- There are 3 components of human sexuality: body image, sexuality or sexual functioning, and reproduction
- Long-term sexual dysfunction has been documented in at least 50% of CRC patients
- The PLISSIT, BETTER, and ALARM models are 3 assessment tools available for evaluating the presence and degree of sexual disruption
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Human sexuality is a broad term that encompasses sex, gender, identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction.1 Our views on sexuality are influenced by cultural, social, ethnic, and religious/spiritual beliefs and practices. These views may change throughout our lifetime and life experiences.
There are 3 components of human sexuality: body image, sexuality or sexual functioning and reproduction. These aspects are distinct, yet they overlap
- Body image is the way in which individuals sees themselves or think that others see them
- Sexual function is a specific aspect of sexuality that incorporates hormonal levels, desire, and gender anatomy
- Reproductive function is the capacity to bear or father children
Sexual health integrates the somatic, intellectual, emotional, and social aspects of being sexual.2
Sexuality is an integral part of normal life and important to quality of life. Sexuality is multifaceted and incorporates the following: Most people have little factual or accurate knowledge about sexual issues, so myths are common. For many patients, alterations in sexuality or sexual function are often dismissed as a normal side effect of the disease and treatment. Therefore, problems may be underdiagnosed or underrated. These sexual disturbances can be severe, may be temporary or permanent, and can affect all aspects of life.
- Everything that makes us male or female
- Connection to every area of our lives
- The way in which we relate to one another
- What we believe and how we behave
- Feeling free to enjoy touch and caressing
- Feelings about our bodies
- Need to connect to other human beings in an intimate way
- Interest in engaging in sexual behaviors and ability to do so satisfactorily
- Communicating feelings and needs to a partner
Scope of the Problem
For the person with cancer, the components of sexuality may be affected by all aspects of the disease3:
- Origin and stage of disease
- Side effects and bodily changes resulting from surgery
- Chemotherapy and/or radiation therapy
- Psychological issues resulting from cancer and its treatment
Sexual dysfunction can occur in 20% to 100% of cancer patients. Long-term sexual dysfunction has been documented in at least 50% of CRC patients. Although these percentages are elevated, fewer than 20% of men and women seek medical help.4
The diagnosis of CRC often involves a change in self-image. This is initiated by the transition from seeing oneself first as “a well person” to “a person with cancer.” The presence of a colostomy or ileostomy and/or chemotherapy or radiation therapy increases the potential for disruption in sexuality.5
Cancer or associated treatments can affect or damage physiology in hormonal, vascular, and neurologic or psychological systems needed for healthy sexual responses.4
Potential hormone disturbances in men and women include gonadotropin-releasing hormone from the hypothalamus and luteinizing hormone and follicle-stimulating hormone from the anterior pituitary. In females, estrogen and progesterone levels from the ovaries may be affected, while in males, testosterone levels produced by the Leydig cells may be disrupted. Any treatment that affects the levels of hormone production has the potential to alter sexual function.3
The vascular and nervous system can be damaged or disrupted as a result of surgical intervention. A standard surgical procedure for cancer in the lower part of the rectum is an abdominoperineal resection. Through this procedure, removal of the rectum and lymphatics can cause nerve damage and sexual dysfunction. The damage to the nerves in this area can interfere with a wide range of sexual functions, including erectile dysfunction, absent or retrograde ejaculation, dyspareunia, and diminished orgasm.6
The psychological well-being of patients can be impacted not only by a diagnosis of cancer but also by disruption of body image following CRC surgery. Research has recorded a higher incidence of distress among women and younger patients.7 Additionally, the literature supports that having an ostomy after surgery can negatively alter an individual’s body image and psychological well-being. Whyness and Neilson have reported that a statistically significant improvement both emotionally and psychologically has been demonstrated in CRC patients 3 months following surgery.8
Effects of Cancer Treatments and Comorbidities on Sexuality
Surgical treatment for CRC consists of removing portions of the colon and/or rectum. Colostomy or ileostomy can impact sexual function from a psychological perspective in the realm of desire and body image. Additionally, postoperative CRC patients may experience increased gas and flatulence, diarrhea, fecal incontinence, or urinary urgency. Although these symptoms can be devastating, transitioning through them is possible with adequate medical assessment and appropriate intervention. Depending on the surgical procedure, sexual dysfunction after CRC surgery—particularly following abdominoperineal resection—can be temporary or permanent. Impotence and ejaculatory failure are among the types of sexual dysfunction.9,10
The effects of chemotherapy on sexual function are dependent on the agent used. Alkylating agents, antimetabolites, and antitumor antibiotics can cause amenorrhea,oligospermia, azoospermia, decreased libido, ovarian dysfunction, and erectile dysfunction. Alkylating agents may cause primary ovarian failure in females and are responsible for sexual dysfunction and infertility in men.4
There is little information about the effects of targeted therapies on sexuality and/or sexual function. Most effects may be related to fatigue (decreased lidibo), dry mucous membranes (dyspareunia), dermatologic toxicities (body image), or secondary hypertension requiring medical management (erectile dysfunction).
