How to Improve Life After Gynae Cancer

Key Messages

  • Pelvic floor dysfunction commonly occurs after treatment for gynaecological cancers, including bladder, bowel and sexual dysfunction.
  • These symptoms are often treatable with conservative management.
  • Women will often not seek help for these symptoms, so screening is essential.
Gynaecological cancer is the third most commonly diagnosed cancer among women.  Thankfully the survival rates are increasing, but, as a consequence, many women are now having to live with the adverse effects of treatment.  These often include bothersome bladder, bowel and sexual dysfunction.  Research and awareness in this area is improving, with Associate Professor Helena Frawley from Monash University leading a project investigating pelvic oncology and the side effects of treatment.  Ms Carina Siracusa, American pelvic floor Physiotherapist, also presented at the International Continence Society meeting late last year, exploring what can be done to enhance recovery for these women.
 

The After Effects Of Gynaecological Cancer

Gynaecological cancer includes cancer of the cervix, ovaries, uterus, vagina, and vulva.  Treatment can often involve surgery, chemotherapy and radiation.  In addition to the common cancer side effects, including pain, fatigue, anxiety and emotional distress, treatment for gynaecological cancer also has other significant side effects which may include:
  • Lymphoedema in the pelvis or legs 
  • Menopause – surgically or chemically induced 
  • Loss of fertility 
  • Emotional and psychological impact including body image, sexuality and relationship concerns 
  • Sexual dysfunction, including vaginal dryness, bleeding and stenosis, and dyspareunia 
  • Urinary dysfunction and incontinence 
  • Bowel dysfunction and incontinence
Pelvic floor Physiotherapists can help women recover from sexual dysfunction, urinary incontinence and bowel incontinence or dysfunction. 
 

Sexual Dysfunction 

Sexual dysfunction can occur due to scarring after radiation or surgery, poor lubrication due to reduced oestrogen, reduced arousal, increased tension in the pelvic floor muscles, or fear/anxiety about intercourse. 
 
Helpful treatments include:
  • Use of vaginal trainers to help stretch scar tissue. A recent Cochrane review found that the use of vaginal trainers may help with reducing the risk of scarring and restoring vaginal length1.
  • Advice on vaginal gels / lubricants. Good options include olive oil and vaginal moisturisers such as Replens2.
  • Pelvic floor muscle training. In women with dyspareunia, the pelvic floor muscles often have increased tension, and exercises will be focused on downtraining and relaxation2.  Yang and co-authors found that pelvic floor muscle training reduced sexual dysfunction in women with cervical or endometrial cancer3.
  • Education regarding arousal, desire and the association with dyspareunia.

Urinary Dysfunction And Incontinence

Symptoms often include incontinence, increased frequency, urgency, reduced bladder storage capacity, and incomplete emptying. This can occur due to the effect of radiation on the bladder tissue and associated nerves, hormonal changes from menopause, and pelvic floor muscle dysfunction.  A recent systematic review found that radiation therapy in the pelvic area has detrimental effects on the pelvic floor muscle structure and function4.
 
Helpful treatments include:
  • Pelvic floor muscle training. Two randomised controlled trials found pelvic floor muscle training effective in reducing urinary incontinence after gynaecological cancer treatment3,5.
  • Voiding re-education. Teaching women how to properly and effectively empty their bladder.
  • Bladder retraining and urge suppression. Educate women in strategies to control and delay episodes of urgency. 
  • Education regarding healthy bladder habits and fluid intake.

Bowel Dysfunction And Incontinence

Bowel symptoms, including diarrhoea, constipation, bloating, and urgency or incontinence can often occur after pelvic radiation or surgery.  Similarly to bladder dysfunction, this can occur due to the effect of radiation on the bowel tissue and associated nerves, and pelvic floor muscle dysfunction.  
 
Treatment often includes:
  • Pelvic floor muscle training. Improving pelvic floor function, with a particular focus on the external anal sphincter.
  • Retraining defecation dynamics. Learning how to empty the bowel effectively. 
  • Education regarding stool consistency. Using dietary changes or supplements to optimise stool consistency. 
  • Urge suppression strategies. Learning how to control episodes of bowel urgency.

Women Won’t Often Seek Help

42% of women are bothered by pelvic floor dysfunction after gynaecological cancer treatment, but often don’t seek help.  This is due, in part, to women not prioritising their pelvic floor symptoms in light of their cancer diagnosis. However, Hazewinkel and colleagues also found that most women don’t realise that these symptoms are treatable, and want timely referral to a pelvic floor physiotherapist when these symptoms occur6.
 
Screening for pelvic floor dysfunction in women with gynaecological cancer is important, as these symptoms are often treatable, and recovery can make a huge difference to a woman’s life after cancer. 
 
References 
Miles, T., Johnson, N. (2014). Vaginal dilator therapy for women receiving pelvic radiotherapy. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD007291. DOI: 10.1002/14651858.CD007291.pub3
2Juraskova, I., Jervis, S., Mok, K. et al. (2013). The Acceptability, Feasiblity and Efficacy (Phase I/II Study) of the OVERcome (Olive Oil, Vaginal Exercise and MoisturiseR) Intervention to Improve Dyspaurenia and Alleviate Sexual Problems in Women with Breast Cancer.  J Sex Med, DOI 10.1111/jsm.12156
3Yang, E. J., Lim, J., Rah, U. W., Kim, Y. B. (2012). Effect of a pelvic floor muscle training program on gynaecologic cancer survivors with pelvic floor dysfunction: A randomized controlled trial. Gynecologic Oncology, 125(3), 705-711.