Lesson 37: Sexual Counseling Flashcards
Impact on Male Sexuality - Normal function
Dependent of intact blood flow, hormone levels, and normal psyche
Erection
- Neurovascular phenomenon mediated by parasympathetic nerves
- Causes release of acetylcholine -> metabolized into nitric oxide -> dilation of penile arteries
Orgasm + Ejaculation
- Controlled by sympathetic and pudendal nerves
- Sympathetic stimulation -> contraction of prostate gland + seminal vesicles -> propels fluids into urethra
- Pudendal nerve controls ejaculation and orgasm
Impact on Male Sexuality - Radical Pelvic Dissection
- Nerves controlled erection and ejaculation pass through perirectal and periprostatic tissue
- Parasympathetic pathway exit cord at S2-S4 -> perirectal tissue -> along prostate -> Erectile tissue
- Radical pelvic dissection disrupts nerve pathway
Impact on Male Sexuality - Radical cystoprostatectomy - non-nerve sparing
Permanent loss of erectile and ejaculatory function
- Due to removal of prostate gland
Rarely done unless patient has dementia or severe comorbidities
Impact on Male Sexuality - Radical cystoprostatectomy - nerve sparing
Permanent loss of ejaculatory function d/t removal of prostate gland
Temporary loss of erectile function
Usually returns in 3-6 months
Sensation and potential for orgasm is preserved
Impact on Male Sexuality - Wide Rectal Resection/APR
- Loss of erectile and ejaculatory function possible d/t nerve trauma/edema
- Any dysfunction is only temporary
- Risk of dysfunction impacted by
— Extent of dissection
— Anatomic variations
— Vascular disease
— Open vs lap surgical approach
Impact on Male Sexuality - Narrow Resection d/t Benign Disease
Usually done d/t IBD
Dysfunction is extremely unlikely
The resection doesn’t include perirectal tissue
Lap approach is associated with even lower risk
Impact on Female Sexuality - Normal Function
- Vaginal lubrication and clitoral congestion equivalent to male erection
- Mediated by parasympathetic pathways
— Exit cord at S2-S4 -> perirectal tissue -> clitoris + vaginal glands - Sensation/orgasm mediated by pudendal nerve
— Exists cord S2-S4 -> perineum -> pelvic floor muscles
Impact on Female Sexuality - Radical Pelvic Dissection
No significant changes or effects
Impact on Female Sexuality - Wide Rectal Resection/APR
- Potential for reduction in vaginal lubrication + clitoral congestion
— Temp or long-term - Lubrication also reduced post-menopause + women who need radiation
- Dyspareunia possible
— Loss of lubrication
— Change in vaginal angle d/t resection
— Stenosis causes by radiation - Counsel patients re: need for lubrication and benefit from changing positions during intercourse
Impact on Female Sexuality - Narrow Rectal Resection for Benign Disease
- Potential for temp reduction in vaginal lubrication and clitoral congestion
- Potential for dyspareunia d/t loss of rectum and altered vaginal angle
- Counsel patients re: need for lubrication and benefit from changing positions during intercourse
Impact on Female Sexuality - Partial Vaginectomy
- May be required for advanced pelvic cancer requiring resection
- May be required for patient with bladder of urethral cancer requiring radical resection
- Usually involves resection of proximal ⅓ of vagina
- Intercourse delayed until suture line well-healed
- Will need modified positioning for intercourse
Impact on Female Sexuality - Total Vaginectomy
Neovagina constructed at time of surgery
- From gracilis muscle or sigmoid colon
- Supports psychosocial rehabilitation
- Re-educated risk of bowel complications by creating separation between abdo + pelvic cavities
- Need to delay intercourse until neovagina well-healed
- May need vaginal dilation to prevent stenosis
Typically no change to sensation or orgasmic function
PLISSIT Model for Sexual Counseling
- Permission
- Limited Information
- Specific Suggestions
- Intensive Therapy
PLISSIT Goals
Assist sexually active patient + partner to resume/maintain their sexual relationship
Assist non-sexually active patients to realize the potential to establish a satisfying sexual relationship
Provide patient and partner the opportunity to explore their sexual concerns
PLISSIT - Permission
Should be provided to every older teen + adult who is cognitively intact
Provide permission by bringing up topic
- Has your doctor talked to you about the possible effects of surgery on sexual function?
- What concerns do you have?
PLISSIT - Limited Information
- Information re: anticipated changes in sexual function
- Critical component of preop teaching and informed consent
— IF patient is undergoing radical pelvic dissection resulting in altered function - If no anticipated changes, discussion can be delayed until post-op
PLISSIT - Specific Suggestions
To reduce anxiety re: resumption of sexual activity
- Talk openly with partner about concerns and their concerns
- Select clothing/lingerie that makes you feel attractive
- Set the mood (ie. music, lighting, candles)
- Assure pouch is secured and concealed
PLISSIT - Specific Suggestions
To manage stoma/pouch during sexual activity
- Empty pouch and check seal prior to sexual activity
- Consider use of mini-pouch or stoma cap
- Secure pouch to abdo to prevent flapping
- Use of wrap or pouch covers
- Help patient and partner focus on each other and not the pouch
PLISSIT - Specific Suggstions
To Manage Altered Sexual Function
Erectile dysfunction
- Refer to urologist for vacuum therapy, oral meds, injection therapy, or prosthetic device
- Discussion of alternatives to intercourse
Post-vaginectomy
- Use of touch, oral stimulation, vibrator, and simulated intercourse until cleared by surgeon
PLISSIT - Specific Suggstions
For when/how to tell your partner
- An individual choice on who and when to tell
- Be straightforward and upbeat
- Convey the message “there is something unique about me” not “I am sick or disabled”
- Helps to practice
- Need to prepare for worst-case scenario
— Termination of relationship?
— What does it say about you?
— What does it say about them?
PLISSIT - Intensive Therapy
- For patients with complex or longstanding sexual/relationship issues
- Refer to family/relationship counselor or sex therapist
- Common concerns usually arise 4-12 weeks post-op
- Important to follow up to address questions in a timely manner
