Incontinence, Voiding Dysfunction, and Other Urologic Complications After Radiotherapy for Gynecologic Malignancies

Gynecological radio-induced secondary malignancy after a gynecological primary tumor: a rare entity and a challenge for oncologists

The management of radiation-induced secondary malignancies in the female genital tract after pelvic radiation treatment for a primary gynecological tumor is a challenge for multidisciplinary teams that follow survivors. Considering the lack of data on the incidence of this disease and the absence of guidelines for its management, in this review, the available literature is analyzed to determine the characteristics and the clinical management of gynecological radiation-induced secondary malignancies. Gynecological radiation-induced secondary malignancies were found to be predominantly more aggressive, poorly differentiated, and had rare histologic types compared with sporadic tumors. The management is influenced by previous radiation doses and the localization of the radiation-induced secondary malignancies. Surgery, when feasible, was the cornerstone; re-irradiation was an option when a surgical approach was not feasible and high-dose conformal techniques should be preferred considering the need to spare previously irradiated surrounding normal tissues. Clinical outcomes, when reported, were poor in terms of local control and survival. Given the difficulty in managing these uncommon malignancies, a centralization of care in sites that are connected to research networks actively partaking in international discussions and with higher expertise in complicated surgery or radiotherapy should be considered to improve clinical outcomes.

Barriers to and facilitators of adherence to pelvic floor muscle exercises and vaginal dilator use among gynecologic cancer patients: a qualitative study

Objective

Women with gynecologic cancer may suffer from pelvic floor dysfunction (PFD). Before radiotherapy, prehabilitation with pelvic floor muscle exercises (PFME) and vaginal dilator (VD) might prevent it and foster sexual life. This study aims to explore the experience of gynecologic cancer patients getting external beam radiation treatments regarding barriers to and facilitators of adherence to a prehabilitation program to prevent PFD.

Methods

This qualitative research with thematic content analysis included 11 women with gynecologic cancer and different levels of adherence to PFME and VD. Participants were interviewed based on a semi-structured script. The information was analyzed manually, assisted with Nvivo12® software, and triangulated with open coding.

Results

High self-motivation, desire to improve their health, symptoms of improvement, availability of time, the desire to resume sexual life, and the support of the partner were facilitators of adherence. The instructional exercise audio, clarity of the information, and closer communication with the physical therapist were also valued. The main barriers were general malaise secondary to oncological treatments, forgetfulness, lack of time, misinformation, lack of coordination with the treatment team, discomfort with the VD, and a feeling of shame. Feedback from the attending physician was a facilitator when present or a barrier when absent.

Conclusion

These barriers and facilitators should be considered when designing and implementing preventive programs with PFME and VD. Behavioral counselling should consider the desire to remain sexually active; in such cases, including the partner in the therapeutic process is appraised. Otherwise, the focus should be on benefits for maintenance of pelvic floor function.

Sexual Health Dysfunction After Radiotherapy for Gynecological Cancer: Role of Physical Rehabilitation Including Pelvic Floor Muscle Training

Introduction

The present study aims to describe: 1. How the side effects of radiotherapy (RT) could impact sexual health in women; 2. The effectiveness of physical rehabilitation including pelvic floor muscle training (PFMT) in the management of sexual dysfunction after RT.

Materials and Methods

Search keys on PubMed, Web of Science, Scopus, PEDro, and Cochrane were used to identify studies on women treated with radical or adjuvant RT and/or brachytherapy for gynecological cancers with an emphasis on vulvo-vaginal toxicities and PFMT studies on sexual dysfunction for this group of women.

Results

Regarding the first key question, we analyzed 19 studies including a total of 2,739 women who reported vaginal dryness, stenosis, and pain as the most common side effects. Reports of dosimetric risk factors and dose-effect data for vaginal and vulvar post-RT toxicities are scant. Only five studies, including three randomized controlled trials (RCTs), were found to report the effect of PFMT alone or in combination with other treatments. The results showed some evidence for the effect of training modalities including PFMT, but to date, there is insufficient evidence from high-quality studies to draw any conclusion of a possible effect.

Conclusions

Gynecological toxicities after RT are common, and their management is challenging. The few data available for a rehabilitative approach on post-actinic vulvo-vaginal side effects are encouraging. Large and well-designed RCTs with the long-term follow-up that investigate the effect of PFMT on vulvo-vaginal tissues and pelvic floor muscle function are needed to provide further guidance for clinical management.

Pre-rehabilitation of the pelvic floor before radiation therapy for cervical cancer: a pilot study

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate pelvic floor muscle (PFM) function regarding strength, activation and incontinence, approximately 1 month before and after radiation therapy in women with cervical cancer.

METHODS

This was a pilot study of 49 women with cervical cancer at stages I to III. These women attended an educational session with a physical therapist who taught them to perform preventive pelvic floor muscle exercises (PFMEs; slow and fast contractions and the "knack") at home before, during and after radiation therapy. The women received instructions for performing PFME prior to radiation therapy. The modified Oxford scale, electromyography (EMG), the International Consultation on Incontinence Questionnaire Short Form to assess urinary incontinence and two questions for faecal and gas incontinence were used.

RESULTS

Twenty-eight women (57%; mean age = 44 years, range 27-66) completed the study, 21 (43%) were lost to follow-up. There was no significant change from baseline to post-radiation therapy in muscle strength, EMG records and incontinence (p > 0.05). The median of PFM strength was equal at baseline and after intervention (median = 2; IQR = 1).

CONCLUSIONS

The results of this study suggest that pre-rehabilitation teaching PFMEs might be a protective factor for preserving PFM strength and preventing incontinence 1 month after radiation therapy. It is a feasible intervention.