Abstract
In light of the improving prognosis for patients with rectal cancer, the quality of functional outcome has become increasingly important. Despite the good functional results achieved by expert surgeons, large multicenter studies show that urogenital dysfunction remains a common problem after rectal cancer treatment. More than half of patients experience a deterioration in sexual function, consisting of ejaculatory problems and impotence in men and vaginal dryness and dyspareunia in women. Urinary dysfunction occurs in one-third of patients treated for rectal cancer. Surgical nerve damage is the main cause of urinary dysfunction. Radiotherapy seems to have a role in the development of sexual dysfunction, without affecting urinary function. Pelvic autonomic nerves are especially at risk in cases of low rectal cancer and during abdominoperineal resection. Data concerning nerve damage during laparoscopic surgery for resection of rectal cancer are awaited. Structured education of surgeons with regard to pelvic neuroanatomy, and systematic registration of identified nerves, could well be the key to improving functional outcome for these patients. Meanwhile, patients should be informed of all associated risks before their operation, and their functional status should be evaluated before and after surgery.
Key Points
-
Sexual and urinary function should be explicitly discussed in preoperative consultations with patients with a rectal carcinoma as they are likely to be compromised after rectal cancer treatment
-
Technical aspects of the surgical procedure play a major role in the etiology of urogenital dysfunction after rectal cancer treatment, with an additional effect of radiotherapy on sexual function
-
Structured education in pelvic neuroanatomy and improved training of junior surgeons is the key to improving functional outcome
-
Several therapies, including further surgery, are available for urogenital dysfunction; conservative treatments should be the first line of treatment
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Jemal, A., Siegel, R., Xu, J. & Ward, E. Cancer statistics, 2010. CA Cancer J. Clin. 60, 277–300 (2010).
Heald, R. J. & Ryall, R. D. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1, 1479–1482 (1986).
Kapiteijn, E. et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N. Engl. J. Med. 345, 638–646 (2001).
Heald, R. J. & Karanjia, N. D. Results of radical surgery for rectal cancer. World J. Surg. 16, 848–857 (1992).
Murty, M., Enker, W. E. & Martz, J. Current status of total mesorectal excision and autonomic nerve preservation in rectal cancer. Semin. Surg. Oncol. 19, 321–328 (2000).
Desnoo, L. & Faithfull, S. A qualitative study of anterior resection syndrome: the experiences of cancer survivors who have undergone resection surgery. Eur. J. Cancer Care (Engl.) 15, 244–251 (2006).
Vironen, J. H., Kairaluoma, M., Aalto, A. M. & Kellokumpu, I. H. Impact of functional results on quality of life after rectal cancer surgery. Dis. Colon Rectum 49, 568–578 (2006).
Moreira, E. D. Jr, Hartmann, U., Glasser, D. B. & Gingell, C. A population survey of sexual activity, sexual dysfunction and associated help-seeking behavior in middle-aged and older adults in Germany. Eur. J. Med. Res. 10, 434–443 (2005).
Smith, L. J., Mulhall, J. P., Deveci, S., Monaghan, N. & Reid, M. C. Sex after seventy: a pilot study of sexual function in older persons. J. Sex. Med. 4, 1247–1253 (2007).
Miles, W. E. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2, 1812–1813 (1908).
Chang, P. L. & Fan, H. A. Urodynamic studies before and/or after abdominoperineal resection of the rectum for carcinoma. J. Urol. 130, 948–951 (1983).
Fazio, V. W., Fletcher, J. & Montague, D. Prospective study of the effect of resection of the rectum on male sexual function. World J. Surg. 4, 149–152 (1980).
Santangelo, M. L., Romano, G. & Sassaroli, C. Sexual function after resection for rectal cancer. Am. J. Surg. 154, 502–504 (1987).
Heald, R. J. A new approach to rectal cancer. Br. J. Hosp. Med. 22, 277–281 (1979).
[No authors listed] Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N. Engl. J. Med. 336, 980–987 (1997).
Heald, R. J. & Ryall, R. D. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1, 1479–1482 (1986).
Mynster, T., Nielsen, H. J., Harling, H. & Bulow, S. Blood loss and transfusion after total mesorectal excision and conventional rectal cancer surgery. Colorectal Dis. 6, 452–457 (2004).
