Pelvic Malignancies: Overview of treatment of urinary and sexual complications in cancer survivors

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    Gary MacKenzie

    Pelvic Malignancies: Overview of treatment of urinary and sexual complications in cancer survivors

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    In general, cancer survivors experiencing urinary side effects are bothered by symptoms of urinary incontinence, urinary retention, bladder overactivity, hematuria, and/or bladder pain. These symptoms may be isolated or overlapping, making treatment challenging to physicians—and confusing and frustrating to patients.

    In men with urinary incontinence, an assessment of the driving cause of their incontinence is critical if the practitioner is to provide adequate counseling regarding management options. Stress incontinence can be managed, after a detailed urologic evaluation, with PFMT, a transobturator urethral sling, or an artificial urinary sphincter. These interventions have been shown to improve overall QOL in these patients, as in the patient in Case 1. Women with stress urinary incontinence after treatment of a gynecologic malignancy should be evaluated for fistulous disease or cancer recurrence. In the absence of an ominous finding, surgical treatment with a midurethral sling, retropubic colposuspension, or injection of bulking agents is feasible. The choice of approach is driven by the effect of the incontinence on the patient’s QOL, the severity of leakage, and the degree of lower urinary tract dysfunction.

    Urinary frequency, urgency, and nocturia classically are considered irritative lower urinary tract symptoms secondary to bladder overactivity. These changes may occur after either an insult to bladder mucosa or bladder innervation. Surgery, chemotherapy, and RT can all lead to bothersome irritative urinary tract symptoms. Such symptoms may respond to dietary modifications (avoiding bladder irritants), antimuscarinic drugs, treatment with a β3 agonist, onabotulinum toxin A intravesical injections, or neuromodulation. When these therapies are exhausted, urinary diversion may be indicated in very-well-selected patients.

    Urinary retention after pelvic surgery may present as overflow incontinence or frank retention. In this setting, appropriate bladder drainage is necessary. Urethral catheterization is reasonable in the acute setting; however, urethral catheterization or suprapubic catheterization is not an appropriate long-term form of bladder management and is discouraged. Clean intermittent catheterization carries a lower risk of urinary tract infection, allows more flexibility in daily activities, and is a safe mode of bladder management in patients who are able to reliably self-catheterize or who have an adequate support structure to assist with catheterization.

    Erectile dysfunction is commonly seen in men treated for pelvic malignancies. Erectile dysfunction is normally managed initially with phosphodiesterase type 5 (PDE5) inhibitors. PDE5 inhibitors are excellent treatments for erectile dysfunction resulting from RT. A recent survey of erectile function in prostate cancer patients treated with hormonal therapy and IMRT showed that PDE5 inhibitors provided satisfactory response in 66% of men using the medications. Additional therapies include vacuum erection devices, intraurethral alprostadil suppositories, intracavernosal injections (papaverine, phentolamine, alprostadil), and penile prostheses. All of these modalities have been shown to improve QOL in patients with erectile dysfunction.

    Sexual dysfunction may be present in both men and women with pelvic malignancies. The interplay between physical, psychological, and social factors influences sexual desire, libido, and satisfaction. Therapists specializing in psychosexual care can help address the psychological and social component of sexual dysfunction at the same time that medical and surgical therapies are being used to address the biological facets of the problem. This is an area where a great need for additional support has been identified. However, this need is not yet well addressed in the comprehensive care of cancer survivors.

    Key Points

    • After cancer treatment, patients report difficulty adjusting to changes in physical appearance, daily functioning, and social roles.
    • Urinary and sexual dysfunction are common and burdensome sequelae of treatment of pelvic malignancies.
    • Numerous pharmacologic and surgical therapies exist to address urinary and sexual dysfunction that can follow treatment of pelvic malignancies.
    • Recognition of the sequelae of oncologic treatment allows for early intervention and subsequent improvement in the quality of life of cancer survivors.

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