Urinary incontinence and other pelvic floor disorders after radiation therapy in endometrial cancer survivors

Natural history of pelvic floor disorders before and after hysterectomy for gynaecological cancer

OBJECTIVE

To investigate the prevalence and severity of pelvic floor disorders (PFD), and the associations between treatment type and PFD, and cancer stage and PFD in patients before and after hysterectomy for gynaecological cancer; and the changes in outcomes over time.

DESIGN

Longitudinal cohort study.

SETTING

Gynaecological oncology outpatient clinics.

POPULATION

Patients undergoing hysterectomy for endometrial, uterine, ovarian or cervical cancer.

METHODS

Participants were assessed before, and 6 weeks and 3 months after hysterectomy. Changes over time were analysed using generalised estimating equations or linear mixed models. Associations were analysed using logistic regression models and analyses of variance.

MAIN OUTCOME MEASURES

Incontinence Severity Index, Pelvic Floor Distress Inventory-short form (PFDI-20), Female Sexual Function Index.

RESULTS

Of 277 eligible patients, 126 participated. Prevalence rates of PFD were high before (urinary incontinence [UI] 66%, faecal incontinence [FI] 12%, sexual inactivity 73%) and after (UI 59%, FI 14%, sexual inactivity 58%) hysterectomy. Receiving adjuvant therapy led to moderate-to-very severe UI 3 months after surgery compared with surgery only (odds ratio 4.98, 95% CI 1.63-15.18). There was no association between treatment type and other PFD, or cancer stage and any PFD.

CONCLUSION

Prevalence of PFD was high before and after hysterectomy for gynaecological cancer. Moderate-to-very-severe UI was associated with adjuvant therapy.

Educational telerehabilitation program for women with pelvic floor dysfunctions after gynecological pelvic cancer treatment: protocol study for a randomized and controlled clinical trial

BACKGROUND

Educational and self-care measures are important for women after gynecological pelvic cancer treatment. Pelvic floor muscle training exercises (PFMT) are a conservative treatment for pelvic floor (PF) dysfunction. The purpose is to evaluate the impact of a telerehabilitation and self-care program on PF dysfunctions, reports of urinary incontinence (UI), and physical-emotional factors of participants post-treatment for gynecological pelvic cancer.

METHODS

Two-arm randomized clinical trial: an intervention group (IG) will evaluate the effect of a telerehabilitation program on women undergoing clinical practice of radiotherapy for the treatment of gynecological pelvic cancer and a control group (CG) will maintain the routine. Primary outcome is the prevalence of reports of UI, which will be assessed using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). The secondary outcomes will be the severity and impact of UI on quality of life, location and perception of pain intensity, presence and intensity of dyspareunia, vaginal stenosis, fecal incontinence (FI), and levels of physical activity. Statistical analysis will be performed by intention-to-treat, and multivariate mixed effects analysis will be used to compare results.

DISCUSSION

Activities in the context of telerehabilitation using PFMT and self-care can represent a viable and effective solution to minimize the side effects of gynecological cancer treatment and improve women's quality of life.

Pelvic floor dysfunction in gynecologic cancer survivors

Pelvic floor dysfunction (PFD) is a common complication in gynecologic cancer survivors (GCS) and is now a worldwide medical and public health problem because of its great impact on the quality of life of GCS. PFD after comprehensive gynecologic cancer treatment is mainly reflected in bladder function, rectal function, sexual dysfunction and pelvic organ prolapse (POP), of which different types of gynecologic cancer correspond to different disease incidence. The prevention strategies of PFD after comprehensive gynecologic cancer treatment mainly included surgical treatment, physical therapy and behavioral guidance, etc. At present, most of them still focus on physical therapy, mostly using Pelvic Floor Muscle Training (PFMT) and multi-modal PFMT treatment of biofeedback combined with electrical stimulation, which can reduce the possibility of PFD after surgery in GCS to some extent. This article reviews the clinical manifestations, causes and current research progress of prevention and treatment methods of PFD after comprehensive treatment for GCS.