The agents and associated drug class for therapies used in treatment of CRC are listed in the table below.
Chemotherapy and Targeted Therapy Agents Used to Treat CRC
Water-soluble vitamin (folate group)
Topoisomerase 1 inhibitor
Monoclonal antibody, anti-VEGF
Monoconal antibody, anti-EGFR
Monoconal antibody, anti-EGFR
Effects of radiation therapy on sexuality and fertility can be temporary or permanent.
In males, radiation therapy to the pelvis may contribute to In females, radiation therapy may contribute to
- Urinary issues
- Bowel dysfunction
- Penile or testicular atrophy
In females, radiation therapy may contribute to
- Pelvic fibrosis
- Vaginal atrophy or stenosis
- Decreased lubrication
- Decreased elasticity
- Increased irritation to the vagina
Several models are available to assist health care providers in assessment of sexuality within appropriate frameworks. Once sexual function has been assessed, interventions to promote optimal functioning, well-being, and quality of life are essential.
Models for Assessment and Counseling
Limited Information (education)
Specific Suggestion (counseling)
Intensive Therapy (referral)
Bringing up the topic
Explaining that sex is a part of quality of life
Telling patients that resources will be found to address their concerns
Timing the intervention (when the patient is ready)
Educate patients about potential changes in sexual response and side effects that may affect response
Recording discussions, assessment, plan, interventions and evaluation
Arousal (and orgasm)
Medical information (related to cancer and comorbidities)
Role of the Nurse
The nurse is ideally positioned to provide patient and family education, understand and facilitate patient goals, and use guidelines to discuss sexuality and support sexual rehabilitation. This should be accomplished in a safe, judgment-free environment. Key points to consider when addressing the issue of sexuality with the patient are as follows4:
- The topic should be proactively approached
- Discussion should occur prior to treatment decision making
- Fertility preservation should be considered for those in childbearing years
- Written information should be provided for the patient and partner to review
- Appropriate referral should be made in the event that you are unable to provide the required information or treatment
There are no published clinical guidelines for treatment of sexual dysfunction in patients with cancer.
Lee SJ, Schover LR, Partridge AH, et al. American Society of Clinical Oncology (ASCO) recommendations on fertility preservation in people treated for cancer. J Clin Oncol. 2006;24:2917-2931. http://jco.ascopubs.org/cgi/content/full/24/18/2917. Accessed February 18, 2010.
Patient guide: http://www.cancer.net/patient/Survivorship/Late+Effects. Accessed February 18, 2010.
Miles C, Candy B, Jones L, et al. Interventions for sexual dysfunction following treatments for cancer [Cochrane Review], 2009.http://www.cochrane.org/reviews/en/ab005540.html. Accessed February 18, 2010.
National Cancer Institute PDQ. Sexuality and Reproductive Issues, Updated October 10, 2009.
Health care professional version: http://www.cancer.gov/cancertopics/pdq/supportivecare/sexuality/HealthProfessional/. Accessed February 18, 2010.
Patient version: http://www.cancer.gov/cancertopics/pdq/supportivecare/sexuality/Patient. Updated October 6, 2009. Accessed February 18, 2010.