Peeters, K. C. et al. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann. Surg. 246, 693–701 (2007).
Havenga, K. et al. Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J. Am. Coll. Surg. 182, 495–502 (1996).
Masui, H., Ike, H., Yamaguchi, S., Oki, S. & Shimada, H. Male sexual function after autonomic nerve-preserving operation for rectal cancer. Dis. Colon Rectum 39, 1140–1145 (1996).
Hojo, K., Vernava, A. M. III, Sugihara, K. & Katumata, K. Preservation of urine voiding and sexual function after rectal cancer surgery. Dis. Colon Rectum 34, 532–539 (1991).
Enker, W. E. Potency, cure, and local control in the operative treatment of rectal cancer. Arch. Surg. 127, 1396–1401 (1992).
Maas, C. P., Moriya, Y., Steup, W. H., Klein, K. E. & van de Velde, C. J. A prospective study on radical and nerve-preserving surgery for rectal cancer in the Netherlands. Eur. J. Surg. Oncol. 26, 751–757 (2000).
Junginger, T., Kneist, W. & Heintz, A. Influence of identification and preservation of pelvic autonomic nerves in rectal cancer surgery on bladder dysfunction after total mesorectal excision. Dis. Colon Rectum 46, 621–628 (2003).
Marijnen, C. A. et al. Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial. J. Clin. Oncol. 23, 1847–1858 (2005).
Moriya, Y. Function preservation in rectal cancer surgery. Int. J. Clin. Oncol. 11, 339–343 (2006).
Pollack, J. et al. Late adverse effects of short-course preoperative radiotherapy in rectal cancer. Br. J. Surg. 93, 1519–1525 (2006).
Pietrangeli, A. et al. Sexual dysfunction following surgery for rectal cancer—a clinical and neurophysiological study. J. Exp. Clin. Cancer Res. 28, 128 (2009).
Sterk, P. et al. Voiding and sexual dysfunction after deep rectal resection and total mesorectal excision: prospective study on 52 patients. Int. J. Colorectal Dis. 20, 423–427 (2005).
Bruheim, K. et al. Sexual function in females after radiotherapy for rectal cancer. Acta Oncol. 49, 826–832 (2010).
Frumovitz, M. et al. Quality of life and sexual functioning in cervical cancer survivors. J. Clin. Oncol. 23, 7428–7436 (2005).
Jayne, D. G. et al. Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br. J. Surg. 92, 1124–1132 (2005).
Platell, C. F., Thompson, P. J. & Makin, G. B. Sexual health in women following pelvic surgery for rectal cancer. Br. J. Surg. 91, 465–468 (2004).
Lange, M. M. et al. Risk factors for sexual dysfunction after rectal cancer treatment. Eur. J. Cancer 45, 1578–1588 (2009).
Lange, M. M. et al. Urinary dysfunction after rectal cancer treatment is mainly caused by surgery. Br. J. Surg. 95, 1020–1028 (2008).
Lindsey, I., Guy, R. J., Warren, B. F. & Mortensen, N. J. Anatomy of Denonvilliers' fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br. J. Surg. 87, 1288–1299 (2000).
Wallner, C. et al. Causes of fecal and urinary incontinence after total mesorectal excision for rectal cancer based on cadaveric surgery: a study from the Cooperative Clinical Investigators of the Dutch total mesorectal excision trial. J. Clin. Oncol. 26, 4466–4472 (2008).
Kinugasa, Y. et al. Operating behind Denonvilliers' fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis. Colon Rectum 49, 1024–1032 (2006).
Grigsby, P. W. et al. Late injury of cancer therapy on the female reproductive tract. Int. J. Radiat. Oncol. Biol. Phys. 31, 1281–1299 (1995).
Ulmsten, U. Some reflections and hypotheses on the pathophysiology of female urinary incontinence. Acta Obstet. Gynecol. Scand. Suppl. 166, 3–8 (1997).
Grise, P. & Thurman, S. Urinary incontinence following treatment of localized prostate cancer. Cancer Control 8, 532–539 (2001).
Marks, L. B., Carroll, P. R., Dugan, T. C. & Anscher, M. S. The response of the urinary bladder, urethra, and ureter to radiation and chemotherapy. Int. J. Radiat. Oncol. Biol. Phys. 31, 1257–1280 (1995).