Gastrointestinal outcomes among older women with endometrial cancer

OBJECTIVE

Treatment for endometrial cancer may contribute to bowel dysfunction and other gastrointestinal outcomes. We investigated the risk of several gastrointestinal diagnoses among older women with endometrial cancer and matched women without a history of cancer.

METHODS

Women aged 66 years and older diagnosed with endometrial cancer during 2004-2017 (N = 44,386) and matched women without a known cancer history (N = 221,219) were identified in the SEER-Medicare linked data. An index date was defined as the endometrial cancer diagnosis date in that matched set. ICD-9 and -10 diagnosis codes were used to define gastrointestinal outcomes, including constipation, abdominal pain, IBS, fecal incontinence, bowel obstruction, ileus, radiation enteritis or proctitis, colonic stricture, and vascular insufficiency of the bowel in the Medicare claims. Hazard ratios (HRs) for incident gastrointestinal diagnoses were estimated using multivariable Cox proportional hazards regression models.

RESULTS

Compared to women without cancer, women with endometrial cancer had an increased risk of gastrointestinal symptoms after the index date, including constipation (HR = 2.27; 95% CI: 2.22-2.32), abdominal pain (HR = 2.94; 95% CI: 2.89-2.99), and fecal incontinence (HR = 1.96; 95% CI: 1.83-2.10). The risk of other gastrointestinal diagnoses was also higher among women with endometrial cancer (e.g., bowel obstruction: HR = 5.72; 95% CI: 5.47-5.98; ileus: HR = 7.22; 95% CI: 6.89-7.57). These associations were also apparent in sensitivity analyses limited to 1+ and 5+ years after the index date.

CONCLUSIONS

Older women with endometrial cancer experience an excess risk of gastrointestinal diagnoses that may persist long after cancer diagnosis. Surveillance for these conditions may be a critical part of survivorship care.

Sexual quality of life in young gynaecological cancer survivors: a qualitative study

PURPOSE

The impact of cancer diagnosis and treatment on sexual quality of life (SQoL) is a significant and often neglected issue in the treatment and survivorship period of young gynaecological cancer survivors (YGCS). This study sought to explore women's lived experiences to understand how to protect and improve SQoL.

METHODS

A qualitative study with women aged 18-45 and pre- or perimenopausal at diagnosis (n = 15). A thematic analysis was performed in NVivo. Participants also completed a pre-interview questionnaire and The Female Sexual Distress Scale-Revised (FSDS-R).

RESULTS

YGCS experienced high psychosexual distress. Notably, seven themes were identified: adjustment, confidence, fear, loss, shame, trauma, and communication. Gynaecological cancer (GC) treatment interfered with everyday life and had a long-term impact on mental, physical, and emotional health, with many reporting an altered sense of self, body image and sexual identity. Single women felt vulnerable in new relationships, while partnered women reported low sexual desire and guilt about sexual difficulties. Open communication, emotional intimacy, and an acceptance of the 'new normal' buffered the trauma of cancer and were vital to relationship satisfaction. Lastly, absent, or blunt patient-clinician communication contributed to psychosexual distress.

CONCLUSION

GC interferes with sexual function, partner relationships, psychosexual wellbeing, and quality of life. A better understanding of the lived experiences of YGCS can help healthcare providers to adopt a holistic, patient-centric, and multidisciplinary approach to SQoL. YGCS want psychosexual communication and support, across all stages of treatment and care. Healthcare providers should initiate and normalise conversations on the impact of treatment on SQoL.