Lack of Interest or Decreased Libido
Counseling the patient or couple together, encouraging them to verbalize feelings and emotions
- A gradual trial of therapy with phosphodiesterase-5 inhibitors (sildenafil, tadalafil or vardenafil)
- Vacuum pump
- Intraurethral alprostadil
- Intracorporeal injections
- Surgical implants
Female Painful Intercourse
- Trying alternative positions for penetrative intercourse—try positions that can control the depth of thrusting (woman on top or side by side positions)
- Vaginal dilatation—can be done with a dilator or a clean, well-lubricated finger gently inserted into the vagina to stretch tissues
- Nonpenetrative intercourse, such as oral sex, mutual or solitary masturbation, massage, hugging, kissing, or “outercourse” in which a man places his erect penis between the thighs of the partner and initiates thrusting in that position
Aesthetic Challenges With an Ostomy
- Empty appliance prior to sexual activity
- Irrigating the ostomy prior to sexual activity (for those to whom this applies)
- Place opaque cover over the pouch
- Apply stoma cap when appropriate
- Women may wear crotchless underwear to conceal stoma and appliance while allowing access to the genitalia
- Men may find wearing boxer shorts stabilizes the appliance, with the opening allowing access to the genitals
- Wagner G, Bondil P, Dabees K, et al. Ethical aspects of sexual medicine. J Sex Med. 2005;2:163-168.http://www.cancer.gov/cancertopics/pdq/supportivecare/sexuality/HealthProfessional/. Accessed February 18, 2010.
- Penson R, Gallagher J, Gioiella M, et al. Sexuality and cancer: Conversation comfort zone. Oncologist. 2000;5:336-344.
- Krebs L, Marrs JA. What should I say? Talking with patients about sexuality issues. Clin J Oncol Nurs. 2006;10:313-315.
- Vogel W. Alterations in sexuality. In: Newton S, Hickey M, Marrs J, eds. Oncology Nursing Advisor: A Comprehensive Guide to Clinical Practice. St Louis, MO: Mosby; 2008:340-343.
- Hughes MF. Sexuality and Cancer: The Final Frontier For Nurses. Onco Nurs Forum. 2009;36:E241-E245.
- Katz A. Colorectal cancer. In: Breaking the Silence on Cancer and Sexuality: A Handbook for Healthcare Providers. Pittsburgh, PA: Oncology Nursing Society; 2007:97-105.
- Sprangers MAG. Quality of life assessment in colorectal cancer patients: evaluation of cancer therapies. Semin Oncol. 2007;26:691-696.
- Whyness DK, Neilson AR. Symptoms before and after surgery for colorectal cancer. Qual Life Res. 1997;6:61-66.http://www.cancer.gov/cancertopics/pdq/supportivecare/sexuality/HealthProfessional/. Accessed February 18, 2010.
- Pietrangeli A, Bove L, Innocenti P, et al. Neurophysiological evaluation of sexual dysfunction in patients operated for colorectal cancer. Clin Auton Res. 1998;8:353-357.
- Hendren SK, O’Connor BI, Liu M, et al. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg. 2005;242:212-223.
- National Cancer Institute. Sexuality and reproductive issues. 2009.
- Katz A. Sexual health assessment. In: Breaking the Silence on Cancer and Sexuality: A Handbook for Healthcare Providers. Pittsburgh, PA: Oncology Nursing Society; 2007:19-29.
- Annon JS. A proposed conceptual scheme for the behavioral treatment of sexual problems. In: The Behavioral Treatment of Sexual Problems: Brief Therapy. Hagerstown, MD: Harper and Row; 1976:43-47.
- Mick J, Hughes M, Cohen MZ. Using the BETTER model to assess sexuality. Clin J Oncol Nurs. 2004;8:84-86.
- Anderson BL, Lamb M. Sexuality and cancer. 2nd ed. In: Murphy GP, Lawrence W, Lenhard RE, eds. American Cancer Society Textbook of Clinical Oncology.Atlanta, GA: American Cancer Society; 1995:699-713.
Amenorrhea—absence or cessation of normal menses
Azoospermia—absence of measurable levels of sperm in the semen
Dyspareunia—painful or difficult sexual intercourse, usually reported by women but can be experienced by men
Erectile dysfunction—inability of a man to obtain or sustain an erection
Oligospermia—low level of sperm in the semen
Retrograde ejaculation—semen enters the bladder during orgasm rather than being ejaculated from the penis