Havenga, K., Maas, C. P., DeRuiter, M. C., Welvaart, K. & Trimbos, J. B. Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer. Semin. Surg. Oncol. 18, 235–243 (2000).
Maas, C. P. et al. Radical and nerve-preserving surgery for rectal cancer in The Netherlands: a prospective study on morbidity and functional outcome. Br. J. Surg. 85, 92–97 (1998).
Maurer, C. A. et al. Total mesorectal excision preserves male genital function compared with conventional rectal cancer surgery. Br. J. Surg. 88, 1501–1505 (2001).
Nesbakken, A., Nygaard, K., Bull-Njaa, T., Carlsen, E. & Eri, L. M. Bladder and sexual dysfunction after mesorectal excision for rectal cancer. Br. J. Surg. 87, 206–210 (2000).
Bonnel, C. et al. Effects of preoperative radiotherapy for primary resectable rectal adenocarcinoma on male sexual and urinary function. Dis. Colon Rectum 45, 934–939 (2002).
Bruheim, K. et al. Sexual function in males after radiotherapy for rectal cancer. Int. J. Radiat. Oncol. Biol. Phys. 76, 1012–1017 (2010).
Zelefsky, M. J. & Eid, J. F. Elucidating the etiology of erectile dysfunction after definitive therapy for prostatic cancer. Int. J. Radiat. Oncol. Biol. Phys. 40, 129–133 (1998).
Ogilvy-Stuart, A. L. & Shalet, S. M. Effect of radiation on the human reproductive system. Environ. Health Perspect. 101 (Suppl. 2), 109–116 (1993).
Bachmann, G. A. & Leiblum, S. R. The impact of hormones on menopausal sexuality: a literature review. Menopause 11, 120–130 (2004).
Daniels, I. R., Woodward, S., Taylor, F. G., Raja, A. & Toomey, P. Female urogenital dysfunction following total mesorectal excision for rectal cancer. World J. Surg. Oncol. 4, 6 (2006).
Kyo, K., Sameshima, S., Takahashi, M., Furugori, T. & Sawada, T. Impact of autonomic nerve preservation and lateral node dissection on male urogenital function after total mesorectal excision for lower rectal cancer. World J. Surg. 30, 1014–1019 (2006).
Hendren, S. K. et al. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann. Surg. 242, 212–223 (2005).
Schmidt, C., Daun, A., Malchow, B. & Kuchler, T. Sexual impairment and its effects on quality of life in patients with rectal cancer. Dtsch. Arztebl. Int. 107, 123–130 (2010).
Nelson, H. et al. Guidelines 2000 for colon and rectal cancer surgery. J. Natl Cancer Inst. 93, 583–596 (2001).
Sugihara, K. et al. Indication and benefit of pelvic sidewall dissection for rectal cancer. Dis. Colon Rectum 49, 1663–1672 (2006).
Akasu, T., Sugihara, K. & Moriya, Y. Male urinary and sexual functions after mesorectal excision alone or in combination with extended lateral pelvic lymph node dissection for rectal cancer. Ann. Surg. Oncol. 16, 2779–2786 (2009).
Jayne, D. G. et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3 year results of the UK MRC CLASICC Trial Group. J. Clin. Oncol. 25, 3061–3068 (2007).
Kim, S. H., Park, I. J., Joh, Y. G. & Hahn, K. Y. Laparoscopic resection for rectal cancer: a prospective analysis of thirty-month follow-up outcomes in 312 patients. Surg. Endosc. 20, 1197–1202 (2006).
Leroy, J. et al. Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes. Surg. Endosc. 18, 281–289 (2004).
Ng, S. S. et al. Laparoscopic-assisted versus open abdominoperineal resection for low rectal cancer: a prospective randomized trial. Ann. Surg. Oncol. 15, 2418–2425 (2008).
Breukink, S., Pierie, J. & Wiggers, T. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database of Systemic Reviews Issue 4. Art. No.: CD005200. doi:10.1002/14651858.CD005200.pub2 (2006).
Buunen, M. et al. COLOR II. A randomized clinical trial comparing laparoscopic and open surgery for rectal cancer. Dan. Med. Bull. 56, 89–91 (2009).