Functional Changes of the Genitourinary and Gastrointestinal Systems before and after the Treatment of Endometrial Cancer-A Systematic Review

The incidence of endometrial cancer (EC), which coexists with such civilization diseases as diabetes, obesity or hypertension, is constantly increasing. Treatment includes surgery as well as brachytherapy, teletherapy, rarely chemotherapy or hormone therapy. Due to the good results of the treatment, the occurrence of side effects of therapy becomes a problem for the patients. One of the large groups of side effects includes the pelvic organ prolapse, urinary and fecal incontinence. The aim of this study was to present current knowledge on the occurrence of pelvic floor dysfunction in women treated for EC. A literature review was conducted in the PubMED and WoS databases, including articles on pelvic floor dysfunction in women with EC. PRISMA principles were followed in the research methodology. A total of 1361 publications were retrieved. Based on the inclusion and exclusion criteria, 24 papers were eligible for the review. Mostly retrospective studies based on different questionnaires were evaluated. No prospective studies were found in which, in addition to subjective assessment, clinical examination and objective assessment of urinary incontinence were used. Studies show a significant increase in the incidence of pelvic floor disorders, including urinary incontinence, after various forms of EC treatment. We believe that assessment of complications after endometrial cancer treatment is clinically relevant. The review emphasizes the importance of programming prospective studies to prevent and address these disorders at each stage of oncologic treatment.

Factors of sexual quality of life in gynaecological cancers: a systematic literature review

Background

The impact of cancer diagnosis and treatment on sexual quality of life (SQoL) is a well-established survivorship issue for gynaecological cancer survivors (GCS), yet little is known on how to intervene.

Purpose

The aim of this systematic review was to identify the factors explaining the variability in SQoL for GCS.

Methods

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework and the software Covidence. Electronic databases Scopus, Web of Science, PUBMED and CINAHL were searched for original research on GCS published between 2002 and 2018. We performed a two-stage screening process against selection criteria and quality assessment of individual studies. The Salutogenic Theory and the PRECEDE–PROCEED model were used as theoretical frameworks to identify and categorise factors.

Results

The initial search yielded 3,505 articles resulting in a total of 46 studies used to examine the association between factors of SQoL and gynaecological cancers. Our findings suggested that SQoL varies across subgroups based on age, menopausal status, relationship status, and treatment modality. Protective factors included clinicians’ knowledge and confidence, preventive medical approach, risk and needs assessment, patient–clinician communication, relationship quality, psychosocial support, symptom management, accessibility of psychosexual care, and self-efficacy in the rediscovery of sexuality.

Conclusion

Despite the high incidence and long-term impact of sexual health issues on quality of life, supportive care needs are not being met. A better understanding of the evidence base around the factors of SQoL can help health professionals take steps to protect and improve SQoL in GCS.

Reliability of ultrasound imaging of pelvic floor morphology and function among females who have undergone pelvic radiotherapy

AIMS

To investigate the intra- and inter-rater reliability of two-dimensional (2D) transperineal ultrasound imaging (USI) measures of bladder wall thickness (BWT), urethral length (UL), and parameters related to levator plate length (LP) and transient changes in LP during pelvic floor muscle (PFM) contraction, and on Valsalva in women who received radiation therapy (RT) for treatment of pelvic cancer.

METHODS

Twenty women with a history of RT for the treatment of pelvic cancer were assessed independently by two raters on the same day. Five outcomes were assessed for reliability: BWT, UL, and LP at rest (LP-R), during a maximal voluntary contraction of the PFMs (LP-MVC), and during a maximal-effort Valsalva maneuver (LP-MVM). Reliability was determined using intra-class correlation coefficients (ICC) and Bland-Altman analyses. Measurement error was determined using standard error of the measurement (SEM) and minimal detectable difference.

