Bladder Cancer: A Focus on Sexuality
Bladder Cancer: A Focus on Sexuality
Female sexual dysfunction is a multifactorial problem that has been classified into sexual desire disorder, subjective sexual arousal disorder, genital arousal disorder, combined sexual arousal disorder, persistent sexual arousal disorder, orgasmic disorder, vaginismus, and dyspareunia (El-Bahnasawy et al., 2011). These classifications encompass a complex variety of sexual dysfunction components that are relevant to women undergoing treatment for MIBC.
Female sexual function depends on the integrity of the internal genitalia including the vagina, fallopian tubes, uterus, and ovaries, and the external genitalia including the labia, clitoris, and vestibular bulbs. During radical cystectomy, transection of the neurovascular bundle on the lateral walls of the vagina results in a lack of blood engorgement to the clitoris and vagina. Denervation can result in loss of lubrication, leading to sexual arousal disorder. Nerve-sparing techniques have become available but are not widely accepted. Devascularization of the clitoris can occur if the distal part of the urethra is removed. The upper vagina is resected during cystectomy, which may result in vaginal narrowing and shortening and dyspareunia (Gontero, Fontana, Kocjancic, Frea, & Tizzani, 2006). The removal of reproductive organs, resulting in loss of ovarian hormones, can cause decreased libido, vaginal dryness, and other menopausal symptoms, including hot flashes, mood swings, and fatigue, all of which can negatively affect women's sexual health. Women also may experience significant body image concerns following cystectomy because of surgical scars and urinary diversions.
Chemotherapy can cause nausea, vomiting, anorexia, fatigue, neuropathy, and alopecia, all of which can lead to decreased sexual interest. Premenopausal women should be informed that chemotherapy could lead to menopausal symptoms. External beam radiation therapy can cause fatigue, leading to decreased interest in sexual activity and vaginal dryness, shortening, and narrowing that causes dyspareunia (Albaugh et al., 2009).
Treatment for female sexual dysfunction following treatment for bladder cancer should include physical and emotional therapy. Nurses can educate patients about different ways to manage fatigue, nausea, and pain. Water-soluble lubricants can be used to improve vaginal dryness. Prescription estrogen cream can keep vaginal tissue soft and supple. For women who experience pain and difficulty achieving orgasm because of vaginal shortening, vaginal dilators are available to help gradually stretch vaginal tissue and keep it pliable. Referrals to a gynecology practitioner or physical therapist trained in women's health can be greatly beneficial. Women have reported that using the female superior position during sexual intercourse helps control the depth of penile penetration and thrusting, which helps control discomfort (Albaugh et al., 2009). Women who have ileal conduit urinary diversions can experience body image disturbances and anxiety related to sexual activity and the possibility of urinary leakage. Nurses should teach women to empty their pouch prior to sexual activity and make sure it is fitted correctly around the stoma to reduce the chance of leaking. Pouch covers, some of which resemble lingerie, are widely available online. Women with neobladders may experience leaking and should be advised to void or catheterize prior to sexual activity. Referrals to mental health providers should be facilitated for women who experience any emotional distress because of sexual dysfunction. Although the vast majority of women diagnosed with bladder cancer are not of child-bearing age, those who are need to be counseled about the impact of treatment on fertility.
Many men with MIBC will undergo cystoprostatectomy, or surgical removal of the bladder and prostate. Although some surgical techniques preserve sexual function (i.e., prostate-sparing surgery), they carry a risk of urothelial carcinoma involvement of the prostate and prostatic urethra (Tal & Baniel, 2005). Prostatectomy can result in erectile dysfunction (ED) because the neurovascular bundle (NVB) that controls erectile function wraps around the posterior aspect of the prostate. The NVB consists of a complex structure related to the vascularization of the outer prostate and to the innervation of the urethra and corpora cavernosa (Gontero et al., 2006). The prostate is an accessory reproductive gland that secretes alkaline fluids that form part of the ejaculate, which aids motility and nourishment of sperm. Following cystoprostatectomy, men will no longer produce seminal fluid, resulting in dry orgasm and infertility. Men who desire to father a child should be given the opportunity to bank sperm preoperatively (Prostate Cancer Foundation, 2014).
Chemotherapy and radiation therapy can cause the same side effects in men as women, with the addition of ED. Treatment for ED should be tailored toward men's preference and previous treatments. Given the advanced age of many patients with bladder cancer, men may already suffer a degree of ED prior to cancer therapy. The Sexual Health Inventory for Men is a questionnaire used to determine the severity of ED and should be evaluated prior to cancer therapy. Treatment options for ED include vacuum erectile devices, oral phosphodiesterase 5 inhibitors, the intraurethral Medicated Urethral System for Erection, intracavernosal injections, and penile implants. Men should be educated that orgasm is still possible, even in the absence of erection.
Men may experience emotional distress related to sexual dysfunction. Men may express feeling like "less of a man" because of sexual dysfunction and body changes. The same tips should be offered to men with ileal conduits as for female patients. Gender-neutral pouch covers are available, and some men choose to wear a comfortable T-shirt during sexual activity to make the conduit more discreet. Men may experience urinary leakage through the urethra and should be advised to wear a condom during sex to absorb the urine.
