Lesson 37: Sexual Counseling

Question 1

Impact on Male Sexuality - Normal function

Answer 1

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

Question 2

Impact on Male Sexuality - Radical Pelvic Dissection

Answer 2

• 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

Question 3

Impact on Male Sexuality - Radical cystoprostatectomy - non-nerve sparing

Answer 3

Permanent loss of erectile and ejaculatory function
- Due to removal of prostate gland

Rarely done unless patient has dementia or severe comorbidities

Question 4

Impact on Male Sexuality - Radical cystoprostatectomy - nerve sparing

Answer 4

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

Question 5

Impact on Male Sexuality - Wide Rectal Resection/APR

Answer 5

• 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

Question 6

Impact on Male Sexuality - Narrow Resection d/t Benign Disease

Answer 6

Usually done d/t IBD

Dysfunction is extremely unlikely

The resection doesn’t include perirectal tissue

Lap approach is associated with even lower risk

Question 7

Impact on Female Sexuality - Normal Function

Answer 7

• 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

Question 8

Impact on Female Sexuality - Radical Pelvic Dissection

Answer 8

No significant changes or effects

Question 9

Impact on Female Sexuality - Wide Rectal Resection/APR

Answer 9

• 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

Question 10

Impact on Female Sexuality - Narrow Rectal Resection for Benign Disease

Answer 10

• 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

Question 11

Impact on Female Sexuality - Partial Vaginectomy

Answer 11

• 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

Question 12

Impact on Female Sexuality - Total Vaginectomy

Answer 12

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

Question 13

PLISSIT Model for Sexual Counseling

Answer 13

• Permission
• Limited Information
• Specific Suggestions
• Intensive Therapy

Question 14

PLISSIT Goals

Answer 14

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

Question 15

PLISSIT - Permission

Answer 15

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?

Question 16

PLISSIT - Limited Information

Answer 16

• 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

Question 17

PLISSIT - Specific Suggestions
To reduce anxiety re: resumption of sexual activity

Answer 17

• 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

Question 18

PLISSIT - Specific Suggestions
To manage stoma/pouch during sexual activity

Answer 18

• 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

Question 19

PLISSIT - Specific Suggstions
To Manage Altered Sexual Function

Answer 19

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

Question 20

PLISSIT - Specific Suggstions
For when/how to tell your partner

Answer 20

• 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?

Question 21

PLISSIT - Intensive Therapy

Answer 21

• 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