Guillou, P. J. et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365, 1718–1726 (2005).
Breukink, S. O. et al. Prospective evaluation of quality of life and sexual functioning after laparoscopic total mesorectal excision. Dis. Colon Rectum 50, 147–155 (2007).
Breukink, S. O. et al. Male sexual function and lower urinary tract symptoms after laparoscopic total mesorectal excision. Int. J. Colorectal Dis. 23, 1199–1205 (2008).
Morino, M. et al. Male sexual and urinary function after laparoscopic total mesorectal excision. Surg. Endosc. 23, 1233–1240 (2009).
Lindsey, I. & Mortensen, N. J. Iatrogenic impotence and rectal dissection. Br. J. Surg. 89, 1493–1494 (2002).
Jones, O. M., Stevenson, A. R., Stitz, R. W. & Lumley, J. W. Preservation of sexual and bladder function after laparoscopic rectal surgery. Colorectal Dis. 11, 489–495 (2009).
Safar, B. & Fleshman, J. Laparoscopic total mesorectal excision for rectal cancer. Semin. Colon Rectal Surg. 75–80 (2010).
Herbison, G. P. & Arnold, E. P. Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults. Cochrane Database of Systemic Reviews Issue 2. Art. no.: CD004202. doi:10.1002/14651858.CD004202.pub2 (2009).
Lindsey, I., George, B., Kettlewell, M. & Mortensen, N. Randomized, double-blind, placebo-controlled trial of sildenafil (Viagra) for erectile dysfunction after rectal excision for cancer and inflammatory bowel disease. Dis. Colon Rectum 45, 727–732 (2002).
Syme, D. B., Corcoran, N. M., Bouchier-Hayes, D. M. & Costello, A. J. Hope springs eternal: cavernosal nerve regeneration. BJU Int. 97, 17–21 (2006).
Denton, A. S. & Maher, E. J. Interventions for the physical aspects of sexual dysfunction in women following pelvic radiotherapy. Cochrane Database of Systemic Reviews Issue 1. Art. No.: CD003750. doi:10.1002/14651858.CD003750 (2003).
Safra, T. et al. Improved quality of life with hyperbaric oxygen therapy in patients with persistent pelvic radiation-induced toxicity. Clin. Oncol. (R. Coll. Radiol.) 20, 284–287 (2008).
Kinugasa, Y., Murakami, G., Suzuki, D. & Sugihara, K. Histological identification of fascial structures posterolateral to the rectum. Br. J. Surg. 94, 620–626 (2007).
de Heer, P. et al. Caspase-3 activity predicts local recurrence in rectal cancer. Clin. Cancer Res. 13, 5810–5815 (2007).
Lahaye, M. J. et al. USPIO-enhanced MR imaging for nodal staging in patients with primary rectal cancer: predictive criteria. Radiology 246, 804–811 (2008).
Author information
Authors and Affiliations
Contributions
M. M. Lange and C. J. H. van de Velde were both involved in researching data for this article, contributed to discussions of content, wrote the article and reviewed and edited the manuscript before submission.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing financial interests.
Rights and permissions
About this article
Cite this article
Lange, M., van de Velde, C. Urinary and sexual dysfunction after rectal cancer treatment. Nat Rev Urol 8, 51–57 (2011). https://doi.org/10.1038/nrurol.2010.206
Published:
Issue Date:
DOI: https://doi.org/10.1038/nrurol.2010.206
This article is cited by
-
Automatic muscle impedance and nerve analyzer (AMINA) as a novel approach for classifying bioimpedance signals in intraoperative pelvic neuromonitoring
Scientific Reports (2024)
-
Preservation versus resection of Denonvilliers’ fascia in total mesorectal excision for male rectal cancer: follow-up analysis of the randomized PUF-01 trial
Nature Communications (2023)
-
Technical aspects of a new approach to intraoperative pelvic neuromonitoring during robotic rectal surgery
Scientific Reports (2023)
-
Fully implantable and battery-free wireless optoelectronic system for modulable cancer therapy and real-time monitoring
npj Flexible Electronics (2023)
-
Evaluation of Depression, Anxiety, and Sexual Function in Rectal Cancer Patients Before and After Neoadjuvant Chemoradiotherapy
Journal of Gastrointestinal Cancer (2023)