent of TME, postoperative erectile dysfunction and retrograde ejaculation rates were observed in 25% to 75% of cases, however careful adherence to TME principles have decreased this to 10% to 29% of cases.[2]

Sexual manifestations of autonomic injury are less well understood in women, for whom dyspareunia is the most common sexual dysfunction symptom. Risks factors for sexual dysfunction include: abdominoperineal resection (APR), age over 65 years, radiation therapy, and the complication of abdominopelvic infection after surgery.[3]

Management of postoperative sexual function is multifactorial. Pilot studies of patients with neurogenic impotence after prostatectomy have shown that multi-disciplinary treatment, including sexual counseling and behavioral therapy, can demonstrate improvements in as soon as 6-12 months.[4] Following proctectomy, pharmacologic treatment with phosphodiesterase inhibitors, such as oral sildenafil, has been shown to improve sexual function in 80% of patients compared to 17% with placebo.[5] Other, less efficacious options include local intracavernous and intraurethral injections and vacuum-constriction devices. Couples counseling not only helps to reassure patients and their partners, but also can enhance response to medical therapy.[6] Ultimately, in the event of failure of behavioral and pharmacologic therapies, placement of a penile prosthesis is effective but irrevocable and should be considered only as a last resort.

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Sexual dysfunction is an important long-term risk of rectal cancer treatment, affecting both men and women. Autonomic nerve injury is a major contributing factor. Autonomic neuropathy can cause urinary dysfunction, erectile dysfunction in men, as well as retrograde ejaculation. Rates of these problems vary widely between studies, but most studies have found that erectile dysfunction is the most common autonomic nerve-related morbidity for men.[1]

Both sympathetic and parasympathetic nerve injury can result from proctectomy surgery. Sympathetic neuropathy caused by injury to the pelvic autonomic plexus at the sacral promontory causes ejaculatory dysfunction, usually manifested as retrograde ejaculation. This can be avoided by preserving the hypogastric nerve trunks, and by minimizing traction on the inferior mesenteric artery (IMA) pedicle and trying to leave a 1-cm margin at the root of the IMA during its division.

Parasympathetic injury, due to excessively lateral dissection along the lateral stalks or injury to the peri-prostatic plexus, can cause erectile dysfunction in up to 30% of men. With the anterior dissection during TME, except when resecting an anteriorly based tumor, it is important to preserve the integrity of Denonvillier’s fascia that is invested by the periprostatic plexus; injury to this plexus can cause additional parasympathetic injury and erectile dysfunction. Prior to the advent of TME, postoperative erectile dysfunction and retrograde ejaculation rates were observed in 25% to 75% of cases, however careful adherence to TME principles have decreased this to 10% to 29% of cases.[2]

Sexual manifestations of autonomic injury are less well understood in women, for whom dyspareunia is the most common sexual dysfunction symptom. Risks factors for sexual dysfunction include: abdominoperineal resection (APR), age over 65 years, radiation therapy, and the complication of abdominopelvic infection after surgery.[3]

Management of postoperative sexual function is multifactorial. Pilot studies of patients with neurogenic impotence after prostatectomy have shown that multi-disciplinary treatment, including sexual counseling and behavioral therapy, can demonstrate improvements in as soon as 6-12 months.[4] Following proctectomy, pharmacologic treatment with phosphodiesterase inhibitors, such as oral sildenafil, has been shown to improve sexual function in 80% of patients compared to 17% with placebo.[5] Other, less efficacious options include local intracavernous and intraurethral injections and vacuum-constriction devices. Couples counseling not only helps to reassure patients and their partners, but also can enhance response to medical therapy.[6] Ultimately, in the event of failure of behavioral and pharmacologic therapies, placement of a penile prosthesis is effective but irrevocable and should be considered only as a last resort.

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Last updated: September 21, 2021

Citation

"Long-Term Complications - Sexual Dysfunction and Its Management." Fundamentals of Rectal Cancer Surgery, 2021. ASCRS U, www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831031/all/Long-Term Complications - Sexual Dysfunction and Its Management.
Long-Term Complications - Sexual Dysfunction and Its Management. Fundamentals of Rectal Cancer Surgery. 2021. https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831031/all/Long-Term Complications - Sexual Dysfunction and Its Management. Accessed March 21, 2023.
Long-Term Complications - Sexual Dysfunction and Its Management. (2021). In Fundamentals of Rectal Cancer Surgery https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831031/all/Long-Term Complications - Sexual Dysfunction and Its Management
Long-Term Complications - Sexual Dysfunction and Its Management [Internet]. In: Fundamentals of Rectal Cancer Surgery. ; 2021. [cited 2023 March 21]. Available from: https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831031/all/Long-Term Complications - Sexual Dysfunction and Its Management.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Long-Term Complications - Sexual Dysfunction and Its Management ID - 2831031 Y1 - 2021/09/21/ BT - Fundamentals of Rectal Cancer Surgery UR - https://www.ascrsu.com/ascrs/view/Fundamentals-of-Rectal-Cancer-Surgery/2831031/all/Long-Term Complications - Sexual Dysfunction and Its Management DB - ASCRS U DP - Unbound Medicine ER -
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Grapherence® [↑6]
    • Fundamentals of Rectal Cancer Surgery
    • Background
    • Rectal Anatomy
    • Rectal Cancer Biology and Hereditary Cancer Syndromes
    • Rationale for Multi-Modality Therapy
    • Preoperative Issues
    • Preoperative Staging
    • Role of Tumor Board
    • Indications for Preoperative Neoadjuvant Therapy
    • Local Excision
    • Indications for LAR Versus Intersphincteric Resection Versus APR
    • Indications for Extended Resection
    • Preoperative Preparation
    • Interoperative
    • Patient Positioning and Equipment for Rectal Cancer Surgery
    • Inferior Mesenteric Artery
    • Inferior Mesenteric Vein (IMV)
    • Splenic Flexure Mobilization
    • Surgical Techniques for Length
    • Technique of Total Mesorectal Excision (TME)
    • Tailored Mesorectal Excision (TME)
    • Bowel Transection and Anastomosis
    • Indications for Fecal Diversion
    • Abdominoperineal Resection
    • Standardized Operative Report
    • Management of Intraoperative Vascular and Urinary Complications
    • Postoperative Issues
    • Rectal Cancer Pathology Assessment
    • Adjuvant Therapy for Rectal Adenocarcinoma
    • Surveillance After Rectal Cancer Treatment
    • Management of Local Recurrences
    • Short-Term Complications - Anastomotic
    • Short-Term Complications - Urinary
    • Ostomy Complications and Management
    • Long-Term Complications – Bowel Dysfunction
    • Long-Term Complications - Sexual Dysfunction and Its Management
    • Parastomal and Perineal Hernias
    • Impact of Postoperative Complications On Oncologic Outcomes
    • Course Complete
    • Final Assessment
Grapherence® [↑6]
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Related Topics

  • Rectal Cancer: Nonoperative Management
  • Surgical Management of Ulcerative Colitis
  • General Postoperative Complications
  • Management of Rectal Cancer
  • Perioperative Evaluation and Management of Frailty Among Older Adults Undergoing Colorectal Surgery
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