April 16, 2017 at 1:04 am #25079
Pelvic Malignancies: Exercise and physiotherapy in the management of urinary and sexual dysfunction resulting from treatment
Image source: Fishpond
Exercise and physiotherapy are of interest for management of both urinary and sexual dysfunction after treatment of pelvic malignancies because many of the etiologies of these dysfunctions are physical in nature. Making maximal use of exercise and physiotherapy has numerous advantages, including improvement in other comorbid conditions, overall well-being, low cost, ease of implementation, and relatively few side effects.
Data supporting exercise or physiotherapy as interventions in sexual dysfunction are limited. A recent Cochrane review identified 11 contemporary randomized controlled trials that assessed the effectiveness of treatments for sexual dysfunction resulting from cancer treatment in women. Only one of the trials evaluated the effect of exercise on sexual function. Of 34 patients with gynecologic cancers and pelvic floor dysfunction following radical hysterectomy and pelvic lymph node dissection, 24 completed a 4-week pelvic floor rehabilitation program (PFRP) or usual care. Outcomes included pelvic floor dysfunction (as measured by the pelvic floor dysfunction questionnaire), pelvic floor muscle strength, motor-evoked potential of the sacral nerve, and patient-reported health-related QOL. At 4 weeks, there were improvements in the PFRP group in pelvic floor strength and sexual functioning, as well as QOL. However, the systematic review concluded that the evidence that pelvic floor exercise improves sexual function is weak.
In men, the evidence for the impact of exercise or physiotherapy is most abundant by far in prostate cancer patients. One trial randomized men post radical prostatectomy to usual care or exercise for 6 months. While improvements in measures of physical fitness were found in the exercise group, exercise had no impact on recovery of erectile function. Recently, higher levels of physical activity have been correlated with better erectile and sexual function in men treated for prostate cancer. Overall, given the likely favorable risk-benefit ratio, PFRP for women and exercise for men with sexual dysfunction seem reasonable.
There is somewhat stronger evidence that physiotherapy may improve urinary incontinence in patients following treatment of pelvic malignancies. In the case of stress incontinence, the chief culprit appears to be pelvic floor weakness. Although an earlier systematic review concluded that PFMT for the treatment of urinary incontinence after radical prostatectomy hastens the return to continence, a more recent systematic review concluded that the benefit of conservative measures is uncertain. The authors of the more recent review did, however, note moderate evidence of an overall benefit from PFMT vs no PFMT in reduction of urinary incontinence.
Physiotherapy in survivors of gynecologic cancers may increase recovery of urinary function. A small pilot randomized controlled trial (N = 40) in which the majority of patients had uterine cancer (60%) and were treated with multimodality therapy (RT, 18%; surgery, 95%; chemotherapy, 35%) randomly assigned patients to 12 weeks of PFMT plus behavioral therapy or to usual care. After 12 weeks, the PFMT group had significantly improved urinary continence. Of note, a Cochrane review found that there is evidence of widespread recommendation of PFMT for women without cancer who have stress or any other type of urinary incontinence. Overall, given this evidence, PFMT seems reasonable as conservative treatment of urinary incontinence, particularly anatomic or stress incontinence, in patients with a history of treatment of a pelvic malignancy.
The management of pelvic malignancies with surgery, chemotherapy, and RT is complicated by the prevalent urinary and sexual side effects that affect long-term patient QOL. Recognition of possible problems with urinary function, such as urge or stress incontinence or hemorrhagic cystitis, is critical if practitioners are to adequately counsel patients and manage their post-treatment course. Similarly, sexual dysfunction—including dyspareunia, vaginal shortening/stenosis, sensory loss, erectile dysfunction, and ejaculatory dysfunction—affects patients psychologically and socially. Having a clear understanding of the sequelae of treatment of pelvic malignancies allows for clinical recognition and improvement in health-related QOL outcomes.
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