RESULTS

Intra-rater reliability was very good for LP-R, LP-MVC, LP-MVM, and UL (ICC: 0.97 [0.93-0.99], 0.95 [0.88-0.98], 0.84 [0.59-0.94], and 0.96 [0.89-0.98], respectively). Inter-rater reliability was very good for LP-R (ICC: 0.82 [0.55-0.93]), and good for LP-MVC, LP-MVM, and UL (ICC: 0.79 [0.46-0.92], 0.79 [0.49-0.92], and 0.75 [0.36-0.90], respectively). BWT had poor intra- and inter-rater reliability. The variability between measurements was the smallest for LP-R, LP-MVC, and UL for intra-rater assessments, and for LP-R and UL for inter-rater assessments. SEM values for intra-rater assessments were LP-R: 1.5 mm, LP-MVC: 1.84 mm, LP-MVM: 4.33 mm, and UL: 1.16 mm.

CONCLUSIONS

Although these results support the reliability of 2D-transperineal USI for the evaluation of UL and PFM parameters, they do not support its use for the assessment of BWT.

Assessment of Dysfunction in the Urinary System as Well as Comfort in the Life of Women during and after Combination Therapy Due to Ovarian and Endometrial Cancer Based on the SWL, II-Q7 and UDI-6 Scales

This work aimed to assess the influence of oncological combination therapy that was done on endometrial or ovarian cancer and how the urinary system is influenced as well as the quality of life in comparison to a group of female patients after the removal of the uterus with appendages due to endometrial cancer, which did not require the supplementation of therapy after operative treatment. The study included 87 patients with endometrial cancer, where, after the removal of the uterus, there was no need for conducting adjuvant therapy (C), as well as 92 female patients with endometrial cancer or 38 patients with ovarian cancer in whom combination therapy was conducted (group A, B). The assessment of the quality of life was conducted using the questionnaires: Satisfaction Life Scale (SWLS), Incontinence Impact Questionnaire, Short Form (IIQ-7), and Urogenital Distress Inventory (UDI-6) for three, six, nine, and 12 months after the conclusion of oncological treatment. It was observed that there was a statistically significant decrease in the quality of life in female patients who underwent combination therapy in comparison to a group in whose treatment only included surgery (p < 0.05). The risk of developing urinary incontinence increases alongside an increase in the scope of the operation and in the case of supplementing treatment with brachytherapy in comparison to chemotherapy.

Importance of the ICRU bladder point dose on incidence and persistence of urinary frequency and incontinence in locally advanced cervical cancer: An EMBRACE analysis

PURPOSE

To identify patient- and treatment-related risk factors and dose-effects for urinary frequency and incontinence in locally advanced cervical cancer (LACC) treated with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT).

MATERIAL AND METHODS

Physician-assessed (CTCAE) and patient-reported (EORTC) frequency and incontinence recorded in the EMBRACE-I study were analysed. Risk factors analysis was performed in patients without bladder infiltration and with baseline morbidity available. Cox regression was used for CTCAE grade (G) ≥ 3 and G ≥ 2 and for EORTC "very much" and "quite a bit" or worse. Logistic regression was used for late persistent morbidity defined when CTCAE G ≥ 1 or EORTC ≥ "quite a bit" were scored in at least half of follow-ups.

RESULTS

Longitudinal data on 1153 and 884 patients were available for CTCAE and EORTC analysis, respectively. Median follow-up was 48[3-120] months. Crude incidence rates of G≥2 were 13% and 11% for frequency and incontinence, respectively. Baseline morbidity and overweight-obesity were risk factors for both symptoms. Elderly patients were at higher risk for incontinence. Patients receiving conformal-radiotherapy were at higher risk for frequency. ICRU bladder point (ICRU-BP) dose was a stronger predictor for incontinence than bladder D_2cm3. The 5-year actuarial estimate of G ≥ 2 incontinence increased from 11% to 20% with ICRU-BP doses > 75 Gy compared to ≤ 65 Gy. Frequency showed weaker associations with dose.

CONCLUSION

ICRU-BP dose, in addition to clinical parameters, is a risk factor for urinary incontinence and shows a dose-effect after radio(chemo)therapy and IGABT. ICRU-BP dose should be monitored during treatment planning alongside volumetric parameters. Frequency seems associated with larger irradiated volumes.

