Common Symptoms of Pelvic Floor Dysfunction Post Gynecological Cancers
Gynecological cancers affect women across the ages and account for 17% of all cancers diagnosed in women (World Cancer Research Fund, 2020). The five main types of gynecological cancers include, cervical, uterine, ovarian, vulvar, and vaginal, but can also include fallopian tube and primary peritoneal. We know that in general pelvic floor dysfunction (PFD) is statistically prevalent among women. However, some gynecological malignancies can actually cause PFD and symptoms.
There is also substantiated research indicating that gynecological cancer treatments increase the risk of PFD. Some of the common symptoms associated with gynecological cancer treatments include, urinary/fecal incontinence, urinary/fecal urgency, urinary retention, and pain (vaginismus and vulvodynia).
Treatment options used for gynecological cancers include, surgery, radiotherapy, hormonal treatment, and chemotherapy, with a combination of modalities often administered. These treatments exert both direct and indirect effects resulting in functional anatomy, neurological, vascular, and myofascial alterations (Bodean et al., 2018).
Surgery
Ceccaroni et al. (2012) suggest that the type of surgery affects the prevalence of PFDs. Nerve-sparing surgical techniques tend to be associated with lower rates of SUI, UUI, and urinary retention than the non-nerve-sparing approaches. It is common knowledge that every surgery comes with risk. In these cases the ureters can be injured during surgery, and there can be damage to pelvic nerves, blood vessels, and pelvic floor muscles, resulting in lower urinary tract dysfunction (Bodean et al., 2018). Manchana et al. (2010) reported that up to two-thirds of cervical cancer survivors after radical hysterectomy had urodynamic abnormalities. Half of them had voiding dysfunction and one-third had storage dysfunction. It has also been noted that symptoms may change over time given the type of intervention. Radical surgical interventions tend to result in immediate symptoms that can potentially improve over time. Whereas radiation tends to elicit late effects that can present over many months. In patients who undergo surgical management of cervical cancer, UI rates tend to be highest in the early post-operative period (Ramaseshan et al., 2018).
Radiation/Radiotherapy
This type of treatment is typically administered by external beam therapy or brachytherapy and can have short-term and long-term side effects. Short term effects can be vulvovaginal skin irritation and discharge, radiation cystitis (bladder irritation), and radiation vaginitis (irritation of the vagina). Long-term side effects include, vaginal dryness and vaginal stenosis due to scaring that develops post treatment (American Cancer Society, 2019). Ultimately, this may contribute to dyspareunia. Hazewinkel et al. (2010) reported stress incontinence after radical hysterectomy and lymph node dissection in 19- 81% of patients. But, a combination of surgery with radiotherapy had two times more severe urological complications and that primary radiotherapy was associated with increased urinary urgency and fecal incontinence in 8-67% of cases.
Hormone Therapy
This type of treatment may be used alone or in combination with other modalities and can have a spectrum of side-effects affecting each individual differently. Some of the common types of hormone therapy drugs include, Luteinizing-Hormone-Releasing-Hormone (LHRH), Anti-Estrogens, and Aromatase Inhibitors. Because these drugs create an effect on estrogen levels they can elicit treatment-induced menopause. Many of the symptoms associated with the drugs are due to this change and patients may experience a new onset or worsening of peri/post-menopausal symptoms which include, vaginal itchiness or discharge, infections (bladder, vaginal, and/or urinary), dyspareunia, SUI, and UUI (Canadian Cancer Society, 2023).
Chemotherapy
This form of therapy is often used in conjunction with radiation or used after another treatment modality if the cancer has returned/spread. Therefore, it can be more challenging to say what symptoms of PFD are specifically associated to the chemotherapy. In a study looking at advanced endometrial cancer, De Boer et al. (2016) found no difference in UI rates between the use of chemo alone or in combination with radiotherapy, suggesting that the addition of chemotherapy contributes little to UI. Constipation and diarrhea are also known side effects, so the patient may ultimately experience a worsening of bowel issues secondary to underlying PFD.
Since the main goal of treatment is malignancy eradication, the concern of PFD may not be the primary focus for doctors or specialists. Unfortunately, due to this many of these changes may not be well discussed with the patient. If you have a patient who has upcoming treatment or has a history of gynecological cancer, you may want to have a discussion around the different treatments and risk factors, or encourage them to ask their doctor about potential side effects. Quality of life post treatment needs to be addressed and much of what Pelvic Health Physiotherapists do can help improve this.
By Laura Powers, Registered Physiotherapist
References:
1. American Cancer Society. (2019, March 27). Radiation Therapy for Endometrial Cancer. https://www.cancer.org/cancer/endometrial-cancer/treating/radiation.html.
2. Bodean OM, Marcu RD, Spinu DA, Socea B, Diaconu CC, Munteanu O, Taus N, Cirstoiu M. Pelvic floor disorders in gynecological malignancies. An overlooked problem? J Mind Med Sci, 5(1): 46-52. DOI: 10.22543/7674.51.P4652
3. Canadian Cancer Society. (2019). Treatment Induced Menopause. https://cancer.ca/en/treatments/side-effects/treatment-induced-menopause#ci_treatmentinduced_menopause_89_125_00
4. Ceccaroni M, Roviglione G, Spagnolo E, Casadio P, Clarizia R, Peiretti M, et al. (2012). Pelvic dysfunctions and quality of life after nerve-sparing radical hysterectomy: a multicenter comparative study. Anticancer Res, 32(2):581–8.
5. de Boer SM, Powell ME, Mileshkin L, Katsaros D, Bessette P, Haie-Meder C, et al. (2016). Toxicity and quality of life after adjuvant chemoradiotherapy versus radiotherapy alone for women with high-risk endometrial cancer (PORTEC-3): an open-label, multicentre, randomised, phase 3 trial. Lancet Oncol, 17(8):1114–26.
6. Hazewinkel MH, Sprangers M, Van der Velden J, Van der Vaart CH, Stalpers L, Burger M, Roovers J. (2010). Long-term cervical cancer survivors suffer from pelvic floor symptoms: a cross-sectional matched cohort study. Gynecol Oncology, 117(2): 281-6. PMID: 20170944, DOI: 10.1016/j.ygyno.2010.01.034
7. Manchana T, Prasartsakulchai C, Santingamkun A. (2010). Long-term lower urinary tract dysfunction after radical hysterectomy in patients with early postoperative voiding dysfunction. Int Urogynecol Journal, 21(1): 95-101. PMID: 19760355, DOI: 10.1007/s00192-009-0996-5
8. Ramaseshan AS, Felton J, Roque D, Rao G, Shipper AG, Sanses TVD. (2018). Pelvic floor disorders in women with gynecologic malignancies: a systematic review. Int Urogynecol Journal, Apr;29(4):459-476. DOI: 10.1007/s00192-017-3467-4.
9. World Cancer Research Fund. (2020, November 4). Worldwide cancer data: global cancer statistics for the most common cancers. American Institute for Cancer Research.