Sexual Dysfunction
Female Sexual Dysfunction
Female sexual dysfunction is a multifactorial problem that has been classified into sexual desire disorder, subjective sexual arousal disorder, genital arousal disorder, combined sexual arousal disorder, persistent sexual arousal disorder, orgasmic disorder, vaginismus, and dyspareunia (El-Bahnasawy et al., 2011). These classifications encompass a complex variety of sexual dysfunction components that are relevant to women undergoing treatment for MIBC.
Female sexual function depends on the integrity of the internal genitalia including the vagina, fallopian tubes, uterus, and ovaries, and the external genitalia including the labia, clitoris, and vestibular bulbs. During radical cystectomy, transection of the neurovascular bundle on the lateral walls of the vagina results in a lack of blood engorgement to the clitoris and vagina. Denervation can result in loss of lubrication, leading to sexual arousal disorder. Nerve-sparing techniques have become available but are not widely accepted. Devascularization of the clitoris can occur if the distal part of the urethra is removed. The upper vagina is resected during cystectomy, which may result in vaginal narrowing and shortening and dyspareunia (Gontero, Fontana, Kocjancic, Frea, & Tizzani, 2006). The removal of reproductive organs, resulting in loss of ovarian hormones, can cause decreased libido, vaginal dryness, and other menopausal symptoms, including hot flashes, mood swings, and fatigue, all of which can negatively affect women's sexual health. Women also may experience significant body image concerns following cystectomy because of surgical scars and urinary diversions.
Chemotherapy can cause nausea, vomiting, anorexia, fatigue, neuropathy, and alopecia, all of which can lead to decreased sexual interest. Premenopausal women should be informed that chemotherapy could lead to menopausal symptoms. External beam radiation therapy can cause fatigue, leading to decreased interest in sexual activity and vaginal dryness, shortening, and narrowing that causes dyspareunia (Albaugh et al., 2009).
Treatment for female sexual dysfunction following treatment for bladder cancer should include physical and emotional therapy. Nurses can educate patients about different ways to manage fatigue, nausea, and pain. Water-soluble lubricants can be used to improve vaginal dryness. Prescription estrogen cream can keep vaginal tissue soft and supple. For women who experience pain and difficulty achieving orgasm because of vaginal shortening, vaginal dilators are available to help gradually stretch vaginal tissue and keep it pliable. Referrals to a gynecology practitioner or physical therapist trained in women's health can be greatly beneficial. Women have reported that using the female superior position during sexual intercourse helps control the depth of penile penetration and thrusting, which helps control discomfort (Albaugh et al., 2009). Women who have ileal conduit urinary diversions can experience body image disturbances and anxiety related to sexual activity and the possibility of urinary leakage. Nurses should teach women to empty their pouch prior to sexual activity and make sure it is fitted correctly around the stoma to reduce the chance of leaking. Pouch covers, some of which resemble lingerie, are widely available online. Women with neobladders may experience leaking and should be advised to void or catheterize prior to sexual activity. Referrals to mental health providers should be facilitated for women who experience any emotional distress because of sexual dysfunction. Although the vast majority of women diagnosed with bladder cancer are not of child-bearing age, those who are need to be counseled about the impact of treatment on fertility.
Male Sexual Dysfunction
Many men with MIBC will undergo cystoprostatectomy, or surgical removal of the bladder and prostate. Although some surgical techniques preserve sexual function (i.e., prostate-sparing surgery), they carry a risk of urothelial carcinoma involvement of the prostate and prostatic urethra (Tal & Baniel, 2005). Prostatectomy can result in erectile dysfunction (ED) because the neurovascular bundle (NVB) that controls erectile function wraps around the posterior aspect of the prostate. The NVB consists of a complex structure related to the vascularization of the outer prostate and to the innervation of the urethra and corpora cavernosa (Gontero et al., 2006). The prostate is an accessory reproductive gland that secretes alkaline fluids that form part of the ejaculate, which aids motility and nourishment of sperm. Following cystoprostatectomy, men will no longer produce seminal fluid, resulting in dry orgasm and infertility. Men who desire to father a child should be given the opportunity to bank sperm preoperatively (Prostate Cancer Foundation, 2014).
Chemotherapy and radiation therapy can cause the same side effects in men as women, with the addition of ED. Treatment for ED should be tailored toward men's preference and previous treatments. Given the advanced age of many patients with bladder cancer, men may already suffer a degree of ED prior to cancer therapy. The Sexual Health Inventory for Men is a questionnaire used to determine the severity of ED and should be evaluated prior to cancer therapy. Treatment options for ED include vacuum erectile devices, oral phosphodiesterase 5 inhibitors, the intraurethral Medicated Urethral System for Erection, intracavernosal injections, and penile implants. Men should be educated that orgasm is still possible, even in the absence of erection.
Men may experience emotional distress related to sexual dysfunction. Men may express feeling like "less of a man" because of sexual dysfunction and body changes. The same tips should be offered to men with ileal conduits as for female patients. Gender-neutral pouch covers are available, and some men choose to wear a comfortable T-shirt during sexual activity to make the conduit more discreet. Men may experience urinary leakage through the urethra and should be advised to wear a condom during sex to absorb the urine.
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