The Effect of Pelvic Floor Muscle Interventions on Pelvic Floor Dysfunction After Gynecological Cancer Treatment: A Systematic Review

OBJECTIVE

The aim of this systematic review was to identify, evaluate, and synthesize the evidence from studies that have investigated the effect of nonsurgical, nonpharmacological, pelvic floor muscle interventions on any type of pelvic floor dysfunction or health-related quality of life in patients after any type of treatment for gynecological cancer.

METHODS

Six electronic databases (Cochrane Library 2018, CINAHL 1982-2018, MEDLINE 1950-2018, EMBASE 1980-2018, PsycINFO 1806-2018, and EMCARE 1995-2018) were systematically searched in June 2018. Reference lists of identified articles were hand searched. Randomized controlled trials (RCTs), cohort studies, and case series were included if they investigated the effects of conservative treatments, including pelvic floor muscle training or dilator training, on bladder, bowel, or sexual function in patients who had received treatment for gynecological cancer. Risk of bias was assessed using the Physiotherapy Evidence Database scale for RCTs and the Newcastle-Ottawa scale for cohort studies.

RESULTS

Five RCTs and 2 retrospective cohort studies were included (n = 886). The results provided moderate-level evidence that pelvic floor muscle training with counseling and yoga or core exercises were beneficial for sexual function (standardized mean difference = -0.96, 95% CI = -1.22 to -0.70, I2 = 0%) and health-related quality of life (standardized mean difference = 0.63, 95% CI = 0.38 to 0.88, I2 = 0%) in survivors of cervical cancer and very low-level evidence that dilator therapy reduced vaginal complications in survivors of cervical and uterine cancer (odds ratio = 0.37, 95% CI = 0.17 to 0.80, I2 = 54%). There were insufficient data for meta-analysis of bladder or bowel function.

CONCLUSION

Conservative pelvic floor muscle interventions may be beneficial for improving sexual function and health-related quality of life in survivors of gynecological cancer. Given the levels of evidence reported in this review, further high-quality studies are needed, especially to investigate effects on bladder and bowel function.

IMPACT

This review provides moderate-level evidence for the role of pelvic floor rehabilitation to improve health outcomes in the gynecological cancer survivorship journey. Clinicians and health service providers should consider how to provide cancer survivors the opportunity to participate in supervised pelvic floor rehabilitation programs.

Body Image, Sexuality, and Sexual Functioning in Women With Gynecologic Cancer: An Integrative Review of the Literature and Implications for Research

BACKGROUND

Cervical and uterine cancers are common in women. Diagnosis and treatment of these cancers can lead to significant issues with body image, sexuality, and sexual functioning. A comprehensive review can improve understanding of these 3 concepts, in turn enhancing identification and management.

OBJECTIVES

To (1) present the qualitative, descriptive, and correlational research literature surrounding body image, sexuality, and sexual functioning in women with uterine and cervical cancer; (2) identify gaps in the literature; and (3) explore the implications of the findings for future research.

METHODS

A comprehensive search of the literature was undertaken by searching PubMed, CINAHL, and PsycINFO using predetermined subject headings, keywords, and exploded topics. After a comprehensive evaluation using specific criteria, 121 articles were reviewed.

RESULTS

Qualitative studies provided information about women's issues with body image, sexuality, and sexual functioning, whereas quantitative studies focused primarily on sexual functioning. The literature lacks correlational studies examining body image and sexuality. Significant issues regarding communication and quality of life were noted, and few studies were based on clear conceptual models.

CONCLUSION

The state of the science gleaned from this review reveals that while much is known about sexual functioning, little is known about body image and sexuality.

IMPLICATIONS FOR PRACTICE

Further work is warranted to develop conceptual models and research on body image, sexuality, and sexual functioning as a foundation for interventions to improve quality of life.